DBT in the Treatment of Eating Disorders

Imagine a world where you could fully accept yourself and simultaneously want to change and grow – where you could accept where you are in the recovery process but still be encouraged and hopeful for change. These seemingly opposite ideas can exist in union when applying the principles of dialectical-behavioral therapy or DBT. At its premise, DBT establishes a “dialectical” view, one that allows us to hold two mutually exclusive positions at one time – a fresh perspective for many who typically engage in black-or-white thinking.

What Is DBT?

DBT, or dialectical behavioral therapy, is a type of therapy that was developed by Dr. Marsha Linehan, to help patients reduce emotional reactivity and improve how they think and interact with others. DBT is a blend of cognitive behavioral therapy (CBT) and some useful sound bites from eastern philosophies (primarily Buddhism). The therapy was originally designed to help those who struggle with borderline personality disorder and chronic suicidal feelings. However, dialectical behavioral therapy can also be useful in treating patients with other difficulties, including eating disorders.

DBT Eating Disorder Treatment

Dialectical behavioral therapy encourages change but also promotes acceptance – of patients themselves and where they currently fall in the recovery process. The dialectical view appeals to many as they navigate recovery – they can accept their difficulties and work toward changing them. Patients learn to avoid either/or thinking (e.g., “I’m either recovered or I’m stuck with this eating disorder forever”) which can help them challenge other all-or-none thinking typical of an eating disorder.

Learning New Skills

Many who struggle with eating disorders will acknowledge they often use symptoms to cope with emotional distress. DBT offers a skill-based approach toward healthier ways of coping with emotional triggers that might precipitate eating disorder symptoms.

Dialectical behavioral therapy teaches patients four broad sets of skills, including mindfulness, distress tolerance, emotion regulation and interpersonal effectiveness. Mindfulness skills include learning how to make decisions based on both emotional and rational input (referred to as using one’s “wise mind”) and reducing judgmental thinking. Distress tolerance helps patients gain skills for coping with crises, such as distraction and self-soothing. Emotion regulation teaches them to identify different feelings, as well as how to make themselves less vulnerable in the first place to extreme shifts in emotions. Interpersonal effectiveness involves the mastery of assertiveness techniques, including asking for help and the often challenging task of saying “no” to others.

What Does the Research Say?

Research studying the effectiveness of dialectical behavioral therapy for disorders like anorexia and bulimia has been promising, though additional, larger-scale research is needed.

In a 2001 study, participants with binge eating disorder who participated in dialectical behavioral therapy experienced a significant decrease in symptoms, with 89 percent symptom-free when the study concluded and 56 percent symptom-free six months later. In a similar study, this time looking at those diagnosed with bulimia, results showed a significant reduction in symptoms following treatment with DBT.

Researchers have also, more recently, studied the use of dialectical behavioral therapy with a small sample of adults diagnosed with anorexia nervosa. The results were encouraging, showing associations between DBT and increased BMI, evident even at six and 12-month follow-ups. A study examining the impact of DBT on women with anorexia nervosa or bulimia nervosa found that DBT was associated with increased emotion regulation and a meaningful reduction in eating disorder symptoms.

Finally, a recent study examined the combined effect of DBT with Family-Based Treatment (FBT) in adolescents with bulimia nervosa. Results showed that the combined treatment led to a significant reduction in binge/purge episodes.

How Does It Work?

Many eating disorder treatment centers offer dialectical behavioral therapy along with other forms of treatment and some patients will pursue DBT treatment in outpatient settings. Dialectical behavioral therapy is typically provided in a group setting; those who work with individual DBT therapists have an opportunity to hone in on the skills they learn in group and focus on practical application of skills in their lives.

