Dialectical behavior therapy (DBT) for eating disorders

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What is dialectical behavior therapy?

Dialectical behavior therapy (DBT) is a type of “talk” therapy, based on cognitive behavior therapy (CBT), that has been adopted for treating people with eating disorders. The goal is to identify and change self-destructive behaviors--including those seen in people with eating disorders--while also pushing for a positive change.

DBT was originally developed to help patients with borderline personality disorder, which is a disorder that commonly occurs alongside eating disorders. It has since been adapted by the eating disorder treatment community as a great tool in their treatment, especially with patients who are emotionally dysregulated. 

The term “dialectical” comes from the idea of how two opposing things could both be true. In DBT for eating disorders, the focus is on balancing change with acceptance, two seemingly opposing therapy strategies. However, DBT teaches patients that achieving both of these goals together is possible.

During DBT, your therapist will work with you to accept yourself as you are and also motivate you to change negative behaviors.

How to treat eating disorders with dialectical behavior therapy

How are eating disorders treated with dialectical behavior therapy?

Dialectical behavior therapy uses emotional regulation to treat eating disorders and is considered by some to be a good alternative to CBT. 

The goal of DBT is to work toward reducing eating disorder behaviors--like purging and bingeing--that provide temporary relief from negative emotions or feelings of vulnerability. (4) A DBT therapist works with patients to cope with negative emotions more healthily.

During DBT sessions, the therapist uses a balance of acceptance and change techniques:

Acceptance techniques

Acceptance techniques place a focus on understanding the self and making sense of why a person might engage in certain eating behaviors.

An example of an acceptance technique is coping statements, which are meant to remind people there are some things you can’t change. It’s not meant to undermine a personal situation, it’s simply a way to let go of negative thoughts and feelings. Examples of coping statements include:

  • I can’t change what happened in the past
  • The present moment is the only one I have control over
  • Even though my emotions are uncomfortable, I will get through it
  • I accept this moment for what it is

Change techniques

Change techniques teach how to replace harmful behaviors with helpful ones. This may involve challenging unhelpful thoughts and encouragement to find new methods of dealing with stress. 

One such technique is distress tolerance, which teaches how to get through rough patches without turning to potentially harmful coping techniques. 

In times of crisis, a person may binge and purge to deal with tough emotions and stress. This may make someone feel better temporarily, but is not a good coping mechanism for the long run. Distress tolerance skills can help a person:

  • Self-soothe by relaxing and using mindfulness to feel more at peace
  • Distract themselves until they feel calm enough to deal with the situation

What to expect in dialectical behavior therapy

DBT can vary between treatment providers, but, usually, a DBT course includes the following types of sessions: (4)

DBT pre-treatment

Prior to beginning treatment, a patient may be offered an assessment to determine how suitable DBT is for them. This assessment may include learning about the DBT model and how it works in treating those with eating disorders. 

Individual therapy

Individual therapy typically involves weekly one-on-one hour-long sessions with a DBT therapist. Typical goals include:

  • Keeping a patient safe by reducing potentially harmful eating behaviors, such as restriction, purging, and bingeing
  • Working on behaviors that interfere with therapy
  • Helping a patient reach personal goals and address the issues that affect their quality of life. This is not limited to eating behaviors. It also includes other mental health issues, like depression or things in a patient’s personal life, such as work, financial, or relationship problems.
  • Teaching new skills to replace unhelpful behaviors triggered by negative emotion

As an example, you may leave sessions with homework, such as being given diary cards that will be discussed at your following appointment. The diary cards are used to track your emotions, to help identify patterns and triggers for your destructive eating behaviors. 

The information on your diary cards is used by you and your therapist to decide what you’ll work on in each session.

Group skill training

Usually, two therapists lead weekly sessions intending to teach you skills in a group setting that you can implement in your everyday life. 

Generally speaking, DBT sessions focus on four main skills modules:

  • Mindfulness: A set of skills that brings your attention to the present, rather than focusing on negative thoughts. Practicing mindfulness tunes our thoughts into what we are sensing in the present moment rather than rehashing the past or worrying about the future.
  • Distress tolerance: Learning to deal with stress or crises without resorting to harmful behaviors, like purging, binging, restricting food, over-exercising. Distress tolerance will help you build up skills for tolerating stress, and stressful situations. 
  • Interpersonal effectiveness: Developing the skills to ask for things and to say no when necessary, while retaining respect for yourself and others. This may involve things like learning how to properly set and maintain boundaries, or learning how to have healthier relationships with others. 
  • Emotional regulation: Learning to understand and be aware of your emotions, so you can have better control over them. The idea that “thoughts are not facts” will come into play here. Emotional regulation can help people learn to communicate with words instead of reacting through emotion. 

You might also be asked to do group exercises and engage in some role-play. Plus, you’ll be given homework each week to help you practice your DBT skills.

Telephone crisis coaching

A DBT course often offers telephone crisis coaching to provide you with support between sessions, like when you need help to deal with an immediate crisis or want advice on how to properly use your DBT skills.

