This case study illustrates how a treatment plan based on dialectical behaviour therapy (DBT) may be used to support a client suffering from bulimia nervosa.
Suggested pre-reading: What is Dialectical Behaviour Therapy?
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The story
Disclaimer: This case study contains fictional names to protect the privacy and confidentiality of individuals and entities involved.
Sandy was a 39-year-old woman who had immigrated to the country from the United Kingdom with her parents as a young adolescent. She was married to her husband Jones – a lawyer for a prominent law firm – and had 13-year-old and 9-year-old daughters and an 8-year-old son. Sandy worked as a copywriter for an advertising company. When the Eating Disorder Examination (EDE; Fairburn & Cooper, 1993) was administered to her at intake, Sandy reported 14 “objective” binge-eating episodes, 10 “subjective” episodes, and 20 episodes of vomiting after a binge in the last 28 days. She estimated that, while she had had a pattern of bingeing/purging for a number of years, the frequency and severity of the episodes at this level had been occurring for perhaps two years. Sandy felt like, when a binge episode started, she simply lost control of herself. Thus, she met the DSM-5-TR criteria for bulimia nervosa (for more information on eating disorders, read this article).
Attempts to influence weight start early
Sandy recalled growing up in her large family in the U.K. With five siblings, a workaholic father, and a mother who was often unwell and – according to Sandy, part-hypochondriac, part-narcissist – Sandy never felt seen or heard in her family. By her third year of primary school, Sandy had decided that she was “overweight” and was trying strategies to become thin like she perceived the other girls to be. In her adult body, Sandy was 163 cm (5’4”) tall, and weighed in at 55 kgs (121 lbs); this constituted a BMI (Body Mass Index) of 20.7, or at the low end of “normal” weight. Sandy believed, however, that she should return to an earlier weight of only 52 kgs (115 lbs); she had previously weighed as much as 58 kgs (128 lbs).
Her issues with binge-eating and purging had started when she was in her senior year as an undergraduate at university (around age 21), while living away from home and experiencing a relational breakup, which had left Sandy feeling lonely and deserted. The bingeing/purging helped assuage feelings of unworthiness and abandonment in the moment and for a short period afterwards, but eventually the sadness, loneliness, and depressed mood would return, accompanied by shame, leaving Sandy feeling worse than before. Sandy had the sense that it always took her a long time to return to her more normal moods after a “shame attack”. Though her symptoms had waxed and waned over the years, they had worsened considerably after the birth of Sandy’s son, eight years prior, coinciding with depressive symptoms she had had post-partum. The depressive symptoms were subclinical, not being severe enough to warrant a diagnosis of “major depressive disorder”. Unfortunately, during the same period Sandy injured her back in the gym, and found it difficult to carry out her household chores or even pick up her infant son. She sought physiotherapy and also counselling at the time, which resulted in Sandy being able to heal her back injury and alleviate her depressive symptoms, but her pattern of emotional eating continued unabated. The intake clinician did not find any other co-morbid conditions.
Impacts on health and relationship
Sandy was clear she just wanted to overcome the bingeing/purging behaviours, as it was beginning to affect her health and relationships in multiple ways. For one thing, her children had found her face down in the toilet several times, and expressed alarm that she might be very unwell. Sandy feared that her daughters in particular would be more susceptible to developing eating disorders if they knew that she had one, and she had been told that she was at elevated risk for heart disease, stroke, high blood pressure, high cholesterol, sleep apnoea, colon cancer, and breast cancer. If that weren’t bad enough, she had begun to experience a raspy voice and cough from the constant irritation to her throat and vocal cords. Sometimes her eyes turned red as if she hadn’t slept well (from the forced vomiting, she thought). Tooth decay, acid reflux, and intestinal problems such as bloating, constipation, and diarrhoea were her constant companions. And though her marriage was solid in general, Sandy was increasingly feeling disloyal to her husband. They shared most secrets with each other, but this was too terrible to tell him. Apart from the concern for her that Jones would have genuinely felt, Sandy reckoned that he would also have been angry that she was endangering her health when her family depended so heavily on her. Low on energy because vomiting was so exhausting, Sandy had little motivation – and with the children’s needs, little time – for socialising with friends. She was aware that she would have felt isolated in any case: the bingeing/purging made her feel alien and pathologically different, and she would not have felt comfortable sharing it.
Treatment structure
The program Sandy’s clinician intended to follow consisted of a pre-treatment interview and 20 weekly sessions of 60 minutes each. Of these, the first 20 minutes or so were to be devoted to reviewing the assigned homework or previously taught skills and a further 30 minutes would be utilised teaching new skills. The skills categories were scheduled to be covered as follows:
- Pre-treatment interview,
- Introductory sessions 1 and 2
- Mindfulness module, Sessions 3 – 5
- Emotion regulation module, Sessions 6 – 12
- Distress tolerance module, Sessions 13 – 18
- Review of skills and future planning, Sessions 19 – 20
Pre-treatment Interview
The purpose of this session was for the therapist to begin building rapport with Sandy, gain a closer look at her presenting problems, review the affect regulation model of bingeing/purging (which sees emotional dysregulation as the cause of eating disorders), and to get her to relate details of a recent binge/purge episode. The goals and targets of treatments were to be reviewed, followed by discussion of the therapist and client agreements that would need to be signed.
