by Elisha Carcieri, Ph.D.
Both cognitive behavioral therapy for eating disorders CBT-E, and interpersonal therapy (IPT) are effective treatments for bulimia nervosa, binge eating disorder, and patterns of disordered eating that don’t meet criteria for diagnosis. CBT for eating disorders involves making changes to patterns of behavior and thinking that serve to maintain the vicious cycle of eating disorders. Most people who undergo these therapies get better in response to treatment and continue to improve after treatment has ended. However, for some clients, the emotional and mood regulatory components of binge eating and/or purging represent a significant part of what keeps their eating disorder going.
According to the affect regulation theory of eating disorders, negative emotions such as anxiety, sadness, and anger precede episodes of binge eating, and individuals engage in binge eating in order to distract from or reduce negative affect or aversive emotions. Behaviors such as laxative use and vomiting may be used to ease anxiety about weight gain as a consequence to overeating. Clients often describe having a difficult time identifying, expressing, and tolerating emotions (especially negative emotions), and the disordered eating behaviors are described as providing some relief, numbing, or outlet. The binge eating and/or purging provide a temporary escape from negative emotions. Unfortunately, the vicious eating disorder cycle continues, as the escape is brief and usually followed by feelings of failure, guilt, and shame.
Dialectical behavioral therapy (DBT) was developed by Marsha Linehan for the treatment of borderline personality disorder, a mental health disorder characterized by emotion dysregulation and risk for self-harm and suicidal behaviors. DBT is influenced and incorporates both cognitive behavioral strategies and mindfulness/zen-based strategies. Inherent to DBT is the notion of practicing both acceptance of the client and their current behaviors and circumstances, and confidence in the client’s ability to make change through the use of adaptive skills.
In its standard form, DBT is delivered with multiple components: individual therapy, group skills training, telephone coaching, and a weekly consultation group for the therapists to provide support and ensure quality delivery of the therapy. We find that comprehensive DBT is often an excellent complement to FBT for adolescents. DBT skills include mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. DBT also focuses on behavior through the use of “chain analysis,” which involves reviewing problem behaviors (binging and purging), prompting events, vulnerability factors, and actions, thoughts, or feelings that eventually led to the problem behavior. Clients also identify skillful solutions to the problem behavior, consequences of the behavior, as well as plans to reduce the behavior in the future. The flexibility in thinking that is characteristic of DBT acts in appropriate opposition to the patterns of black and white, or all-or-nothing, thinking that is so common among clients with eating disorders.
There is an adapted form of DBT developed specifically for the treatment of eating disorders that combines the individual therapy and skills training components. DBT skills in and of themselves can also be taught and incorporated into other treatment plans. DBT skills provide valuable lessons, not only for eating disorder sufferers, but also for anyone looking to improve their quality of life.
The following are the DBT skills relevant to the treatment of eating disorders:
Mindfulness – The skills of mindfulness are essential to DBT. These skills foster focusing one’s attention and mind in the present moment, without judgment and acknowledging that the moment is fluid and ever-changing. Bringing awareness to what is going on within our bodies and minds as well as outside of ourselves. Binge eating is considered a mindless behavior that is improved with an increase in awareness of thoughts, emotions, and bodily sensations that occur before, during, and after eating, binging, and/or purging, or while having the urge to do so.
- Example: Mindful eating – Clients are guided through the process of slowly and deliberately eating a raisin while observing, describing and participating fully in the experience. This practice is encouraged during meal times as eating mindfully acts in opposition to the loss of control and mindlessness that is characteristic of binge eating.
Emotion Regulation – Enhancing control of emotions through identifying and naming emotions, reducing and managing negative emotions, accepting and increasing resilience to extreme negative emotions, and increasing positive emotional experiences. These skills encourage the use of coping strategies other than binge eating.
- Example: Loving your emotion – Based on the principle that mindfulness encourages accepting the entire range of emotions and that one can reduce suffering by avoiding resistance of emotions. During guided meditation clients practice bringing awareness to their emotional experience with radical acceptance, no matter what their emotional experience may be in the moment. Acceptance and love of all emotional experiences eventually reduces the tendency to escape or regulate these emotional experiences through binging or purging.
Distress Tolerance – Sometimes situations or circumstances cannot be changed. Distress tolerance involves learning to tolerate negative emotions or crisis situations without responding in unhelpful ways, such as binging or purging.
- Example: Half Smiling – Based on experimental evidence showing that our facial expressions communicate with our brains and have an effect on our inner experience, this skill teaches facilitating inner acceptance by adopting a facial expression consistent with acceptance, the half-smile.
DBT skills are best learned with the guidance of an experienced therapist. They take commitment and practice, but the benefits are far-reaching. If you are suffering from an eating disorder, don’t hesitate to seek help. There are effective therapies out there!
Linehan, M. M. (2014). DBT® skills training manual. Guilford Publications.
Polivy, J., & Herman, C. P. (1993). Etiology of binge eating: Psychological mechanisms.
Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eating and bulimia. Guilford Press.