Applying Dialectical

Behavioral Therapy to the

Treatment of Eating Disorders
Advanced Recovery Systems
CE Presentation Series
Friday, February 9th, 2018

Elizabeth Carges, PhD

Licensed Clinical Psychologist
Clinical Director, Orlando & Tampa Outpatient Treatment Programs
Center for Discovery
 Learning Objectives
• Identify four major DBT skills
• Understand why DBT is an appropriate treatment modality for
patients with eating disorders
• Learn methods to implement DBT skills within an eating disorder
treatment program or within individual therapy scenarios
Imagine a world where you could fully accept yourself and
simultaneously want to change and grow
• Imagine a treatment during which 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
 Outline

• Brief overview of three major eating disorders

• Brief overview of DBT
• Applying DBT to the treatment of eating disorders
 Eating Disorder Basics
General
• Genetics, environmental factors, co-occurring disorders,
medical complications and personality traits all combine to
create risk factors for the creation and maintenance of an
eating disorder
• Hard to treat
• Relapse is common
• CBT considered the “gold standard”
• What about DBT
• Can we make treatment better? Can we improve patient resiliency?
Can we decrease episodes of relapse?

http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/
 Three Most Common Presentations
• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder
 Anorexia Nervosa-Statistics

• Close to 1% of American women are diagnosed with anorexia in their

lifetime.
• 50-80% of the risk for anorexia is genetic.
• 33-50% of patients have a comorbid mood disorder, such as
depression.
• About half of anorexia patients have comorbid anxiety disorders,
including generalized anxiety disorder and and social anxiety
disorder.
• Obsessive-compulsive disorder
 Anorexia Nervosa: DSM-5
• 1. Restriction of energy intake relative to requirements leading to a
significantly low body weight in the context of age, sex, developmental
trajectory, and physical health. Significant low weight is defined as
weight that is less than minimally normal
• 2. Intense fear of gaining weight or becoming fat even though
underweight
• 3. Disturbance in the way in which one's body weight or shape is
experienced, undue influence of body weight or shape on self-
evaluation, or denial of the seriousness of the current low body weight
 Anorexia Nervosa-DSM-5 Subtypes
• Two subtypes:
• Restricting
• Low body weight and no history of binging or purging in the last three months
• Often co-morbid with depression and anxiety disorders and OCD
• Binge-eating/purging type
• Still characterized by restriction
• History of binging or purging in last three months
• May purge even small amounts of food consumed
• Modes: restriction, exercise, laxatives, vomiting
• Needs differential diagnosis with regard to deciding between this, Bulimia Nervosa, or
Purging disorder
• Mild, Moderate, Severe, or Extreme severity rating based on BMI
 Bulimia Nervosa-Statistics

• 1.5% of American women suffer from bulimia

nervosa in their lifetime
• Approximately half of bulimia patients have a
comorbid mood and/or anxiety disorder
• Patients can be of normal weight, above
normal weight, and sometimes are obese
• Nearly 1 in 10 patients with bulimia have a
comorbid substance abuse disorder, usually
alcohol use.
 Bulimia Nervosa: DSM-5
1. Recurrent episodes of binge eating characterized by BOTH of the following:
a. Eating in a discrete amount of time (within a 2 hour period) large amounts of food
that is definitely larger than what normal people eat
b. Sense of lack of control over eating during an episode
2. Recurrent inappropriate compensatory behavior in order to prevent weight
gain (purging, misuse of laxatives, excessive exercise, fasting).
3. The binge eating and compensatory behaviors both occur, on average, at
least once a week for three months
4. Self-evaluation is unduly influenced by body shape and weight
5. The disturbance does not occur exclusively during episodes of anorexia
nervosa
 Binge Eating Disorder-Statistics
• 2.8% of American adults suffer from binge
eating disorder in their lifetime
• Binge eating disorder affects women slightly
more often than men
• Estimates indicate that about 60% of people
struggling with binge eating disorder are female,
40% are male
• Approximately half of BED patients have
comorbid mood and/or anxiety disorders
• Nearly 1 in 10 BED patients have a comorbid
substance abuse disorder
• Binge eating may be as high as 25% in post-
bariatric patients
 Binge Eating Disorder: DSM-5

1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both

of the following:
• Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is
definitely larger than what most people would eat in a similar period of time under similar
circumstances
• A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop
eating or control what or how much one is eating.)
2. Binge-eating episodes are associated with:
• Eating much more rapidly than normal
• Eating until feeling uncomfortably full
• Eating large amounts of food when not feeling physically hungry
• Eating alone because of feeling embarrassed by how much one is eating
• Feeling disgusted with oneself, depressed, or very guilty
3. Marked distressed regarding binge eating is present
4. Occurs at least once a week for three months
5. Not associated with recurrent use of inappropriate compensatory behavior
 Overview of DBT
What is Dialectical Behavior Therapy?

