Dialectical Behavior Therapy for Eating Disorders

Caucasian women talking in group therapy
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There are many choices when deciding which type of therapy to seek for an eating disorder. One type of therapy you might be offered is dialectical behavior therapy (DBT).

DBT is a specific type of cognitive-behavioral treatment. It was developed in the late 1970s by Marsha Linehan, Ph.D. to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD). It is now recognized as the treatment of choice for this population. In addition, research has shown it is effective for a range of other mental disorders including substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.

The word "dialectical" means that in DBT, therapists and clients work hard to balance change with acceptance, two seemingly opposing forces or strategies. For example, when undergoing dialectical behavior therapy, your therapist will work with you so that you both accept yourself as you are, and are also motivated to change.

DBT Requires Five Components

Full adherent DBT treatment requires five components:

1. DBT Skills Training

DBT skills training usually occurs in a group format run like a class during which group leaders teach behavioral skills and assign homework. The homework helps clients practice using the skills in their everyday lives. Groups meet on a weekly basis, and it takes 24 weeks to get through the full skills curriculum.

Skills training consists of four modules:

  • Mindfulness: the practice of being fully aware and present in the moment
  • Distress Tolerance: how to tolerate distressing feelings
  • Interpersonal Effectiveness: how to express one’s needs and set boundaries to build healthy relationships
  • Emotion Regulation: how to change emotions that you want to change

2. Individual Therapy

DBT individual therapy focuses on increasing client motivation and helping clients to apply the skills to challenges and events in their lives. Individual therapy usually takes place once a week for as long as the client is in therapy, and it runs simultaneously with DBT skills training.

3. Coaching to Ensure Generalization of Skills

DBT uses telephone coaching to provide in-the-moment support. The goal is to coach clients on how to use their DBT skills to effectively cope with difficult situations that arise in their everyday lives. Clients can call their individual therapist between sessions to receive coaching at the times when they need help.

4. Structure the Environment with Case Management

Case management strategies help the client learn to manage his or her own life, such as their physical and social environments.

5. DBT Consultation Team to Support the Therapist

The DBT consultation team provides critical support to the different team members who provide the various aspects of the DBT treatment, including individual therapists, skills training group leaders, case managers, and others who help treat the client or patient.

Other Forms of DBT

There are also many therapists who use DBT skills in individual therapy with clients. Some therapists also may offer a standalone DBT skills-training group. However, any of these components alone are not true or fully adherent DBT treatment. These individual elements of DBT treatment may still be beneficial but may not be as helpful as receiving all five components of the treatment. Dialectical behavior therapy has also been adapted for use in residential and inpatient treatment settings.

Does Dialectical Behavior Therapy Work for Eating Disorders?

Although cognitive-behavioral therapy (CBT) has proven effective for many patients with eating disorders and is usually recommended as the first line of treatment, it does not work for everyone. This has led researchers to look for other treatments that may work for patients who do not respond to CBT. Specialists in eating disorders who learned about DBT drew an analogy between the function of eating disorders, behaviors in eating disorder patients and the function of self-injury in borderline personality disorder patients. Both types of behaviors tend to provide temporary relief from negative emotions. Thus, teaching patients how to regulate and manage effect makes sense.

The results have been promising as the treatment does appear effective in slowing or stopping problematic behaviors in eating disorders. However, most of the research that has been done hasn't compared dialectical behavior therapy to other treatments (or to no treatment at all).

The one study that compared DBT to active comparison group therapy for binge eating found no real differences—both treatments worked equally well.

Most of the studies conducted on dialectical behavior therapy looked at treating people with binge-eating disorder and bulimia nervosa, not anorexia nervosa.

Who Should Try Dialectical Behavior Therapy?

Given the current research on dialectical behavior therapy and eating disorders, it is likely to be most helpful for people suffering from bulimia nervosa or binge eating disorder. It is also likely to be helpful for clients who are suffering from borderline personality disorder and/or intense emotions in addition to an eating disorder. DBT is typically more intensive, more costly, and longer-term than individual outpatient treatment such as CBT, and so is not usually used as a first-line treatment. It may be an excellent option for patients who have not made improvements with CBT or other individual psychotherapies, and who struggle with binge eating episodes clearly triggered by negative emotions.

DBT skills training can be an effective adjunctive treatment for individual therapy for eating disorders. Some of the skills that a person with an eating disorder might work on in dialectical therapy include practicing more mindful eating, learning to identify triggers, and improving responses to negative emotions or stressors.

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By Susan Cowden, MS
Susan Cowden is a licensed marriage and family therapist and a member of the Academy for Eating Disorders.