Anita Federici, Ph.D.
What is dialectical behaviour therapy?
Dialectical Behaviour Therapy (DBT) was originally developed by Marsha Linehan at the University of Washington in Seattle to help people struggling with chronic suicidal and self-harming behaviours.1 The treatment is based on the assumption that impulsive and self-destructive behaviours are caused by an inability to regulate and manage intense emotion. DBT is a sophisticated intervention that blends cognitive behavioural approaches with meditative practices and acceptance-based strategies. In addition, DBT places great emphasis on the therapeutic relationship and adds a range of skill-training modules (including mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness). Due to the success of DBT in helping clients reduce and eliminate suicidal and self-harming behaviours,2,3 it has now evolved into a treatment for people who struggle with other impulsive and problematic behaviours for whom emotion dysregulation may play a central role.
What is emotion dysregulation?
Our ability to experience our feelings, tolerate painful emotions, and express ourselves without shame or anxiety plays a vital role in our mental health and overall wellbeing. The term “emotion dysregulation” is used when people have long-standing difficulties coping with unpleasant feelings or when emotions feel so overwhelming that they lead to self-destructive behaviours (e.g., feelings of anxiety that lead to binge eating). For some people, emotions become so unbearable that they work very hard to avoid or eliminate them altogether. Others find that their emotions lead to impulsive or self-destructive behaviour – for example, binge eating or restricting meals to suppress feelings of anxiety or shame. Other people experience their emotions as extremely chaotic and situationally inappropriate – for instance, feeling rage after missing the bus.
How does someone develop emotion dysregulation?
From a DBT perspective, emotion dysregulation is thought to be caused by the interaction between biology and the environment.1 Researchers believe that some individuals are naturally more sensitive to their emotions from birth, e.g., they may respond to situations with more intense emotions or take longer to “return to baseline” after getting upset. It is thought that these biological vulnerabilities worsen, and lead to symptoms, when the emotionally sensitive person is repeatedly exposed to an “invalidating environment” or an environment that is a “poor fit” for their needs.
Invalidating environments communicate to people that their feelings and experiences are incorrect, unacceptable, or otherwise inappropriate. Instead of providing nurturance and understanding, invalidating environments punish or dismiss an individual’s experiences. Such environments may cause a person to doubt their internal feelings and “gut” reactions. Many people will respond by avoiding feelings altogether which ultimately means that they never get a chance to learn how to understand and express themselves skillfully. While these environments alone do not directly cause emotion regulation problems or disordered eating, they are believed to increase one’s vulnerability to the development of such problems in the future.
What does DBT look like?
DBT consists of four major components:
One-on-one therapy that takes place once per week with a DBT trained therapist. Together with their therapist, clients work on meeting therapy and life goals focusing on suicidal/self-harming behaviour first, followed by behaviours that interfere with receiving treatment , e.g., missing sessions, not doing homework, and quality of life behaviours, e.g., eating disorder symptoms, substance abuse, unemployment, isolation, etc.
Skills-training group therapy
In addition to individual therapy, clients are also expected to attend a two-hour skills building group each week. The core skills of emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness are discussed in detail below.
Skills coaching by telephone
In order to practice using newly learned skills in the “real world”, clients are able to contact their therapist outside of the individual therapy session. Skills coaching (typically done using a pager system) is designed to help clients use skills in the moment (instead of using eating disorder symptoms) when difficult situations and crises are happening.
Consultation team for therapists
In a full DBT program, all of the therapists are active members of a weekly consultation team. This is a meeting where therapists get support, coaching, and guidance from their team members to ensure that therapists (a) avoid burnout, and (b) offer quality DBT treatment to their patients.
Why DBT for eating disorders?