• Dialectical behavior therapy (DBT)

provides clients with new skills to
manage painful emotions and decrease
conflict in relationships

• DBT is a cognitive behavioral treatment

developed by Marsha Linehan, PhD,
ABPP
• It emphasizes individual psychotherapy
and group skills training classes
 Overview of DBT

• DBT establishes a “dialectical” view, one that allows us to hold two mutually exclusive positions at
one time
• The opposite of all-or-nothing thinking
• “Dialectical” a synthesis or integration of opposites
• DBT therapists accept clients as they are while also acknowledging that they need to change in order to reach
their goals.
• All of the skills and strategies taught in DBT are balanced in terms of acceptance and change
• Two sets of acceptance-oriented skills (mindfulness and distress tolerance)
• Two sets of change-oriented skills (emotion regulation and interpersonal effectiveness)
 Overview of DBT
• The theory behind the approach is that some people are prone to
react in a more intense manner toward certain emotional situations:
• primarily those found in romantic, family and friend relationships
• DBT theory suggests that arousal levels for certain people, in such
situations can:
• increase far more quickly than the average person’s
• attain a higher level of emotional stimulation
• take a significant amount of time to return to baseline arousal levels
 Five Components of a Full DBT Program
DBT Skills Training

• There are four modules in skills training:

• Mindfulness: the practice of being fully aware and
present in this one moment
• Distress Tolerance: how to tolerate pain in difficult
situations, not change it
• Interpersonal Effectiveness: how to ask for what you
want and say no while maintaining self-respect and
relationships with others
• Emotion Regulation: how to change emotions that you
want to change
 Five Components of a Full DBT Program
DBT Skills Training (continued)