When asked why she was seeking treatment now, Sandy replied that the episodes of bingeing-purging were becoming more severe and she was experiencing great shame* and isolation, plus feeling like she was a lousy role model for her daughters. When asked to detail a recent episode, Sandy related how she had felt humiliated at work by a colleague of hers, who had criticised her (unjustly) in front of all the staff. Sandy had gone home, gotten dinner, numbly helped the kids with their homework and gotten them into bed, and then collapsed on her couch with a tub of her favourite caramel ice cream, topped off with those creamy chocolate cookies she loved so much. The burning resentment against her colleague for humiliating her publicly, the many household tasks that she took on given Jones’s long work hours, and all the other undone bits of her life melted away in the sweet comfort of the ice cream that poured soothingly down her throat. The comfort was short-lived, though. She soon retired to the bathroom to give it all back in another, increasingly painful episode of vomiting. Sandy knew that all the emotions plaguing her would soon be back at full throttle, along with deep shame for having succumbed yet again to the urge to purge.
When the therapist remarked that it looked to him like Sandy was being helped short-term but suffering from long-term consequences of her binge/purge routines – and that they were keeping her from being the wife, mother, and person she wanted to be – Sandy had a moment of truth: the bingeing/purging really had to go. The therapist’s promise that he could give her much more effective ways to deal with all the emotions was a dealmaker. She said to count her in, and the therapist began to go over the goals and targets of treatment, with the most important goal being to eliminate the bingeing/purging, and a secondary goal being to get rid of any behaviours that interfered with her therapy. The therapist explained the modules that he would be teaching, and handed her a copy of the therapist and client agreements, for her to sign the following week if she had no questions.
*For clinical insights on working with shame in therapy, read these articles: Disentangling Painful Emotions and Building Shame Resilience in Clients.
Session 1
The goals for the first session were:
- To gain a commitment from Sandy to abstain from bingeing/purging
- To present the biosocial model so that Sandy would understand why they would be working to resolve the dialectics inherent in her disordered eating
- To orient her to the diary card and chain analysis
- To sign the therapist and client agreements
The therapist started by inviting Sandy to more fully describe the effects of bingeing/purging on her life. Sandy related how it had seemed like a friend – a lover, even – at the beginning in that she could turn to it when life was difficult, but it had begun to be abusive: a burden to her that she could not get rid of. With a husband and family she loved, a basically good job (apart from that one colleague and the overall stressfulness of the job), and occasional travels with the family, she controlled a lot of her life. A lot of it was good. It was just this one aspect…
The therapist acknowledged that the negative impacts seemed significant, yet of course, Sandy kept doing it; thus, there must be some advantages for her in it? When Sandy responded that it reduced her stress and made her feel more relaxed right after doing it – plus she could eat what she wanted and not gain weight – the therapist commented how it helped to distract her from her feelings and relieve tension, so it was clearly successful in the short run. He followed that up with the remark that perhaps she should re-consider. Giving up bulimia, after all, was going to be hard, and it had a lot going for it. Maybe she could find a way to have a quality life and still keep doing it, he suggested?
With Sandy’s emphatic “No!” followed by a recitation of how disgusting it was, especially her breath afterwards – and how tiring! – the therapist said, “OK, so it sounds like you’re ‘in’. You see that there’s no other way, and you want to stop it now. We will say that that binge you described from several days ago is the last binge/purge you will ever have.”
Sandy was aghast. “The last? I can’t just stop it now!”
The therapist’s response made Sandy pause. He reflected that, with her work and her family duties, it was going to be increasingly difficult to juggle all of that plus continue the draining binge-purge episodes. She said, “OK, I’ll try to make last week’s one the last one.”
The therapist still wasn’t satisfied. “Sandy, he said, “our research shows those who say they’ll try still have it in the back of their minds that they may yet use bingeing/purging as a way to control those strong emotions. I need you to commit to doing it, not to trying it.” With misgivings and protestations that she could commit and then fail, Sandy agreed, only partly reassured by the therapist’s response that, while no one could predict the future, she could commit right now in that present moment to stop. The therapist then went on to explain the biosocial model (that an invalidating environment and a sensitive personality would collude to dysregulate a person’s emotions). He then reviewed the therapist and client agreements, after which he explained the chain analysis, asking Sandy to do one before the next session, and the diary card, letting her know that she’d need to complete this every day.
Session 2
The purpose of this session was to review the homework and teach two skills. In a way, it was also informally about socialising Sandy to the importance of doing the homework: an effort that turned out to be much needed. Sandy had had three bingeing episodes over the week, after two of which she had purged. All of these would normally require chaining in DBT, but Sandy was so ashamed of having had them after committing to not doing that anymore that she couldn’t bring herself complete the chain analyses. She began to see how it all fit together, however, in that the overwhelming desire to binge had occurred after two incidents of being criticised: one by the difficult colleague at work and one by Jones. She managed to get the anger, sense of humiliation, and sense of injustice onto the diary card, but only for three of the days, not completing the other four days.
The therapist began the session by asking to see her homework. Sandy’s downcast face and lowered voice spoke volumes. “I really thought I was finished with all that,” she said. “I committed to stopping, I didn’t know that the urge to purge would come again so strong, and I feel so ashamed about it.”
The therapist patiently explained how, not only the bingeing-purging episodes, but also the failure to “capture” them in the chain analysis and diary card, were therapy-interfering actions that needed to be rectified immediately. They completed both documents together, and Sandy assured the therapist that she now had a better understanding of not only how to fill them in, but also why she needed to.
The therapist noted that the new skills he would teach her that day – dialectical abstinence and diaphragmatic breathing – would help her in the coming week to cope with the shame without avoiding her homework, and to abstain from bingeing/purging, when she felt strong urges to binge.
