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DBT for Eating Disorders (Dialectical Behavior Therapy) - Dr. Ellen Astrachan-Fletcher

By Ellen Astrachan-Fletcher, PhD, FAED, CEDS-S

Dialectical Behavior Therapy (DBT) is a therapeutic treatment created for those who struggle with emotional dysregulation. The main goal of DBT treatment is to help an individual create a life they want to be present in. Dialectical Behavior Therapy also endeavors to teach patients with eating disorders a number of valuable life skills.

Dialectical Behavior Therapy (DBT) is a therapeutic treatment created for those who struggle with emotional dysregulation.

Pervasive emotional dysregulation can occur in individuals that tend to have the following traits:

  • More emotional sensitivity (more things cause distress)
  • High emotional reactivity (distress is more intense)
  • A slow return to baseline (taking longer to calm down after distress)

Dialectical Behavior Therapy has been shown to be quite effective for people struggling with bulimia and binge eating disorders. People with these issues tend to be emotionally under-controlled, struggling with high sensitivity, high reactivity and a slow return to baseline. Dialectical Behavior Therapy can teach the skills necessary to better observe, tolerate and exist within this emotional temperament.

Anorexia nervosa, on the other hand, tends to affect people that have issues of being more emotionally over-controlled. For these patients, Radically Open DBT is a new treatment that is showing promise. Radically Open DBT focuses on helping over-controlled people increase the following traits:

  • Receptivity and openness
  • Adaptability
  • Intimacy and connectedness

Primary Goals of DBT

The main goal of DBT treatment is to help an individual create a life they want to be present in. When this goal is accomplished, target behaviors (including eating disorders, substance abuse, suicidal ideation and self-injury) will no longer be used to escape discomfort and emotional pain.

Dialectical Behavior Therapy also endeavors to teach patients with eating disorders a number of valuable life skills, including the following:

  • Be present in the moment without judgment
  • Use skills to accept life rather than constantly fighting what is
  • Understand and value all emotions
  • Learn how to decrease intense emotions, if acting on the emotions or the intensity of those emotions or are not working for them
  • Learn to coexist with all emotions even if they are uncomfortable

Dialectical Behavior Therapy is based on the dialectics of recovery with the focus on the central dialectic of acceptance and change. In other words, one works to fully accept where one is in the present moment while moving towards change. Dialectical Behavior Therapy teaches patients that the pain of avoidance is worse than the pain of facing what one is avoiding — and teaches patients how to be successful in doing this.

DBT for patients with thoughts of self-harm or suicide

Patients with eating disorders often have thoughts of, and may even act upon, self-harming behaviors. They may also experience suicidal thoughts. These dangerous symptoms may be used to check out from, or escape from, difficult feelings.

A recent study in the Journal of the American Academy of Child and Adolescent Psychiatry looked at DBT treatment for adolescents struggling with emotional dysregulation, symptoms of self-harm and suicidal ideation. Researchers noted the following benefits in the adolescents who underwent DBT treatment for the study — compared to those who experienced “enhanced usual care:”

  • A stronger long-term reduction in self-harm
  • More rapid recovery in suicidal ideation
  • More rapid recovery in depressive and borderline symptoms

These promising results demonstrate that DBT for adolescents is the most efficient and effective way to treat adolescents with the above behaviors and symptoms.

DBT for patients with eating disorders

When someone abuses alcohol and has symptoms of bulimia, if the bulimic symptoms are being treated, the alcohol abuse tends to get worse. When the patient tries to remain abstinent from alcohol, perhaps through a 12-step program, they often return to the bulimic symptoms. On the other hand, when a patient is treated for bulimia and alcohol abuse with DBT, the focus is on learning skills to remain present in their lives.

Patients are encouraged to learn to live with their difficult feelings — without making efforts to escape and without using unhealthy behaviors or symptoms, since these behaviors and symptoms can actually make life worse.

The skills taught by DBT, as exemplified in the examples above, can greatly benefit all people seeking treatment for mental health issues, particularly those with eating disorders.

For further reading on DBT treatment for eating disorders and for other mental health issues, we offer the following recommendations:

  • Astrachan-Fletcher, E. & Maslar, M. (2009). The Dialectical Behavior Therapy Workbook for Bulimia: Using DBT to regain one’s life; Skills for Breaking the Cycle. New Harbinger Publications.
  • Parenting a Teen Who Has Intense Emotions: DBT Skills to Help Your Teen Navigate Emotional and Behavioral Challenges (Pat Harvey & Britt H. Rathbone)
  • Don’t Shoot the Dog: The New Art of Teaching and Training (Karen Pryer)
  • 10 Mindful Minutes (Goldie Hawn with Wendy Holden)
  • Fleischaker, C., Bohme, R., Sixt, B., Bruck, C., Schneider, C., & Schulz, E. (2011) Dialectical Behavioral Therapy for Adolescents (DBT-A): a clinical Trial for Patients with suicidal and self-injurious Behavior and Borderline Symptoms with a one year Follow-up. Child and Adolescent Psychiatry and Mental Health, 5:3.
  • James, A.C., Winmill, L., Anderson, C., & Alfoadari, K. (2011) A Preliminary Study of Extension of a Community Dialectical Behaviour Therapy (DBT) Programme to Adolescents in the Looked After Care System. Child and Adolescent Mental Health, 16, 9-13.
  • Safer, D.L., Telch, C.F., & Agras, W.S. (2001) Dialectical Behavioral Therapy for Bulimia Nervosa. American Journal of Psychiatry, 158, 632-634
  • Chen, E.Y., Matthews, L., Allen, C., Kuo, J.R., & Linehan, M.M. (2008) Dialectical behavior therapy for clients with binge-eating disorder, or bulimia nervosa and borderline personality disorder. International Journal of Eating Disorders, 41, 505-512
  • Safer, D.L., Robinson, A.H., & Jo, B. (2010) Outcome from a Randomized Control Trial of group therapy adapted for binge eating disorder: comparing dialectical behavior therapy for binge eating to an active comparison control. Behavior Therapy, 41, 106-120.
  • Hill, D.M., Craighead, L.W., Safer, D.L. (2011) Appetite-focused dialectical behavior therapy for the treatment of binge eating with purging: A preliminary trial. International Journal of Eating Disorders, 44, 249- 261.
  • Safer, D.L., Joyce, E.E. (2011) Does Rapid Response To Two Group Psychotherapies For Binge Eating Disorder Predict Abstinence?. Behaviour Research and Therapy, 49(5), 339-345.

Ellen Astrachan-Fletcher, PhD, CEDS is Executive Clinical Director at Insight Behavioral Health Centers/Eating Recovery Center. Dr. Astrachan-Fletcher is a clinical psychologist and a nationally recognized expert in the field of DBT. Britt Berg, MS writes for Eating Recovery Center.

dialectical behavior therapy
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Written by

Ellen Astrachan-Fletcher, PhD, FAED, CEDS-S

Ellen Astrachan-Fletcher, PhD, FAED, CEDS-S, is the Regional Clinical Director, Midwest for Eating Recovery Center and Pathlight Mood and Anxiety Center. She has a wealth and breadth of experience…

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