• DBT skills training focuses on enhancing clients’ capabilities by

teaching them behavioral skills
• Skills training is frequently taught in groups; the group is run like a class where
the group leaders teach the skills and assign homework
• The homework helps clients practice using the skills in their everyday lives.
• Groups meet on a weekly basis for approximately 2.5 hours, and it takes 24
weeks to get through the full skills curriculum, which is often repeated to
create a 1-year program
 Five Components of a Full DBT Program
Individual Therapy
• DBT individual therapy is focused on enhancing client motivation and helping clients to
apply the skills to specific challenges and events in their lives
• In the standard DBT model, individual therapy takes place once a week for as long as the
client is in therapy, and it runs concurrently with DBT skills training
Coaching
• Telephone coaching and other in vivo coaching to provide in-the-moment support
• Clients can call their individual therapist between sessions to receive coaching at the
times when they need help the most
• Goal is generalization of skills
 Five Components of a Full DBT Program
Case Management
• Case management strategies help the client manage his or her own life,
such as their physical and social environments
• The therapist applies the same dialectical, validation, and problem-solving
strategies in order to teach the client to be his or her own case manager
DBT Consultation Team
• The DBT consultation team is focused on the people who provide DBT,
including individual therapists, skills training group leaders, case managers,
and others who help treat the client or patient
• The consultation team is designed to help therapists stay motivated and competent
so they can provide the best treatment possible
• This is especially important when they are treating people with severe, complex,
difficult-to-treat disorders so the team can help one another manage burnout and
share their knowledge
 Applying DBT Skills to ED Treatment
• DBT Programs with all 5-components are hard to find
• Only a few DBT certified programs in Florida-closest one to Orlando is in
Tampa
• Not all programs offer all modes, either!
• When applied to the eating disorder population:
• Four main skills are taught with emphasis on examples pertaining to ED
 Applying DBT Skills to ED Treatment
• Mindfulness
• What does this food taste like right now? Texture? Flavor? Enjoyment of Taste?
• What can I do to intentionally live with awareness in this present moment?
• Distress tolerance
• What can I do right now, while I’m eating, to improve this moment? Conversation,
games, art, etc.?
• STOP Skill- Stop, Take a step back, Observe, Proceed Mindfully
 Applying DBT Skills to ED Treatment
• Emotion regulation covers strategies to manage and change
intense emotions that are causing problems in a person’s life.
• When I’m feeling frustrated at the table with my parents/spouse, how can I
communicate my emotions?
• What is my emotional range? What emotions do I frequently experience?
How do my emotions serve me?
• Interpersonal effectiveness consists of techniques that allow a
person to communicate with others in a way that is assertive,
maintains self-respect, and strengthens relationships.
• How can I get others to meet my needs without utilizing eating disorder
behaviors?
• How do I build healthy relationships and end destructive relationships?
 Why use DBT for ED?
• People with eating disorders often start off with dieting and then
realize that their weight-control behaviors also help to regulate
distressing emotions
• Obsessing about food, weight, and calories is a distraction from other
upsetting thoughts or worries
• Bingeing can be self-soothing and creates a numb feeling, and purging
relieves anxiety or other intense emotions
• Eating disorder behaviors may be individuals’ best efforts to care for
themselves
 Why use DBT for ED?
• We teach DBT skills to equip clients with new strategies to cope with
distressing thoughts and emotions
• We also target behaviors to reduce and use ‘behavior chains’ to
analyze what prompts and reinforces these behaviors
• This helps patients increase their awareness about how to change these
behaviors
 DBT for Eating Disorders-Logistics
• The ideal model will include both individual therapy and a weekly
skills training group
• Easy to implement in Residential, PHP, and IOP levels of care
• May be able to implement in private practice
• Overarching goal of DBT for eating disorders: reduce and eventually
extinguish life-threatening behaviors and keep patients out of the
hospital
• Any behavior that interferes with therapy is targeted early on so that
the patient may engage fully and safely on an outpatient basis
• Shorter lengths of stay mandates preparation for discharge from Day 1
 DBT for Eating Disorders-Logistics
• Teach skills (preferably in groups) every day
• Have staff do skills coaching with patients as needed
• Utilize individual therapy to reinforce motivation
and practice applying skills to personal and
challenging scenarios
• Patients fill in daily diary cards and homework
cards to track the target behaviors they are
working to reduce (e.g., bingeing, purging, over-
exercising, laxatives use, etc.)
• The diary cards also track their use of the skills
they’re striving to develop.
 DBT for Eating Disorders-Logistics
• Weekly therapy sessions are highly structured
• Include a mindfulness exercise and a review of homework and skills learned in
prior sessions as well as the teaching of a new skill for the week
• Not process-oriented therapy
• Processing of emotional material is contained to best use time developing
strategies to cope with whatever is coming up
• There is little focus on historical origins of the problem within that
session