Sessions 3 – 5: Mindfulness module
The mindfulness module, often taught before the other modules in a DBT program for eating-disordered clients, attempts to increase clients’ ability to be aware of and experience their feelings without reacting to them by performing emotion-engendered disordered eating, meaning – in Sandy’s case – bingeing/purging. The specific skills the program required, which Sandy’s therapist agreed were appropriate for her, were the “What” and “How” skills, Mindful eating, Urge surfing, and Alternate rebellion.
The therapist discovered that Sandy had a quick mind and readily understood the concepts he was introducing. Her ability to retain what she had learned was also top-notch. What they kept returning to as the sessions unfolded was Sandy’s deep guilt and shame when she was overcome by urges. Moreover, her strong sense of duty as a mother and wife sometimes meant that she sacrificed time for herself in order to complete household duties. Thus, in one of the sessions, they had a discussion about Sandy’s seeming inability to get time to eat by herself, mindfully, as required by her homework.
Mindful eating vignette
When asked about whether she had been able to mindfully eat at least one meal a day, Sandy replied that breakfast – if she got it at all – was a rushed affair, with her gobbling bits of toast in between getting the kids’ breakfasts, followed by gulping her coffee in a travel mug as she drove them to school. Lunch was completed as she sat at her desk; their company only paid the employees for 38 hours of work a week, and required that they be present from 9:00 to 5:00. This meant that two hours over the five days were lunch time: approximately 24 minutes each day, and not really enough for a thoughtfully eaten, slowly chewed meal. So Sandy had decided that dinner would be her mindfully eaten meal, but the problem was that, by the time she helped the kids with their homework and got them into bed, it was very late. Even when Sandy made it to dinner without a snack, she found that she would inhale the food without really noticing it. She almost always consumed much more than she had intended (constituting at least a “small” or “subjective” binge).
When the therapist asked if there was more going on than just hunger, Sandy asked what he meant. “Well,” the therapist explained, “apart from being justifiably hungry, might you be a tiny bit resentful of your husband, who gets a free pass on all those domestic duties because he works late?” Sandy hung her head; her therapist had nailed it, and she realised that there was more to the art of identifying and describing emotions – and then linking them with her binges – than she had realised.
After brainstorming possible ways to deal with this, they came up with a two-part solution, one which required Sandy to take a courageous step with Jones. The first part of the solution was that she would actually disclose to her husband that she had been diagnosed with bulimia nervosa, outline the possible long-term consequences, and share with him what she was already experiencing. Sandy was apprehensive about that, but they partially scripted what she would say, and how she would approach it. The therapist assured her that he would be able to help her process anything that came out of that disclosure at her next session. The second part of the solution called for Sandy to get some outside help. She could either get some babysitting help, or possibly hire someone to help the kids with their homework. Not the teaching type, Sandy chose the latter, so that she could eat her evening meal in peace while the tutor was working with her kids. Of course, one of the reasons she had to disclose her diagnosis to Jones was so that she could explain to him why they needed to spend money on a tutor.
The session after this discussion Sandy came in beaming, noting that Jones – while shocked and almost disbelieving – also told Sandy how much he loved her, and that her mental and physical health was important to him. He recalled that the years when she had had depressive symptoms were difficult for him, and he did not wish for Sandy to be unhealthy: at any level. As to the skills of Urge surfing and Alternate rebellion, Sandy realised that she could usefully practice Urge surfing on weekends when the free time would have allowed her to more easily binge in response to any unexpressed feelings left over from the week. She became quite skilled at it over the course of the therapy.
She still hesitated to employ Alternate rebellion, as the therapist had difficulty convincing her that she needed to “rebel”. In the end, her “rebellion” consisted of re-negotiating cooking arrangements at home, such that her husband agreed to take responsibility for cooking two nights a week, freeing up Sandy a bit. The deal was that, if he couldn’t be home, he would let her know, and she was free to order (including with delivery) a meal for the family from several of the healthy food outlets in their area. The thought that extra money would be spent on takeout food incentivised Jones to make it home earlier on his nights to cook, and being relieved of some of the domestic responsibility helped Sandy to feel less rushed and stressed during some of the evenings; feelings of resentment decreased.
Sessions 6 – 12: Emotion regulation module
By the time Sandy arrived at the emotion regulation module, she had experienced some success with using mindfulness skills to help her avoid binge eating and the compensatory vomiting that she always felt the need to do afterwards. She still had problems with “subjective” binges, meaning times when she ate more than she intended, but not enough for the eating episode to be called an “objective” binge (the equivalent, say, of two full main meals or more). The therapist explained to her that the objectives of this module would be:
- To learn to identify and label her emotions
- To understand the function of her emotions
- To reduce her vulnerability to intense emotions
- To increase her number of positive emotional events
- To increase her mindfulness of emotions
- To learn to change her emotional experience where possible
As they began to discuss the Model of Emotions, the therapist heard that Sandy didn’t really believe that her need to vomit was actually related to emotions; she reckoned it was more that the food felt uncomfortable in her stomach: this, even though she claimed to be eating fairly healthily. “I hate it when the food [often glutenous foods, as Sandy had some food intolerances] just sit there in my guts. It makes me look six months pregnant with my tummy sticking out so much; it’s disgusting!”
The therapist asked if he heard some emotions in that response, and Sandy flatly denied this. “No!” she said, “It’s a purely physical thing.”
