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

remainder of the time to illustrate with metaphors and stories, to rein— force, or simply to rephrase those key points.
    At the end of the session, therapists should clarify and review the homework for the upcoming week. This involves describing homework sheets and making sure clients understand how to practice and record the skills. Then, during the session’s fnal minutes, a wind-down is offered. This involves a few minutes of practicing a specifc skill (e.g., diaphragmatic breathing).
    In conclusion, there is a great deal to cover in each session, with very little time to do so. Therapists must therefore be fexible, using skillful means to be effective rather than trying to be perfect. When necessary, therapists must be will— ing to give up making each and every point during instruction of a skill if the situation calls for spending more time on a client’s question. Alternatively, if the therapist feels the skills training will suffer as a result of omitting a point, the therapist might offer to discuss the question over the break. The idea is to always keep one’s eye on the prize—helping clients stop binge eating by teaching adaptive skills when emotions are dysregulated.

CHAPTER 3
    The Pretreatment Stage The Pretreatment Interview and Introductory Sessions T his chapter describes how the pretreatment stage is conceptualized and structured in DBT for BED or BN. The overall goals of this stage are to (1) orient the client to treatment, (2) obtain the client’s agreement to treatment, and (3) obtain the client’s commitment to abstinence from binge eating (and purging). In our research, this stage begins after we complete the diagnostic assessments and determine the client to be eligible for entry into the study.
    When treatment is conducted in a group format, the orientation stage includes (1) a pregroup pretreatment interview (conducted individually with each group member in the 1–2 weeks prior to the start of the group) and (2) introductory sessions conducted in the group format. In our research studies of 20 sessions, these introductory sessions usually are covered during the frst 2 weeks of treatment. When therapy takes place in an individual-session format, a pretreatment interview is also necessary. One of the goals of the pretreatment interview—obtaining a commitment to coming to treatment—is essential to establish before obtaining a commitment to stop binge eating and/or purging. The purpose of the next session, what we term the introductory session, is a more involved elicitation of a verbal commitment to stop binge eating (and purging). However, if constraints of a par— ticular clinic setting are such that a separate pretreatment session is not feasible, the pretreatment interview goals and materials may be combined in an initial session, with the commitment to treatment attendance a prerequisite to addressing the commitment to abstinence from binge eating (and purging). Nonetheless, it is our experience that separating the functions of the pretreatment and introductory material into distinct sessions is desirable when conducting treatment in an individual-session format, as this gives the therapist adequate time to underscore the importance of the commitments and the treatment without feeling rushed and potentially covering the material in a cursory fashion.
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The Pretreatment Stage
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THE PRETREATMENT INTERVIEW
    The pretreatment interview has a number of important and specifc goals. Usually requiring 30–45 minutes, it is not intended to replace a standard clinical intake (e.g., history of present illness, past psychiatric and medical history, social history) but is scheduled after such diagnostic assessment has been completed. The goals of the pretreatment interview are presented here and discussed in greater detail in the relevant subsections in this chapter, as well as in the case examples in Chapter 8.
    Goals of the Pretreatment Interview
    The seven goals of the pretreatment