1. DBT is based on an affect regulation model.
One of the features that makes DBT unique is the importance it places on understanding and working with emotions. As discussed, DBT is based on the assumption that problem behaviours are caused by an inability to regulate and manage intense emotion. When it comes to treating eating disorders, research now indicates that focusing on emotions may be a valuable and important component for change. Here are several important facts about emotions and eating disorders:
A number of individuals with an eating disorder report that they have difficulty describing, tolerating, and expressing their emotions. For many, emotions are experienced as threatening, confusing and completely overwhelming. Other people report feeling numb, empty, and unable to connect with their emotions.4,5
Many individuals report that they do not have the skills to cope with their emotions in healthy, adaptive ways.6,7
Without adequate emotion regulation skills, eating disorder symptoms can become a way of regulating overwhelming and uncomfortable feelings… at least temporarily. Many people have reported that their symptoms are a way to tolerate and “control” intense and painful emotions. Binge eating, purging, and fasting have been described as coping strategies, “physical escapes”, “ways of withdrawing” or as a “temporary relief” from emotional pain and discomfort.8,9
Negative emotions are one of the most common triggers for eating disorder symptoms. Studies which have tracked individuals’ emotional states before and after an episode of binge eating have shown that depression, anger, guilt, loneliness and self-blame are significantly higher on days in which people engage in symptoms.10 Other studies, in which women with eating disorders have been interviewed, offer further support that symptoms are triggered by difficult and distressing emotions. One woman with bulimia nervosa offered the following account:
“… I was just angry, or something was bothering me. That would trigger a binge – I couldn’t express it any other way… I could go out and aggressively feed my face or binge and then throw up, and that was the release of the anger.” 6
If left untreated, emotion dysregulation may increase a person’s vulnerability to relapse following treatment. Several studies have found that people are more likely to maintain their recovery from an eating disorder when they feel that they can better identify, accept and tolerate emotions.6,7
2. DBT strives to enhance motivation and commitment.
DBT pays particular attention to increasing motivation to change. This is important for the treatment of eating disorders given that many individuals entering treatment report feeling ambivalent and unsure about changing their symptoms. In DBT, the unique and ongoing balance between acceptance and change-based strategies helps to reduce ambivalence and increase commitment. DBT teaches clients how to non-judgmentally accept themselves and the reality of their current situation with efforts to meet their goals and change behaviours that interfere with the attainment of those goals.
3. DBT seeks to increase self-confidence and self-esteem.
DBT therapists place a great emphasis on reinforcing positive behaviours and view their clients as capable and strong. In this treatment, clients are coached to act on their own behalf as they build a “life worth living.” This approach is thought to increase self-confidence and a sense of control because it teaches clients that they are skillful and capable of managing a variety of situations and experiences.
4. DBT includes comprehensive skills-training.
In order to teach people how to better manage their symptoms and engage in more effective coping behaviours, the following four skills modules are offered in DBT:
Mindfulness: Mindfulness skills are designed to teach people how to focus their attention on the present moment without judgment. Very often, people with eating disorders have difficulty staying in the “here and now”. Connecting with emotions, with the body, and with food is often very triggering for someone with an eating disorder. While some people describe episodes of “mindless eating”, others report that they are completely unaware of what triggers their symptoms. Given that it is very difficult to change something that we are first not aware of, mindfulness skills may be essential to the treatment of eating disorders as they help individuals gain insight into their patterns and behaviours. Furthermore, by maintaining full awareness of the present moment, mindfulness teaches people how to let go of distracting and painful thoughts that often trigger symptoms. Practicing mindfulness takes people off “automatic pilot” and allows them to stand back and observe painful thoughts and feelings without judging the experience or acting on it impulsively.
Interpersonal effectiveness: Individuals with eating disorders often report that they have difficulty asserting their needs, saying no to others, and putting their goals and desires before those of others. Often this comes from a place of fear, e.g., fearful of being rejected/disliked by others, or shame, e.g., the belief that one’s needs are not important or that they are not deserving. Maintaining relationships and negotiating needs with others is central to our wellbeing. When we feel taken for granted, invalidated, and pushed aside by the people in our lives, we are more likely to experience negative emotions and distressing urges for self-destructive behaviour. Interpersonal effectiveness skills teach people how to effectively communicate with others and how to increase the likelihood of getting what we want and need.