Knowing that clients with BN often viewed their need to vomit in this way, he persisted. “Yet I believe I hear some judgment in ‘disgusting’, no?” As Sandy realised that her therapist was again “on target” despite her protestations, he continued. “Where there is judgment, there is usually emotion. Might you still be dealing with guilt or shame about this?” Sandy acknowledged that she was embarrassed by her stick-out stomach. “Embarrassment” replied the therapist “is an emotion.” He asked her to look more closely at the Model of Emotion, pointing out how the sensation of fullness after eating, say, bread with gluten in it, would lead to her interpretation that her stomach was “disgusting”. That, in turn, would be linked to changes in her brain and body, whereby she would focus on such sensations and interpretations again and again. Focusing in such a way, he explained, would be part of her embarrassment, which would eventually come to include shame. He finished with the point that these sorts of emotions fire and re-fire in a person’s brain, making them increasingly dominant. Yet for a person with emotional dysregulation, such emotions are hardly bearable; thus, the person turns to bingeing/purging, perceiving consequent gut sensations as a “physical” experience.
Sandy sat back, stunned. “Oh, is that why I don’t notice how full or bloated my tummy feels on days when I’m really busy?” She was ready to deal with her emotions.
As they studied emotions and their functions further, the therapist wondered if there were some more “dots to connect” for Sandy. “Remember how you told me that you could never be properly heard – or, really, even seen – in your family of origin? I’m thinking about how you also told me that most of the people in your world see you as an effortlessly successful wife, mother, worker – a person who has it all together. Yet I am hearing you tell me over many sessions now how you are struggling to juggle everything and meet all your obligations to your high standards. I am also aware of how difficult it has been for you sometimes to even tell me how hard it is.”
“True,” Sandy acknowledged, “people don’t really see the real me. Maybe I don’t let them. It would not have been a good experience in my family to really acknowledge times when I was scared, lonely, sad, or even angry. It either would have been ignored, or I would have been made to feel guilty about it.”
A pleasant emotions vignette
As they worked through the module, they got to the part where Sandy was invited to focus on how she was creating pleasant emotions for herself, to counterbalance negative ones. After thinking for a moment, she offered that she tried to delay her lunch as long as possible at work, with the idea that, as she felt hungrier and hungrier, she began to feel more virtuous, or like a “good girl” in terms of her eating. This, she thought, may have helped to balance out negative emotions being generated by having to deal with her chronically critical, unpleasant colleague.
The therapist looked at Sandy quizzically. “Do you meant to tell me,” he asked, “that your typically most pleasant emotion in the day is the hungry feeling when you need to eat and don’t? Really?” The therapist made an irreverent face.
Laughing, Sandy acknowledged that it didn’t always work that well, because she felt crabby and “foggy” in the brain at the steep end of the hunger. Yet the end of the day, after work, was still a very busy time, even with the tutor’s help and her husband occasionally coming home in time to front the dinner duty. Sandy came up with two options: (1) she could take her lunch to a beautiful nearby park, eating it there to refresh and calm herself; (2) she could plan to treat herself to 20 minutes (more if she could get it) of non-work-related pleasure reading in the evenings. Doing it right before bedtime would help her calm down and ease into sleep in a positive frame of mind. Before the therapy there simply hadn’t been time, but even after hiring the tutor and re-negotiating cooking with her husband, Sandy realised that her overactive sense of duty had her engaging in more domestic tasks right up to bedtime. This she now vowed to re-balance. She told the therapist, however, that a part of her still felt like she was “weak” and “giving in” when she needed to take time just for pleasant things.
Sessions 13 – 18: Distress tolerance module
During the final skills module, the program called for Sandy to learn distress tolerance skills, comprised of Acceptance and Crisis survival skills, to help her cope with painful emotions arising from circumstances and events that could not be changed in the moment. Acceptance skills are about learning to accept one’s situation from a place deep within oneself. These included Observing your breath, Half-smiling, using Awareness of experience exercises, Radical acceptance, and Burning your bridges. Crisis survival skills, meanwhile, involve the techniques of Distracting, Self-soothing, Improving the moment, and Pros and cons: the deliberate consideration of using DBT skills to tolerate the distress versus maladaptive behaviours, such as bingeing/purging.
Acceptance skills vignette
After Sandy had been taught the Acceptance skills, she had an incident at work in which her grumpy, critical colleague again chided her for something that was clearly not her fault, saying that Sandy wasn’t “up to the job” because she hadn’t sent a crucial email to the ad director in time for him to get the information to the client. In the past, Sandy would have felt humiliated, hard done by, and angry, although she would not have shown her anger. This time, she merely remarked calmly that she would re-send the email (which had been sent on time originally) to the ad director so that he could deal with whatever fallout resulted from the client, as his office was where the problem had occurred. Sandy used her Half-smiling skill while in the large open-plan office where the colleague had publicly criticised her (again!). She then returned to her office and quietly spent four minutes calming herself down by using her Observing your breath skill; for the first time, she genuinely accepted that her colleague was probably not going to change, and that if Sandy wanted to continue in the job – which she did – she would have to accept this egregious behaviour. Other colleagues later told her that she had looked empowered and unfazed by the criticism; how did Sandy do it, they asked? Later, Sandy proudly told her therapist that these two skills (aided, no doubt, by her other colleagues’ admiration) had been so effective that she didn’t even have the urge to binge/purge, let alone did she engage an episode.
Crisis survival skills vignette
Sandy, unlike many DBT clients, did not lurch from crisis to crisis. Hers was a life that was outwardly successful, albeit privately a struggle to maintain. But toward the end of her therapy program one crisis occurred which saw Sandy calling on all of the Crisis skills she had learned. In the early evening, Sandy got a call from the hospital that Jones had been in an accident on the way home from work. He’d been taken to the Accident and Emergency Department and was in a medically-induced coma for injuries sustained; his car was totalled. Sandy quickly got the tutor to agree to stay and look after the children until she could get back: all night, if necessary. Although feeling a rising sense of panic, she had the presence of mind to grab her favourite art book and her headset so that she could look at calming, beautiful art images and listen to music and/or guided relaxations on her phone (Self-soothing skills) while she waited to hear news of her husband.
