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.