• Rather, the interest is in managing one’s struggles right now
• Outpatient therapy or treatment program friendly
 DBT for Eating Disorders-Logistics
• Relative to the different therapies for eating disorders:
• DBT is most focused on developing a catalog of concrete skills and strategies
to use
• Purpose is to cope more effectively in day-to-day life AND reduce ED
symptoms, cycles, and behaviors
• Patients are given daily homework assignments to work on between
sessions/days/meals
• At times, patients may even be encouraged to reach out to the
therapist between sessions for coaching or support in accessing skills
• Depends on LOC and treatment infrastructure
 When and How to apply DBT for Eating
Disorders
• DBT is most effective when combined with other therapies to achieve
successful behavior change
• (for patients with eating disorders)
• Still need a combined, multidisciplinary approach, possibly including:
• Medication, CBT, nutrition therapy, process work, interpersonal group
therapy, experiential therapy, etc.
• Estimated 50% of patients with bulimia and BED fail to improve with
standard treatment methods
• When CBT alone does not resolve bingeing or binge/purge behaviors, DBT’s
focus on emotion regulation may be more promising.
 DBT for Bulimia and BED
• Most research to-date pertains to DBT
for Bulimia and BED
• Success in helping clients improve
emotional regulation and affect
• Decreases in binge and/or binge-purge
cycle behaviors
• DBT was developed to treat borderline
personality disorder, where individuals
struggle with chaotic emotions and
impulsive behaviors
• DBT translates more easily to people with
eating disorders who are struggling with
impulsive behaviors like bingeing and
purging,
• Relative to those with anorexia are
struggling with being rigid and controlling
their food and their emotions
 DBT for Bulimia and BED
• Individuals with more impulsive behaviors such as bingeing and/or
purging may embrace DBT skills more readily
• Patients usually experience behaviors like bingeing and purging as more
distressing than restriction
• Patients tend to be more motivated to learn skills that will help them
decrease binge and/or purge behaviors
• All eating disorder behaviors function as ways of coping; learning
alternative strategies to cope is key to extinguishing these behaviors.
 DBT for Anorexia?
• Traditional DBT was not specifically designed for the full
spectrum of thoughts and behaviors that make Anorexia
difficult to treat
• Adaptation is necessary
• Still, DBT offers much patients can connect with and
utilize
• Aspects of DBT that have proven useful in recent research
include mindfulness skills, interpersonal effectiveness, and
understanding the model of emotions as DBT explains it
• Facets of DBT can be used with patients with all types of
eating disorders,
• However, DBT should not be primary mode of therapy for an
outpatient client with anorexia
 DBT for Anorexia!
• Modified form of DBT developed by Thomas Lynch, PhD, called
“Radically Open Dialectical Behavioral Therapy (RO-DBT) that may be
of use to therapists treating anorexia
• New, evidence based treatment targeting a spectrum of disorders
characterized by excessive self control, often referred to
as overcontrol (OC)
 DBT for Anorexia!
• RO-DBT treatment involves both individual treatment
sessions and skills training classes,
• Centers around five OC themes:
• Inhibited and disingenuous emotional expression;
• Hyper-detailed focused and overly cautious behavior;
• Rigid and rule-governed behavior;
• Aloof and distant style of relating;
• High social comparison and envy/bitterness.
• Lynch continues to research the efficacy of this new model
with patients with anorexia
• 2 RCTs already completed; 2013 and 2014
 How can I Implement DBT for ED?
• DBT Skills Corner
• (or basket, or box, or treasure chest, or whatever works for your space!)
• Diary Cards
• Worksheets
• Get out of the “Processing” frame of mind
• At least while using DBT!
 DBT Skills Corner
DBT Skills Corner
• DBT skills corner in the milieu-based program can promote “in the moment skill
development” to supplement DBT skills base learned in psycho-educational
groups
• This enables clients to develop self-efficacy and autonomy in applying skills to in real-time
• Staff checks in at the beginning and at the end of this time
• Only exception is if client is at a 10;
• Staff may remain present for duration of time
• DBT Scale: 1-10
• Assist in linking to appropriate skill set on 10-point scale
• 7-10= Distract/ Distress Tolerance
• 4-6= Self-soothe
• 1-3= IMPROVE
 DBT Skills Corner
DBT Skills Corner
• Levels 7-10: Distress Tolerance
• Highly Stressful situations, triggering
events
• (e.g., Exposure Meal/Restaurant Night or
Family Therapy/Family Meal
• Utilize “Wise Mind ACCEPTS” activity
• Some activities include: “find it,” stress
ball, rip a phone book, frozen fruit
DBT Skills Corner
 DBT Skills Corner
Distress Tolerance Example Activities
• “Find it” Activity- There is hidden objects in the plastic capsule that is filled with small beads, and the goal of the ct.
is to find the objects hidden in the capsule. This activity takes their mind off of their stress in order to focus on the
current task
• Frozen Limes- Clients are to squeeze or scratch the limes. The texture, scent, color, and temperature of the fruit
collectively helps the client to focus on the “here and now”, a state of awareness that is encouraged in Dialectical
Behavioral Therapy
• Holding Ice- Clients can squeeze ice in their hands or throw it at an outside wall. The squeezing and throwing of ice
stimulates a physiological effect that takes the client’s focus away from their ruminating thoughts and emotions and
directs it towards the sensation of the coldness in their hands
• Scream into a pillow- This activity helps to expend a client’s stored up physical energy that result from their intense