She flew to the hospital and sat quietly soothing her visual and auditory senses. She also used Improve the moment skills by interspersing the Self-soothing skills with conscious relaxation practice and prayer. At times, she merely mindfully focused on her breath, using Diaphragmatic breathing and other Observing your breath exercises. Despite all that, it was a long night before her husband was wheeled out of the surgical theatre, groggy but – they said – certain to make a full recovery, although there would be a considerable period of rehabilitation. During her next session (the one on skills review), Sandy triumphantly related that, although the urge to wander down the corridor to the hospital’s 24-hour cafeteria/snack bar was strong at times, she had mostly resisted the urge, buying only a healthy sandwich to eat for her dinner: no bingeing at all!
Sessions 19-20: Review of skills and planning for the future
Sessions 19 and 20 saw Sandy and her therapist reviewing previous skills, especially the more recent distress tolerance skills. They then moved forward with future planning: in particular, working out how to help Sandy avoid a relapse to bingeing/purging behaviour. The emotions which Sandy found the most difficult to tolerate were the sense of powerlessness and humiliation, resulting in deep shame and anger (particularly when she believed people were not hearing her or were being unjust). Thus, these were the emotions that most needed a plan in order for her not to relapse into bingeing because she experienced them and didn’t know how to deal with them. When the therapist asked Sandy what skills she planned to use to deal with each of these, here is how she responded.
In general terms, Sandy commented that – as much as she had fought them in the beginning – the diary card and behaviour chain analysis tools were useful. She said that she would be photocopying and completing the diary card every day; the card also listed all the skills she had learned, so she could review the list each time she needed to see which skill would work out best in a given situation. Whether she completed the behaviour chain analysis or not in a written form, she vowed to study the template for it whenever she became aware of an urge to binge, or actually did so, so that she could discern the prompting event and work in future to better manage situations that led her into bingeing/purging. And lastly for general skills, Sandy realised how much the Mindfulness skills had given her, and knew that – no matter what came at her in life – she would continue to practice those daily, in various ways. In terms of the specific emotions, Sandy had evolved a few “favourite” tools.
Humiliation, resulting in shame (and sometimes anger)
With these emotions, Sandy realised that her past experiences, mostly in her family, had resulted in a persisting inner conflict that tended to generate humiliation: on the one hand, she deeply desired to be seen and heard, but on the other, she feared being seen in a way that would make her look “bad” or not be a genuine reflection of her “real” self. Thus, when unjustly attacked, she had frequently found it difficult to maintain her composure, rebut the attack, and think calmly and logically. Rather, she would collapse into shame, but given that this often was not valid (as with attacks from her colleague), she would generate the secondary emotion of anger. Prior to her training, she could not even identify and label these emotions. After it, she got better and better at doing it in the moment – rather than later on after an incident – so that she could use her DBT skills in the moment.
And what skills did she most want for this? Half-smiling worked a treat immediately, conveying a sense of serenity even in the face of criticism. Then, as soon as possible afterwards, Sandy would begin to use Observing your breath. Diaphragmatic breathing was especially helpful to her. With a cheeky flick of her hair, Sandy also named Alternate rebellion as a skill which would help her deal with anger; she had finally come to agree with the therapist that, when those feelings of resentment crept in, she was a bit of a rebel anyway, so it was better to be conscious about employing the skill. It had worked well in her marriage, and Sandy eventually began to see ways to use it at work.
Powerlessness
Sandy recalled that her mother’s narcissism often led her to feel like there was no way to break through to get her mother to notice her. The resulting sense of powerlessness became a more generalised response to many situations in life. Realising that she did have tools and strategies at her disposal to create a more just, bearable situation for herself, Sandy now undertook to be mindful of skills such as Alternate rebellion, Building positive experiences (so that people and situations wouldn’t get under her skin as much), and Building mastery. As part of this last skill, Sandy declared that she would be practicing Tai Chi in earnest now; she had begun it some time ago, but abandoned it because of all her other duties. Its calming effects on her, plus the fact that it improved her flexibility and balance, led Sandy to believe that mastery in this art would not only help her to feel an overall sense of empowerment, but also allow her to maintain an equilibrium on other levels of life.
And the Distress tolerance skills were at the top of Sandy’s list for managing to feel empowered, or at least not incapable of coping, in deeply distressing situations, such as her husband’s accident had been. Sandy could see the wide transferability of the Self-soothing and Improve the moment skills she had relied on that night.
Outcome of treatment
Sandy had thanked her therapist profusely at the last session, feeling simultaneously glad to be finished with a very demanding therapy, slightly anxious about whether she could continue to use the skills as necessary, and deeply grateful for what the program had taught her. At the end of treatment, Sandy weighed in at 56 kgs (123 lbs), having gained a kilogram (2 lbs) over the course of the 20 sessions. For her 1.63m (5’4”) height, that meant a new BMI of 21.1 instead of 20.7: still closer to the lower end of normal weight than the higher end. Sandy was – surprisingly to herself – ok with that, in that the 52 kg (115 lbs) “lowest” weight now looked, in light of all she had learned, like a goal weight that wasn’t worth all the hassle, near-starvation, and problems of bingeing/purging.