Distress tolerance: These skills are all about learning new ways of getting through a crisis without making matters worse! When emotions feel overwhelming and situations get difficult, people who lack distress tolerance skills will turn to their symptoms as ways of coping and regulating themselves. In addition to a set of skills that teach people how to bear pain skillfully, e.g., not engaging in symptoms that make the situation worse, there are also a group of skills that teach people how to radically accept reality for what it is (without judgment) in order to move forward.
- Emotion regulation: These skills teach people how to observe and describe their emotions and how to understand their emotional world without fear, judgment, or self-hatred. As reviewed earlier in this article, people struggling with an eating disorder often have trouble identifying, experiencing, and communicating their emotions. Instead of rejecting or suppressing emotions, these skills emphasize the adaptive nature of emotions and teach people how to reduce their vulnerability to negative emotions, and how to generate more positive emotions.
Currently, research on the effectiveness of DBT for eating disorders is underway with early reports showing exciting and promising results. The following are several suggested readings for more information:
Linehan, M.M. 1993. Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press.
McKay, M., Wood, J. C., & Brantley, J. 2007. Dialectical behaviour therapy workbook: Practical DBT exercises for learning mindfulness, interpersonal effectiveness, emotion regulation, & distress tolerance. Oakland, CA: New Harbinger.
1. Linehan, M.M. 1993. Cognitive behavioural treatment of borderline personality disorder. New York: Guilford Press.
2. Linehan, M.M., Armstrong, H.E., Suarez, A., Allmon, D., & Heard, H.L. 1991. Cognitive-behavioural treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry, 48:1060-1064.
3. Linehan, M.M., Comtois, K.A., Murray, A.M., Brown, M.Z., Gallop, R.J., Heard, H.L., et al. 2006. Two-year randomized trial and follow-up of dialectical behaviour therapy vs. therapy by experts for suicidal behaviours and borderline personality disorder. Archives of General Psychiatry, 63:757-766.
4. Bydlowski, S., Corcos, M., Jeammet, P., Paterniti, S., Berthoz, S., Laurier, C., Chambry, J., & Consoli, S.M. 2005. Emotion-processing deficits in eating disorders. International Journal of Eating Disorders, 37:321-329.
5. Zonnevijlle-Bendek, M. J.S., van Goozen, S.H.M., Cohen-Kettenis, P.T., van Elburg, A., & van Engeland, H. 2002. Do adolescent anorexia nervosa patients have deficits in emotional functioning? European Child & Adolescent Psychiatry, 11:38-42.
6. Federici, A., & Kaplan, A.S. 2007. The patient's account of relapse and recovery in anorexia nervosa: A qualitative study. European Eating Disorders Review, 26:1-10.
7. Cockell, S.J., Zaitsoff, S,L., & Geller, J. 2004. Maintaining change following eating disorder treatment. Professional Psychology: Research and Practice, 35:527-534.
8. Polivy, J. & Herman, C. P. 2002. Causes of eating disorders. Annual Review of Psychology, 53:187-213.
9. Heatherton, T.F., & Baumeister, R.F. 1991. Binge eating as escape from self awareness. Psychological Bulletin, 110:86-108.
10. Stein, K.F., & Corte, C.M. 2003. Ecologic momentary assessment of eating disordered behaviours. International Journal of Eating Disorders, 34: 349-360.
11. Meyer, C., Waller, G., & Waters, A. 1998. Emotional states and bulimic psychopathology. In J.W. Hoek, J.L. Treasure, & M.A. Katzman (eds.), Neurobiology in the treatment of eating disorders (pp. 271-289). New York, NY: Wiley.
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