Patients commonly report benefiting from the solution-focused nature of DBT, enjoying the opportunity to leave sessions with concrete skills in their emotional and behavioral toolboxes. Patients who are in psychodynamic therapy, and even those who are learning cognitive behavioral therapy, often struggle with knowing what to do in moments of distress. These are often the times when they might want to engage in eating disorder symptoms. With DBT, patients can use the skills they’ve learned to cope with emotional challenges, potentially helping them to avoid behaviors like binging and purging.

Case Studies

Let’s look at DBT in action. We’ll start with Angela, a 23-year-old woman with anorexia nervosa, binge-eating/purging subtype. Angela went to residential treatment for six months, when, with the help of her family and outpatient team, she realized that her eating disorder was no longer manageable on an outpatient basis. In treatment, Angela learned a couple of DBT skills that she found particularly useful. She often had specific difficulty with meals at the center, especially early on. One of the DBT skills she enlisted at this time was “Opposite Action,” which as it sounds, involves acting in direct opposition to your emotional experience. When greeted with a plate full of food, Angela experienced significant distress and wanted to restrict. Countering her distress, she chose to take some deep, calming breaths, practiced gratitude for the meal in front of her and the opportunity to recover, and used this frame of mind to work her way through the meal. Another DBT skill that Angela benefitted from was “Radical Acceptance.” As Angela began to weight-restore, she struggled, as many do, with body image distress. Her prior self would have engaged in self-attack, made promises to restrict, or would have schemed to start purging her meals. Now, in order to cope with this distress, she practiced “Radical Acceptance.” One day, as she was sizing up what she could of her body as she brushed her teeth, she found her critical voice ready to pounce. Instead, she caught herself in this moment and practiced Radical Acceptance by telling her body – even though she didn’t really believe it at the time – “I will love and accept you through this process.” Angela made a commitment to reframe all body bashing with this promise, and over time, her inner dialogue, along with her consequent moods, began to shift.

Now take the case of a Javier, a 42-year-old man with binge eating disorder. He first encountered DBT during a several-month-long stint at a local intensive outpatient program. Javier described a chronic pattern of emotional overeating, with binges occurring several times a week, sometimes daily. Javier reported that learning DBT was helpful in reducing his binge episodes through various mechanisms. First, mindfulness techniques help him become more aware of physical versus emotional hunger, as well as what emotions he was experiencing in the moment. He realized that he often ate when he wasn’t physically hungry but out of sadness and frustration. From skills in the emotional regulation module, Javier learned how better to insulate himself against emotional distress. Behaviors like taking his medications regularly and getting enough sleep helped buffer him against unnecessary emotional waves. Javier found the distress tolerance skills especially helpful since before treatment, he had coped with distress primarily with food. Some of his new go-to self-soothing skills included going for a walk or calling up his nieces/nephews, which always seemed to provide a good distraction. Javier found that if engaged in one of these skills, the urge to binge would often pass by the time he was done. Finally, Javier had learned that a significant trigger for his binges was feeling unappreciated by others. Through the interpersonal effectiveness module, Javier mapped out an approach for how to ask his boss for a raise, a conversation that had previously intimidated him. Initiating this conversation – and getting a well-deserved raise – helped him to feel respected and more in control of his life, which also seemed associated with a reduction in his binge episodes.

As you can see from these examples, learning DBT skills can be a helpful adjunct to other forms of eating disorder treatment. DBT skills can help patients navigate difficult emotions and situations and cope more smoothly with the process of recovery.

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About The Author:

This article was written by Dr. Stacey M. Rosenfeld, a psychologist located in Coral Gables, Florida. Dr. Rosenfeld specializes in eating disorders and addictions.

Additional Reading:

Astrachan-Fletcher, E. & Maslar, M. (2009). The Dialectical Behavior Therapy Skills Workbook for Bulimia: Using DBT to Break the Cycle and Regain Control of Your Life. Oakland, CA: New Harbinger.

McKay, M., Wood, J.C., & Brantley, J. (2007). The Dialectical Behavior Therapy Skills Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation & Distress Tolerance. Oakland, CA: New Harbinger.

Written – 2016