emotions
• Stress Balls/bean bags- By expending physical energy, the activity of squeezing soft balls relieves intense emotions
that are stored up within a client’s body
• Silly Putty- Silly putty is a great exercise in mindfulness. It offers endless possibilities for sculpting and manipulating
its shape, while also providing the client the opportunity to sooth him or herself through feeling its unique texture.
Similarly to stress balls, it expends physical energy to relieve a client’s intense emotions
• Ripping up Phone Books- Ripping up phone books is a particularly helpful outlet in relieving anxious or angry
emotions because it expends the adrenaline produced by anxiety or anger
• Etch a sketch- This activity draws attention away from intense emotions and to a detailed task of creating a picture
 DBT Skills Corner
DBT Skills Corner
• Levels 4-6: Self-Soothe
• Become aware of and sooth 5 senses
• Grounding
• Some activities include: aromatherapy,
sand-tray, art books, make a playlist
DBT Skills Corner
 DBT Skills Corner
Self-Sooth Skills
• Aromatherapy/Scents- Engaging the sense of smell allows a client to distract themselves from self perceived crises situations that are
causing them distress or emotional dysregulation. Gives a client the opportunity to shift their attention away from their current distressing
or dysregulated emotion to a new memory or emotion.
• Walk Barefoot- This activity allows clients to be mindful of their feet—which literally and figuratively grounds the client’s physical and
emotional state.
• Dry Lentils/container of rice- Clients can play with dry lentils or rice. The firm rounded texture of the lentils or smooth surface of rice can
soothe the client’s current jagged emotional state.
• Feet in pool- A client can put their feet into the pool for sensual stimulation. Being in water increases dopamine and norepinephrine levels,
which reduces a client’s state of stress and anxiety.
• Relaxation CDs- Here is a description if you do: A client can calm their visual and audio senses in watching a video and consequently quiet
their current dysregulated emotional state.
• Create a Playlist- We often tie music to memories. This distracting task of putting together inspirational songs can help clients to recall
happy times, or when they went through difficult times and how they got through them.
• Pool Waterfall/Being Around a Fountain- The sound of water can sooth a client’s current emotionally dysregulated state.
• Art Books- Looking through different photos or pieces of art allows clients to focus on beauty rather than their distressed emotional state.
It can also trigger different nostalgic memories, bringing clients to a more positive state of mind.
• Deep Breathing- This exercise helps clients by taking a deep breath and stepping away from their current emotional state. It slows their
heart rate and decreases physiological arousal associated with intense emotions.
 DBT Skills Corner
DBT Skills Corner
• Levels 1-3: Improve the Moment
• In the moment mood-regulation
• Some activities include: Buddha
Book, Magnetic Poetry, Card-
making/writing, Positive
affirmations
DBT Skills Corner
 DBT Skills Corner
Improve the Moment
• Playing Cards- This is a distracting activity and provides a goal for clients to be working towards (for example, the goal may be winning a game of
solitaire). It can also encourage social connection by requiring the client to invite others to play card games with them.
• The Buddha Board- This is a mindfulness activity in which one starts by drawing a picture on the Buddha board. The picture will slowly erase and
during that time one can practice other mindfulness activities.
• Magnetic Poetry- Clients can create poetry sentences with cut out magnetic words. This creates an opportunity for clients to express their
emotions through a constructive and calming activity.
• Reading Entry Letter- When clients first come into treatment they will write a letter to themselves explaining their current attitude towards
treatment and their goals. Reviewing their original thoughts and goals helps clients to recognize how far they have come since their admission.
• Sandbox- Clients can use the sandbox to sift sand between their hands or to draw pictures. This technique is utilized to distract clients from their
current state of emotion, or to express their distress through sculpting.
• Quote Books- Clients can read through quotes from different inspirational figures and authors to encourage them through difficult times when
they are experiencing intense emotional dysregulation. These quotes can provide clients inspiration and guidance.
• Write a letter/card- This activity provides clients the opportunity to reach outside of themselves and encourage another individual in their life.
Shifting the attention from oneself onto another can alleviate distress and emotional dysregulation while also encouraging another who may be
experiencing similar feelings.
• YouTube Videos- Watching movie clips can provide inspiration and guidance for clients during distressing or emotionally disturbing times, while
also giving clients insight about their current state or how to constructively handle their emotions.
• Affirmation Cards- Clients can encourage others by providing affirmation or words of advice. This takes away a client’s distress or emotional
dysregulation by shifting the client’s focus away from oneself and focusing on another.
• Word Searches- Clients can exercise their brain through engaging in word games or searches. Such stimulation benefits clients by strengthening
their cognitive functioning and helping them to focus on problems solving rather than ruminating on negative or distressing emotions.
Diary Card Example
Homework Skills Card Example