Evaluating dialectical behavior therapy as an effective eating disorder treatment

Regardless of your diagnosis, DBT may not be the right treatment option for you. DBT is more likely to work if:

  • You want to make positive changes
  • You’re ready to look to your present and future, instead of focusing on the past
  • You feel able to attend group sessions.

That being said, in the right patients, researchers have found that DBT is effective regardless of a person’s sex, gender identity, sexual orientation, age, race, and ethnicity. (5)

What are the benefits of DBT?

DBT can improve relationships

With group sessions, DBT provides you with a good support network to help you overcome your challenges. DBT helps you form healthy relationships - with respect and trust - which can be beneficial way beyond treatment.

The social skills developed in DBT can be carried through to your current relationships, by helping define boundaries and developing trust.

The skills are transferable

The skills taught during a DBT course not only improve the symptoms of people living with an eating disorder but can also be applied to many other areas of life too, including at work, home, and play.

DBT can boost your quality of life

Acceptance is a key part of moving forward and improving your overall quality of life. DBT encourages you to make positive changes, but to also accept that it’s okay to find things difficult at times.

The disruptive emotions felt by many people with eating disorders can have a significant impact on their quality of life. Distress tolerance and emotional regulation skills can help in managing and gaining control over these feelings.

What are the limitations of DBT?

Not effective on it’s own

DBT is not effective on it’s own as an eating disorder treatment. Instead it will form part of a multidisciplinary approach, which includes nutrition education and counselling, psychiatry, and medical interventions if necessary.

Big time commitment

Completing DBT is a big time commitment. It requires attendance to multiple sessions a week and you’re expected to complete homework on a regular basis. 

Efficacy of dialectical therapy in healing eating disorders

The rationale for using DBT to treat people with eating disorders has been described comprehensively through scientific research. The primary hypothesis is that DBT would benefit people with eating disorders by addressing the emotional dysregulation that commonly triggers eating behaviors, such as purging, restricting, and binge-eating. (6)

While a lot of the research has been positive, the majority of the studies conducted on DBT have looked at treating people with bulimia nervosa (BN) and binge-eating disorder (BED). (2) For example studies have shown that DBT has resulted in meaningful changes in the behaviors associated with BN and BED, including a reduction of binge eating episodes. (3,8)
Research into DBT as a treatment for anorexia nervosa (AN) is much more limited. However, Kroger et al. (2010) (7) discovered a 33% remission rate in people with a comorbidity of AN and borderline personality disorder (BPD) after an inpatient DBT program.

Dialectical behavior therapy at Within Health

Our clinical care team at Within Health believes DBT is an effective way to treat patients with eating disorders, particularly those struggling with interpersonal relationships, or emotion dysregulation. Within Health incorporates DBT into our virtual treatment programs, with specific DBT sessions and groups. We offer a DBT skills group that teaches the four categories of skills aimed to enhance the regulation of emotion and improve relationships. We also use a trauma-informed approach to treatment, as we understand the significant role trauma can play in the development of an eating disorder. 


If you are looking for a DBT approach to your eating disorder treatment, or are interested in learning more about our virtual treatment modalities, call our clinical care team today. Our clinical team will work with you to craft the right program for your specific needs.

Disclaimer about "overeating": Within Health hesitatingly uses the word "overeating" because it is the term currently associated with this condition in society, however, we believe it inherently overlooks the various psychological aspects of this condition which are often interconnected with internalized diet culture, and a restrictive mindset about food. For the remainder of this piece, we will therefore be putting "overeating" in quotations to recognize that the diagnosis itself pathologizes behavior that is potentially hardwired and adaptive to a restrictive mindset.

Resources

  1. Wisniewski L, Ben-Porath DD. Dialectical Behavior Therapy and Eating Disorders: The Use of Contingency Management Procedures to Manage Dialectical Dilemmas. Am J Psychother. 2015;69(2):129-40.
  2. Susan Cowden, M. S. (2020, February 18). Can dialectical behavior therapy help treat your eating disorder? Verywell Mind
  3. Lammers, M.W., Vroling, M.S., Crosby, R.D. et al. (2020) Dialectical behavior therapy adapted for binge eating compared to cognitive behavior therapy in obese adults with binge eating disorder: a controlled study. J Eat Disord 8, 27 
  4. Mind. Dialectical Behavior Therapy (DBT)
  5. Van Dijk S, Jeffrey J, Katz MR. A randomized, controlled, pilot study of dialectical behavior therapy skills in a psychoeducational group for individuals with bipolar disorder. J Affect Disord. 2013;145(3):386-393.
  6. Wisniewski L, Kelly E. The application of dialectical behavior therapy to the treatment of eating disorders. Cognitive and Behavioral Practice. 2003;10:131–138
  7. Kröger C, Schweiger U, Sipos V, Kliem S, Arnold R, Schunert T, Reinecker H. Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up. J Behav Ther Exp Psychiatry. 2010 Dec;41(4):381-8. 
  8. Telch, C. F., Agras, W. S., & Linehan, M. M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69, 1061-1065

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