Title: The Application of Dialectical Behavior Therapy to Eating Disorders
1The Application of Dialectical Behavior Therapy
to Eating Disorders
- Melissa Freizinger, Ph.D.
- Laurel Hill Inn, Medford, MA
2Objectives for Today
- Briefly outline of Dialectical Behavior Therapy
(DBT) basics. - Explain how ED behaviors fit into the DBT
framework. - Discuss case examples for each DBT module and the
applicable DBT skills. - Discuss barriers to use of DBT skills.
- QA
3What is DBT?
- A comprehensive treatment approach that was
developed by Marsha Linehan for the treatment of
people with borderline personality disorder (BPD)
and parasuicidal behaviors also including self
injurious behaviors.
4What is DBT (continued)
- DBT is an empirically - supported treatment.
- DBT is based on biosocial theory of emotion
dysregulation model of symptoms and theory of
invalidating environments. - DBT utilizes a complete array of cognitive and
behavioral techniques. - DBT incorporates acceptance-based philosophies
and strategies, primarily Zen Buddhism practices,
in the context of a dialectical philosophy.
5The Dialectics of DBT Therapy
- Is the tension between promoting change (behavior
therapy) and acceptance (Zen).
6A Dialectical View of Our Patients
- Balancing Acceptance,
- Validation, and Change
- We know you have suffered a great deal and your
life is really terrible right now, but you must
work harder to recover
Validate the Valid Understand and
Accept Validation is not agreeing dont
validate the invalid
7Why DBT for ED Patients?
- Comorbid BPD and parasuicidal behaviors are
common among patients w/EDs. - Suicide is one of the leading causes of death in
patients w/AN. - Many patients with EDs engage in high risk
behaviors. - Substantial numbers of patients w/EDs are
refractory to front line treatments. - DBT is a concrete and cost effective treatment.
- People with eating disorders often have the same
type of issues with managing overwhelming
emotions.
8Traditional DBT Treatment
- Individual Psychotherapy
- Group Skills Training
- Team Consultation
- Telephone Consultation
9Integrating DBT into Therapy
- Balance change with acceptance.
- Therapist must have strong, positive relationship
with patient. - Therapist responsible for helping patient replace
maladaptive behaviors with skillful adaptive
behaviors. - Orient client to DBT and elicit commitment to
therapy and collaborate on goals for treatment.
10Possible DBT Solutions
- Solve the problem.
- Change your emotional reaction to the problem.
- Tolerate the problem.
- Stay miserable.
- Make things worse.
11Treatment Hierarchy
- Target One
- Life Threatening Behaviors
- Target Two
- Therapy Interfering Behaviors (anything that
threatens the continuation of therapy) - non-compliance
- Target Three
- Quality of Life Interfering Behaviors
(inconsistent with a meaningful life) - Substance abuse or housing problems
- Employment issues
- Target Four
- Increasing Behavioral Skills to facilitate a life
worth living
You can set treatment goals for each of these
targets but you always focus on resolving the
highest target before moving on to another target.
12DBT Four Modules
- Acceptance Skills
- 1. Mindfulness
- 2. Distress Tolerance
- Change Skills
- 3. Emotional Regulation
- 4. Interpersonal Effectiveness
DBT is effective because it breaks down complex
concepts into teachable skills that patients can
understand and access when in crisis.
13Behaviors treated by DBT Skills
- 1. Mindfulness inability to identify cues of
hunger and satiety, mindless eating - 2. Distress Tolerance impulsivity, anxiety,
tolerating re-feeding, using ED to manage
emotions - 3. Emotional Regulation labile or no affect,
inability to identify emotions - 4. Interpersonal Effectiveness interpersonal
chaos, saying no, asking for help, passivity
14DBT can be helpful to
- Increase
- Structured eating
- Awareness of hunger/fullness
- Non-judgmental approach toward food and body
- Skill use when emotionally dysregulated
- Decrease
- Unstructured eating
- Food avoidance
- Food/body obsessions
- Judgments about weight, shape, appearance
- Compensatory behaviors
- Use of ED to cope with difficult emotions
15Mindfulness
- Mindfulness means paying attention in a
particular way on purpose,in the present
moment, andnonjudgmentally. - Jon Kabat-Zinn
16Mindfulness Works in Tandem with the Other DBT
Skills
- Mindfulness is incompatible with ED behaviors
because one cannot be mindful and engage in
behaviors that decrease affect. - Patients become mindful of their avoided emotions
and self-judgments. - Mindfulness provides a framework for teaching the
difference between thoughts, emotions, and the
values of each and prepares patients to use
other DBT skills.
17Three Primary States of Mind
Wise Mind is the integration of Reasonable Mind
and Emotion Mind
Emotion Mind emotions Override logical
thought And control thinking
Reasonable Mind devoid of emotion, emphasizes
use of logic
18Mindfulness Skills
- The What Skills
- Observe
- Describe
- Participate
- The How Skills
- Non-judgmentally
- One-mindfully
- Effectively
- States of Mind
Emotional mind
Rational mind
Wise mind
19Mindfulness Applied
- Examples
- Im so full. Im gross.
- Thats it, Im going on a 10 miles run!
- When my Dad says Why dont you just eat - I
want to restrict more.
- DBT Skills
- Describe non-judgmentally
20MINDFULNESS HANDOUT 2
Taking Hold Of Your Mind "What"
Skills Observe Just notice the experience without
getting caught in the experience. Experience
without reacting to your experience.Notice what
comes through your senses your eyes, ears, nose,
skin, tongue. Describe Put words on the
experience. Describe to yourself what is
happening. Call a thought just a thought, a
feeling just a feeling. Don't get caught in
content. Participate Enter into your experience.