As to that target behaviour, Sandy had managed to bring the bingeing/purging episodes under control, so that by the seventh session, she wasn’t doing them anymore; she maintained that abstinence throughout the program. At six-month follow-up, Sandy reported that she had had a couple of intense emotionally-charged incidents at work, and had succumbed to objective bingeing followed by purging on two occasions: one at the three-month mark, and one a month later. While she had had several subjective or small binges early in the follow-up period – for which she did not purge – Sandy was increasingly skilled at getting food into herself before she was too hungry, and then knowing when she had had enough. She felt cautiously optimistic about not capitulating to these, and very optimistic that she could avoid “objective” binge/purge episodes in future. In summary, Sandy saw her DBT program as life-changing, commenting that both Jones and her work colleagues had noticed a new spring in her step.
Case Questions
Some of the questions posed by this case are below. Take a few minutes to read them and think about what you believe the answers should be before going on to the analysis.
- Was DBT an appropriate therapy for Sandy? Why or why not?
- This was DBT: dialectical behaviour therapy. What do you see as the main dialectics in Sandy’s case?
- How severe would you rate Sandy’s BN as being? Why? What factors do you need to take into account?
- Would you consider Sandy to be co-morbid with any other mental health conditions? Why or why not?
- What commitment strategy/strategies was the therapist using in Session 1: first, when he noted that Sandy kept bingeing/purging, despite the acknowledged negative impacts, and second, when he noted that BN is a hard thing to overcome, and perhaps she should re-consider giving up the bingeing/purging? Did you notice any other commitment strategies on the part of the therapist?
- The therapist asks Sandy if some of her mindless eating might be related to a sense of resentment that – even though she works fulltime like her husband – Jones gets out of a lot of domestic duties. Sandy at first rejects the notion that she may be experiencing resentment. What, if anything, in Sandy’s personality or life circumstance might make it more difficult for her to identify emotions such as resentment? How do the DBT skills aim to overcome this tendency?
- Given what you know of Sandy’s story, which DBT skills would seem to be the most useful? How many of these does Sandy prioritise? What other skills might be useful for her (which she may have used, but we are not told about)?
- What do you see as the prognosis for Sandy’s long-term healing from BN? Do you believe that she will be able to achieve and maintain abstinence? Why or why not?
Case Analysis
Was DBT an appropriate therapy for Sandy? Why or why not?
To answer this question, we can look both to specific aspects of Sandy’s situation and also to general similarities of those with BN to DBT’s original population of borderline clients. First, Marsha Linehan originally founded DBT because she noticed how the cognitive behavioural therapies mostly utilised for borderline clients were engendering feelings of invalidation in them. Already feeling invalidated by their early life experiences – and thus highly vulnerable to emotional upset – such clients did not take kindly to being told that they needed to change; they often perceived situations and events as more stressful than non-borderline clients would, and tended to react with a lot of emotional intensity, taking a long time to return to their baseline emotional levels. The notion of dialectics came into play, in that the therapist could extend unconditional positive regard (i.e., “You are ok and I accept you just as you are”) while also noting that, if the client were willing to make some changes, they could have a higher quality life. Sandy’s situation of a workaholic father and hypochondriac, narcissistic (so self-obsessed) mother – plus having five siblings – meant that she was invalidated not by abuse, but by virtue of neglect: no one in the family really saw her. Sandy also recognised that she was easily upset emotionally and that the effects of an upset would linger with her.
Both borderline clients and those with eating disorders tend to be prone to anxiety, depression, and other mood disorders. This was true for Sandy, too, although her depressive symptoms were subclinical, somewhat situational (being post-partum), and were resolved by a stint of counselling.
Understandably, many borderline clients, through poor-quality relationships in their early environment, were unable to see modelled the flexible, appropriate strategies for dealing with relational and other life problems that would have enabled them to respond effectively themselves. Likewise, Sandy’s “absent” parents (father through overwork and mother through illness/narcissism/caring for multiple siblings) meant that she would rarely have been able to observe or participate in effective relating or problem-solving, so all those heightened emotions would not have easily been discharged. The resulting emotional dysregulation – and concomitant lack of means to deal with it – led Sandy, as many borderline clients, to escape those same emotions through maladaptive behaviours: frequently cutting or self-harming for borderline clients, but equally long-term damaging bingeing/purging episodes for Sandy.
In the adaptations of DBT that have been created for various non-borderline client populations, it is sometimes recommended that clients come to DBT after they have tried a more traditional therapy (say, CBT) and had that fail them. This was Sandy’s situation, as she had attended counselling earlier and relieved her depressive symptoms through it, but the therapy did nothing to alleviate her BN behaviours. The capacity of DBT to challenge maladaptive thinking, as CBT does, but also include validation of the client – and then transcend those polar opposites in a higher-level dialectical resolution, seems made to order for someone like Sandy. With her over-the-top daily schedule, the mindless eating would seem to be almost inevitable, so the mindfulness exercises that are foundational to DBT also made it a most appropriate therapy for her.
This was DBT: dialectical behaviour therapy. What do you see as the main dialectics in Sandy’s case?
We can defend both DBT-typical dialectics and also some that are more specific to Sandy. Regarding the typical DBT dialectical considerations, we can note that, just as borderline clients want to be accepted for how they are at the present moment and yet acknowledge that they are unhappy and may need to consider changing, so too was Sandy propelled into the DBT program because of the worsening bingeing/purging, yet the prospect of change was frightening. She acknowledged the dialectical nature of her stance that, with BN, she could “have my cake and eat it, too” (that is, many things about it worked in the short term) and yet she was also holding the opposing reality of worsening health and relationships with an increasingly grim long-term outlook. She would eventually resolve these dialectically using some of the skills from Radical acceptance and Loving your emotions, as she learned to accept that she had to quit bingeing/purging, and that to do it, she would need to come into relationship with her emotions (“loving” them).
