Dialectical Behavior Therapy for Binge Eating and Bulimia by Debra L. Safer, Christy F. Telch, Eunice Y. Chen Page B

The irreverent communication strategy is designed to gently shock or wake the client up by being quite frank and honest with her or him, thus helping the client to get moving. For example, if a client says “I couldn’t keep practicing the skills because they were taking too much time,” the therapist, with a humorous tone, may say, “Ah—I get it. Practicing the skills took up too much time ... but you were able to ft in time for a binge,” or “If you had time to binge, you had time to practice the skills.”
    Motivation and Commitment Strategies
    Eliciting commitment and agreements from clients is an ongoing task for therapists throughout treatment. The frst agreement clients make is to come to treatment. The next is to agree that the goal of treatment is to stop binge eating, and the next is to learn and practice the skills. Therapists constantly gauge a client’s level of commitment, using motivation and commitment strategies as commitment waxes and wanes.
    In DBT, motivation is not viewed as an internal state or an intrinsic quality of the client. Instead, therapists understand the necessary role of situational vari— ables that, when present, increase the likelihood that clients will exhibit a desired behavior (i.e., be “motivated”). Therapists also keep in mind that eliciting commitment and agreement from a client is an ongoing job that requires therapists to constantly gauge the client’s current level of commitment, returning to the motivation and commitment strategies as the client’s commitment waxes and wanes.
    In standard DBT, group skills training focuses on remediating clients’ defcits in capability, whereas individual treatment helps clients identify applications of the newly taught skills to everyday situations and also involves analyzing motivational issues that may interfere. This analyzing may take the form of a behavioral chain analysis or a solution analysis, or it may involve using commitment strategies.
    The challenge for therapists conducting this adapted DBT treatment is to pro— vide in one session both the motivational component usually focused on during individual treatment in standard DBT and the skills training usually taught in group skills training (see also Chapter 3). It is the job of therapists to cheerlead clients in using skills in diffcult situations. When clients give up, the therapist should not assume that clients either can or cannot solve problems for themselves.

Orientation for Therapists
25
    Wherever possible, the therapist needs to work on “dragging out” new behaviors in clients in these situations.
    Commitment strategies are discussed briefy here and throughout the relevant sections of this book. Again, readers are also referred to Linehan’s text (1993a, particularly pp. 284–291) as essential reading. Evaluating Pros and Cons involves helping the client review the advantages of whatever behavior is being evaluated, as well as counterarguments to those advantages. The therapist should highlight the short-and long-term consequences of the pros and cons. For example, behaviors that look attractive in the short run may have very negative sequelae. In Play— ing the Devil’s Advocate, the therapist counters or challenges the client in a way that results in the client’s providing his or her own reasons that he or she must change. In the Foot-in-the-Door technique (Freedman & Fraser, 1966), the therapist enhances compliance by frst asking for something easy, followed by something more diffcult. In the Door-in-the-Face techniques (Cialdini et al., 1975), the therapist frst makes a challenging request followed by an easier one. In Connecting Present Commitments to Prior Commitments, the therapist reminds the client of previously made commitments to bolster a commitment that may be waning or when the client is behaving in ways that are inconsistent with previous commitments. The strategy of Highlighting Freedom to Choose in the Absence of Alternatives