Let yourself get involved in the moment, letting
go of ruminating. Do just what is needed in each
situation - neither willful nor sitting on your
hands.
21Distress Tolerance
- Goal of DT to help patients tolerate pain and
accept life as it is in the moment rather than
using impulsive behaviors. - Four sets of crisis survival skills are taught
- Distracting
- Self-soothing
- Improving the moment
- Pros and cons
- Acceptance skills are taught radical acceptance,
turning the mind willingness vs. willfulness.
22Distress Tolerance Applied
- Examples
- My mom told me I look healthy.
- Im going to restrict dinner tonight.
- Im gaining weight and I cant stand it!
- DBT Skills
- Managing crisis
- Distraction, Accepting Reality
- Distraction
23Distress Tolerance Handout 1
- Crisis Survival Strategies DISTRACT - Wise Mind
ACCEPTS - With ACTIVITIES
- With CONTRIBUTING
- With COMPARISONS
- With EMOTIONS (Opposite Emotions)
- With PUSHING AWAY
- With THOUGHTS
- With SENSATIONS
24Emotion Regulation
- Goal Emotion regulation skills focus on
improving control over emotions and learning
techniques for modulating emotions. - Skills
- Understand emotions
- Reduce emotional vulnerability
- Decrease emotional suffering
- Act opposite to painful emotions
- Identify and label emotions vs. hunger/fullness
- Increase pleasant activities
25Emotional Regulation Applied
- Examples
- Im so depressed I dont want to go to the
movies.
DBT Skills Changing Emotions by Acting Opposite
to Current Emotion
26Emotional Regulation Handout 10
- Changing Emotions by Acting Opposite to Current
Emotion - FEAR Do what you are afraid of doing....OVER AND
OVER AND OVER. - GUILT OR SHAME
- When guilt or shame is JUSTIFIED (emotion FITS
your wise mind values) Repair the transgression,
say you are sorry. - When guilt or shame is UNJUSTIFIED (emotion DOES
NOT fit your wise mind values) Do what makes you
feel guilty or ashamed....OVER AND OVER AND OVER.
- SADNESS OR DEPRESSION Get active, approach,
don't avoid. Do things that make you feel
competent and self-confident. - ANGER Gently avoid the person you are angry with
rather than attacking them (Avoid thinking about
him or her rather than ruminating).
27 Interpersonal Effectiveness
- Goal To help patients learn to use their voice
rather than using their ED behaviors to become
socially effective. - Skills
- Obtaining changes one wants while maintaining the
relationship and self-respect - Negotiating conflict
- Asking for what one needs
- Assertiveness and saying no
- Dealing with interpersonal conflict
- Staying emotionally regulated while in conflict
28Interpersonal Effectiveness Applied
- Examples
- I need to ask my school for a leave of absence
to get treatment and Im scared. - My roommate posted on her Facebook page that I
have an eating disorder! - My husband thinks Im in recovery but Ive
relapsed.
- DBT Skills
- Situations for Interpersonal Effectiveness,
Getting What You Want - DEARMAN
29Interpersonal Effectiveness Handout 8
- Guidelines for Objective Effectiveness Getting
What You Want DEAR MAN - DESCRIBE Describe the situation when necessary -
stick to the facts and no judgmental statements - EXPRESSExpress feelings/opinions about the
situation clearly. - ASSERT Assert your wishes. Ask for what you want
or say no clearly. - REINFORCE Reward people who respond positively
to you when you ask for something, say no or
express an opinion. - STAY MINDFUL 1. Broken Record 2. Ignore
- APPEAR CONFIDENT Use confident tone of voice
confident physical manner. - NEGOTIATE Be willing to give to get Offer and
ask for alternate solutions.
30Structuring the Session
- First address Target One issues
- Burning issues? (yours and mine)
- Homework Review
- Summarize
- Goal Setting
- Homework
31Barriers to Treatment
- What do you do if your client rejects the skill?
1. Commitment and Motivation work with patient
- What are you willing to do? 2. Refer to
Possible DBT solutions. 3. Play devils advocate
to engender counter argument from patient It is
really difficult to change Maybe now is not
the time..
32Q A
33Resource list
- Cognitive-Behavioral Treatment of Borderline
Personality Disorder. Marsha Linehan. The
Guilford Press. (May 14, 1993). - http//behavioraltech.org
- Skills Training Manual for Treating Borderline
Personality Disorder. Marsha M. Linehan. The
Guilford Press. (May 14, 1993). - Dialectical Behavior Therapy in Clinical
Practice Applications across Disorders and
Settings. Linda A. Dimeff, Kelly Koerner. Marsha
M. Linehan (Foreword). The Guilford Press.
(August 14, 2007). - Dialectical Behavior Therapy with Suicidal
Adolescents. Alec L. Miller, Jill H. Rathus,
Marsha M. Linehan. The Guilford Press (November
16, 2006). - Helping Teens Who Cut Understanding and Ending
Self-Injury. Michael Hollander. The Guilford
Press. (June 10, 2008). - The High Conflict Couple A Dialectical Behavior
Therapy Guide to Finding Peace, Intimacy,
Validation. Alan Fruzzetti, Ph.D. (Foreword-
Marsha M. Linehan). New Harbinger Publications.
(December 3, 2006). - Dialectical Behavior Therapy Workbook Practical
DBT Exercises for Learning Mindfulness,
Interpersonal Effectiveness, Emotion Regulation,
Distress Tolerance. Matthew McKay, Jeffrey C.
Wood, Jeffrey Brantley. New Harbinger
Publications. (July 2007). - Depressed and Anxious The Dialectical Behavior
Therapy Workbook for Overcoming Depression
Anxiety. Thomas Marra. New Harbinger
Publications. (May 2004).