Similar to the reactions of borderline clients who are asked to stop making suicide attempts or substance abusers who are asked to immediately abstain from their liquor or drug of choice, Sandy first said that yes, she wanted to commit to having no more bingeing/purging episodes, but then was aghast to be told that the most recent episode was to be her last: that she was expected to abstain immediately. The dialectic here goes something like, “I must stop doing this”, but also “I can’t stop now”.
We can recall that the point of setting out opposing realities for traditional DBT clients is so that they can be dialectically resolved: that is, the two seeming polar opposites can be reconciled at a higher level, in which each of the sides is acknowledged for its kernel of truth. This is true, too, in DBT for eating disorders. The clinician here utilises the notion of dialectical abstinence to elicit and strengthen the client’s commitment to change. This says, “You must commit unreservedly now to abstaining permanently from this behaviour AND if you fail, I will help you to pick up the pieces and re-commit.” There is an understanding that, although clients may commit with the best of intentions, life and mistakes happen, and the client is still accepted by the therapist if that happens.
How severe would you rate Sandy’s BN as being? Why? What factors do you need to take into account?
At intake, Sandy reported that she had had 14 objective or large binges and 10 subjective or small ones in the last 28 days (24 total), after which she had purged on 20 of the occasions. Thus, she had had a total of 20 bingeing/purging episodes, or on average, 5 per week. The DSM-5-TR states that, for it to be classified as BN, the bingeing and compensatory behaviours must occur at least once a week, and be happening for at least three months (Sandy reckoned that hers had been going on at that level for around two years). She met the criterion for sense of lack of control during a binge episode. As to severity, the DSM-5-TR states that an average of 1 – 3 episodes per week is considered mild; 4 – 7 episodes per week would be deemed moderate, and 8 – 13 per week would be severe, with 14 or more episodes per week classified as extreme.
The DSM states that one may also increase the severity grading in the presence of other factors or functional disability. Thus, if a client were not only vomiting, but also engaging other compensatory behaviours, such as overusing laxatives or diuretics; fasting; and/or exercising excessively; or the person were markedly disabled in their life in a functional sense; the grading could be made higher than what would be reflected in only the number of bingeing/purging episodes in a week. Considering only the bingeing/purging, Sandy would be seen to have had “moderate” BN. When we consider other compensatory behaviours or functional disability, however, we do not need to upgrade the severity rating. At least as far as we are told, Sandy did not use laxatives or diuretics. With her schedule, any exercise was welcome; she was in no position to overdo it. And she was coping – albeit with struggle – with her job, her children, and her overall life, so upgrading Sandy’s severity rating due to “functional disability” was not warranted.
Would you consider Sandy to be co-morbid with any other mental health conditions? Why or why not?
Sandy reported at intake that she had had counselling for post-partum depressive symptoms, and that these had been deemed subclinical at the time: that is, not severe enough to warrant diagnosis as “major depressive disorder”. The symptoms had resolved following on from the counselling. Over the course of the DBT program, Sandy herself came to appreciate the formerly unrecognised role that intense emotion had been playing in her life. But while emotional dysregulation is the common denominator in DBT for both borderline and other client populations, it is not in itself considered to be a diagnosable mental health condition (i.e., listed in the DSM). In fact, Sandy’s therapist was happy to accept her onto the program, as it was still in fairly early stages of development when she went through it, and having a client without co-morbidities was “cleaner” in the sense of being able to discern the effect of the program on the actual eating disorder, as opposed to having an additional condition confounding results.
What commitment strategy/strategies was the therapist using in Session 1: first, when he noted that Sandy kept bingeing/purging, despite the acknowledged negative impacts, and second, when he noted that BN is a hard thing to overcome, and perhaps she should re-consider giving up the bingeing/purging? Did you notice any other commitment strategies on the part of the therapist?
When the therapist held up the dialectic for Sandy’s consideration that she was, on the one hand saying that bingeing/purging had to go, but on the other hand she was still doing it, he added that there must be some advantages to her in continuing to do it. In saying this, he was attempting to elicit/strengthen her commitment via the skill of Pros and cons: considering both the advantages and disadvantages of a maladaptive behaviour versus the upside and downside of using DBT skills. Once Sandy had stated the advantages (namely, that it reduced tension, relaxed her, and allowed her to eat what she wanted without gaining weight), he was able to move to a second commitment strategy: that of Devil’s advocate, which he utilised in his follow-up remark that, clearly, it had some real “pluses” in the short run; maybe she shouldn’t be trying to give it up now? This was successful, in that it elicited a definite “No!” from Sandy, whereupon she detailed the downsides of it (aspects such as the health consequences, the loss of energy and motivation, and the bad breath); all of this moved her closer to full commitment.
When the therapist demanded that Sandy commit to the most recent bingeing/purging episode being her last and she baulked (saying that she couldn’t just stop it now and that she was afraid to commit because she might fail), the therapist used a modified Door in the face strategy (when a clinician initially makes a very big demand and then appears to concede ground) to clarify that no one can predict the future. Rather, she was being asked to commit right then, right there, in that moment to no more bingeing/purging. Sandy agreed that she could commit then and there in that moment.
The therapist asks Sandy if some of her mindless eating might be related to a sense of resentment that – even though she works fulltime like her husband – Jones gets out of a lot of domestic duties. Sandy at first rejects the notion that she may be experiencing resentment. What, if anything, in Sandy’s personality or life circumstance might make it more difficult for her to identify emotions such as resentment? How do the DBT skills aim to overcome this tendency?
