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K. Michelle Hunnicutt Hollenbaugh
Texas A&M University- Corpus Christi
Overview of DBT
Intro to DBT & Eating Disorders
Treatment targets and behavior chain analysis with eating
behaviors
Specific DBT skills for disordered eating behaviors
Developed by Marsha Linehan (1993)
A multifaceted, cognitive-behavioral approach that includes aspects of mindfulness practice, behaviorism and dialectics.
Originally developed for clients with Borderline Personality Disorder
Now used transdiagnostically with clients struggling with various disorders
Helps clients gain insight and skills to manage their thoughts, emotions, and behaviors
DBT therapists balance validation and change
Change is constant, there are no absolutes
Two seemingly conflicting ideas or view points can both be
true
There are several modes of treatment in standard DBT: Individual therapy
Addresses target behaviors
Skills training groups Mindfulness
Interpersonal Effectiveness
Emotion Regulation
Distress Tolerance
Between session skills coaching Promotes skills generalization and reinforces skill use
Consultation team Support for counselors, maintains treatment fidelity
Researchers believe many eating disordered behaviors are
related to an inability to effectively regulate emotions
DBT targets emotion dysregulation and its symptoms
Individuals who struggle with eating disorders are more likely
to struggle with other DSM-5 diagnoses. They are also more
likely to struggle with life threatening behaviors.
DBT may be well suited to help clients who are considered
“treatment resistant”
Address eating disorders in addition to full DBT
Clients who struggle with NSSI/suicidal thoughts and eating disorders
Add DBT in addition to current eating disorder treatment Clients who are not responding to traditional eating disorder
treatments, and/or struggle with NSSI/suicidal thoughts
Implement full DBT for Stage 2 clients who wish to address quality of life interfering behaviors Clients who are not struggling with life threatening
behaviors
Biological Predisposition for Emotional
Sensitivity/Reactivity
Invalidating Environment
Pervasive Emotion Dysregulation
Biological Predisposition for Emotional
sensitivity AND nutritional vulnerability
Invalidating Environment
(includes media)
Disordered Eating Behavior
(pervasive emotion dysregulation)
DBT INTERVENES
CUE EMOTION DYSREGULATION
AVOIDANCE OR ESCAPE
Binging/Purging/Restricting
TEMPORARY RELIEF
Teach skills on how to regulate emotions and
reduce vulnerability to cues
Teach how to stop the
behavior; which stops
reinforcement
DBT teaches how to avoid or
distract without disordered eating
Stage 1
Decrease life-threatening behaviors
Decrease therapy interfering behaviors
Decrease quality of life interfering behaviors
Increase behavioral skills
Stage 2
Decrease post-traumatic stress
Stage 3
Individual goals
Stage 4
Finding Freedom and Joy
Binge eating & Purging
Mindless Eating
Over exercising
Being underweight
Restricting
Preoccupation with food, urges, and cravings
Capitulating
Apparently Irrelevant behaviors
Behaviorism is central to DBT
Each problem behavior is evaluated via a behavior chain
analysis
Client and counselor work together to identify steps that lead
to the disordered eating behavior
Create a new chain leading to use of skills and effective
emotion regulation
Problem Behavior (Disordered Eating Behavior)
Prompting Event
Vulnerabilities
Consequences
Thoughts, feelings, actions, or beliefs that led up to the
disordered eating behavior
New Behavior
Thoughts, feelings, actions (skills used), or beliefs that
will lead to the new behavior
Complete the Behavior Chain Analysis based on a client you
have worked with or might work with. Choose one behavioral
treatment target and practice working through the behavior
chain.
Feel free to ask questions!
Over structured eating vs. no eating plan at all
No activity vs. over-activity
Apparent compliance vs. active defiance
Client will commit to abstaining from disordered eating
behaviors permanently, AND the client commits to reducing
them when they do occur
This synthesis of two seeming conflicting ideas will allow
flexibility for the client during treatment to completely
abstain from these behaviors, while also working to reduce
them when they do occur.
WISE MINDREASONABLE MIND EMOTION MIND
Binge eating/purging/restricting comes from emotion mind
Mindful Eating
clients are encouraged to be acutely aware of every bite they are
taking, and to slowly savor the flavors, smells, and textures of their
foods. By engaging in this practice regularly, clients will be better
able to use their mindfulness skills to be aware of their eating
behaviors, and avoid dialectical dilemmas such as over-structured
eating vs. no structure to eating at all
Urge Surfing
Common in many other treatment approaches
Clients are taught to be aware of the urge, experience it as an ebb
and flow, and in that awareness remind themselves that the urge
will pass
Alternate Rebellion (Effectively)
Rebellion among clients with eating disorders takes the form of
engaging in binging/purging or restricting behaviors in order to
fight against treatment, family members, society, or the therapist.
the goal is to help clients validate their urge to rebel, but do so in
a manner that is not harmful and does not include engaging in
eating disordered behaviors.
Burning your bridges
Invites the client to engage in radical acceptance regarding the
idea that they will “burn the bridge” to binging and purging
behaviors.
Evaluating the Pros and Cons
In DBT for eating disorders, this is completed on an index card at
the very beginning of treatment, and reviewed daily
Get in a small groups.
In your group, work through the pros and cons of engaging in
a specific behavior related to eating disorders. Have someone
right down the groups’ responses for each. What are the
benefits of doing this? What challenges do you foresee?
Next Meal or Snack Rule
In traditional DBT, clients must wait 24 hours after engaging in a
behavior to contact the clinician
This may be too long for clients struggling with eating disorders-
and is shortened when specifically targeting disordered eating
behaviors
For Clients to Create Their Own Diary Card:
Go to www.dbtselfhelp.com
In the menu on the left, click “Everyday DBT” and then click
“extras”
Decide which version of the diary card you wish to use, then click
“printer friendly version” for it to begin download into a word
document
Once it has downloaded, make your changes, save, and print!
“DBT skills diary”
“DBT diary card and skills app”
Questions?
Thank you!
Federici, A., & Wisniewski, L. (2013). Dialectical behavior therapy for clients with complex and multidiagnostic eating disorder presentations. In L. H. Choate, L. H. Choate (Eds.) , Eating disorders and obesity: A counselor's guide to prevention and treatment (pp. 375-397). Alexandria, VA, US: American Counseling Association.
Linehan, M. M. (1993a). Cognitive-behavioral treatment for borderline personality disorder. New York: The Guilford Press.
Linehan, M. M. (2015). DBT Skills training manual (2nd ed.). New York, NY: Guilford Press.
Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eating and bulimia. New York, NY, US: Guilford Press.
Wisniewski, L., & Ben-Porath, D. D. (2015). Dialectical behavior therapy and eating disorders: The use of contingency management procedures to manage dialectical dilemmas. American Journal Of Psychotherapy, 69(2), 129-140.
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