To understand the dynamic here, we must remind ourselves that emotions become dysregulated in the first place because they are invalidated, not accepted: usually in the person’s family of origin. Sandy had remarked that in her family any strong display of feelings – whether it was sadness, loneliness, anger, or something else – would either have been ignored, or she would have been made to feel guilty. She definitely did not feel “allowed” to have most emotions, especially intense ones. Like many others struggling with emotion regulation, all that emotion needs to be addressed somehow. So borderline clients may cut themselves, substance misuse clients get drunk or high, and those with BED (binge eating disorder) and BN are likely to have an episode of bingeing/purging, or at least some form of mindless eating.
Consequently, given that almost no strong emotions were accepted in Sandy’s family, it is highly unlikely that a “negative” emotion such as resentment would have been allowed to surface. We can imagine the guilt induction that might have occurred: “You feel resentful? You should be grateful for all we’ve done for you” or “Resentful? What is wrong with you; you have a great life!” And Sandy readily acknowledged that she did have (mostly) a great life. But at a very basic level, we can understand some part of her asking, “Why, when Jones and I both work full time, am I expected to take care of all the domestics as well as putting in a full work day? Why is it that he can come home (albeit a bit later) and just plop on the sofa?” Yet the part of her that demanded very high standards for everything she did may have felt like she was “weak” or “not coping” – possibly not a good wife, mother, or worker – if she acknowledged how challenging it was to meet all the obligations. And feeling guilty is miserable, so the resentment went “underground”, from where it drove mindless eating and bingeing.
The DBT module of Emotion regulation seeks to help people identify and label their emotions. The skills in the module teach clients to “love” their emotions, even (or especially?) the “negative” ones such as anger and resentment, as they serve a purpose. Indeed, Sandy came to recognise that resentment’s purpose was to alert her to an unworkable situation that needed to be re-negotiated if she was going to have a high-quality life.
Given what you know of Sandy’s story, which DBT skills would seem to be the most useful? How many of these does Sandy prioritise? What other skills might be useful for her (which she may have used, but we are not told about)?
Sandy, in conjunction with her therapist, seemed to get a reasonable handle on her needs as she moved through the program. Once she understood the reasons for the diary card and behaviour chain analysis, she was faithful in completing them; she reflected at the end of the program that these had been invaluable. Paying attention to her breathing – as in both Diaphragmatic breathing and the Observing your breathing exercises – came to her aid multiple times: both after incidents with her hostile colleague and when her husband was in the hospital.
In terms of the Emotion regulation skills, she could perhaps have prioritised exercises for Loving your emotions, Reducing vulnerability, and Building mastery more than she did (although she may have done so and it was not reported on by her therapist). Perhaps Opposite-to-emotion action would be useful in future for dealing with people such as her critical colleague, or in other situations when Sandy would be unjustly criticised and want to either collapse in shame or explode in anger.
Sandy made good use of the Distress tolerance skills, employing Half-smiling and Observing your breath after the incident with her colleague. Likewise, she found she could use Self-soothe and Improve the moment skills while awaiting word on Jones’s condition in the hospital. We are not told if Sandy employed the skill of Radical acceptance in this situation or not. That would have been a good circumstance in which to use it, but the fact that she was able to even employ the Self-soothe skills with a modicum of calm speaks to at least a degree of acceptance of what happened.
Finally, while Mindfulness skills – the foundation of the other DBT skill sets – are implicated in most of the skills that Sandy utilised well, she may be able to use more of them consciously as she gains increasing mastery of the DBT skills. For example, she could choose to eat more than one meal a day mindfully. She could practice Mindfulness exercises while driving or doing domestic tasks (such as the dishes), and she could use Urge surfing to forestall capitulation to binge-eating/purging episodes after the program. Finally, if she finds that her determination to stay binge/purge-free decreases, she could boost her motivation and commitment by re-engaging the Burning your bridges exercise, perhaps even doing this at a follow-up “booster” session with her therapist.
What do you see as the prognosis for Sandy’s long-term healing from BN? Do you believe that she will be able to achieve and maintain abstinence? Why or why not?
Because Sandy had ceased bingeing/purging by Session 7 out of 20 and because she had only two episodes of that behaviour during a six-month follow-up period (i.e., an average of one every three months), the chances are good that Sandy will succeed in leaving behind this health- and quality-of-life-threatening condition. At the start of the program, Sandy already had some self-discipline, as evidenced by her ability to juggle her many roles (albeit at high cost to herself). In conjunction with the increase in self-awareness and understanding of how disordered eating works which she gained through the program, Sandy was in a strong position to be able to maintain abstinence from mindless emotional eating, especially bingeing-purging, indefinitely. Moreover, she went into the post-program period weighing only a kilogram (two pounds) more than when she was vomiting up a good portion of her food, so concern with weight increases did not need to push her toward maladaptive behaviours. The therapist later remarked that Sandy was a joy to behold in her blossoming self-confidence toward the end of the program. He really believed her when she said, “Yup. I’m done with throwing my life up and away!
This case study was extracted from Mental Health Academy’s course, Dialectical Behaviour Therapy: Case Studies. This course – a case study companion to Dialectical Behaviour Therapy for Eating Disorders, Dialectical Behaviour Therapy for PTSD, and Dialectical Behaviour Therapy for At-risk and Suicidal Adolescents – explore how DBT has been employed to support two undergoing life-changing therapy programs.
References
- American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). American Psychiatric Publishing.
- Fairburn, C.G., & Cooper, Z. (1993). The Eating Disorder Examination (12th Ed.). In C.G. Fairburn & G.T. Wilson (Eds.), Binge eating: Nature, assessment, and treatment (pp 317-360), New York: Guilford Press.