Adjunctive Therapies to FBT: What are the Additional Therapies That May be Added to FBT? And When Should They Be Added?

Image Description: Paper in window that reads "Mindfulness" Adjunctive therapies that go alongside FBT for Eating Disorders
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In a previous post, I have discussed who is typically on an FBT team. In its traditional manualized form, the core team is a therapist, a medical doctor, and the parents. The team often also includes a registered dietitian nutritionist (to guide the parents) and may include a psychiatrist.

It is not uncommon for medical providers unfamiliar with FBT and treatment centers to encourage additional individual therapy for the patient. As I have said previously, this is not always advisable. In FBT, less can be more—the work of the parents may be undermined by an individual therapist who either does not believe in or does not support FBT.

So, I thought it would be useful to describe in greater detail the situations in which I think additional therapies are warranted and which therapies are most aligned with FBT.

FBT is primarily a behavioral treatment, administered by parents. The two therapies I discuss below—Dialectical Behavior Therapy and Exposure and Response Prevention—are also behavioral treatments that can be applied consistently alongside FBT without confusion. By contrast, non-behaviorally-based therapies may create splitting or confusion when offered alongside FBT. In particular, you should be cautious about and avoid therapies that do not reinforce the parents’ authority over eating or introduce different theories about the cause of an eating disorder.

Comprehensive Dialectical Behavioral Therapy

Dialectical Behavioral Therapy (DBT) is a form of cognitive-behavioral treatment (CBT) developed in the 1980s by Marsha Linehan, Ph.D. It was developed to treat chronically suicidal individuals diagnosed with borderline personality disorder and is now considered the most effective treatment for this population. Research has demonstrated its effectiveness for a range of other mental disorders including substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders.

DBT stands out as the treatment of choice for people with difficulty regulating emotions—those prone to outbursts of anger and impulsive behaviors such as self-harm and purging. It focuses on the teaching of skills to tolerate emotions and improve relationships.

Be aware that there are many therapists (including us!) who use DBT skills in individual therapy with clients. Some therapists also may offer a standalone DBT skills training group. However, while these individual elements of DBT treatment may be beneficial, comprehensive DBT has a powerful advantage.

For DBT to by comprehensive it must comprise the following components:

  • DBT skills training. This almost always occurs in a group format run like a class. Group leaders teach behavioral skills and assign homework. Groups meet weekly for 24 weeks to complete the curriculum. Skills training consists of four modules: Mindfulness, Distress Tolerance, Interpersonal Effectiveness, and Emotion Regulation.
  • Individual therapy. Weekly sessions run concurrently with the skills training. The individual therapist helps clients apply the DBT skills.
  • Phone coaching. Clients are encouraged to reach out to their individual therapists to receive in-the-moment support applying skills during times of need.
  • DBT Consultation Team to Support the Therapist. All the members of the DBT team (group therapists and individual therapists) support each other in managing these clients who are in high distress.

When a teen is in comprehensive DBT, there is usually a parallel track for the parents that includes a parent skills group and a parent phone coach so that the parents receive help supporting their teen who is learning to apply DBT skills.

Exposure and Response Prevention

Exposure and Response Prevention (ERP) refers to specific CBT strategies used to address obsessive-compulsive disorder (OCD) or similar symptoms. OCD is characterized by distressing and intrusive thoughts and compulsive behaviors in which a person engages to try to reduce the distress. In ERP, the patient is exposed to the distressing situation and encouraged to prevent their compulsive behavior so they can learn to tolerate the distress. Once a person feels capable of handling their distress they will no longer need to engage in the compulsive behavior.

OCD and eating disorders commonly co-occur, and eating disorders can result in compulsive behaviors that require additional attention, such as compulsive exercise or other rituals not related to eating. Patients with eating disorders who engage in these behaviors may benefit from the addition of ERP.

DBT Skills for Eating Disorders

DBT Skills for Eating Disorders [image description: woman look sad leaning against window]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!

References

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.

The gift of food by Dr. Elisha Carcieri

image description: a sleeping baby
stock photo (not Elisha’s baby)

Two months ago, I experienced one of life’s greatest gifts when my first child was born. Throughout my pregnancy, I was mindful of what I was eating and drinking in a way I had never experienced before. Another person was reliant on what I chose to put in my body and I was acutely aware of the need to provide good nutrition to my little one. With this came an overwhelming sense of responsibility that I carried with me throughout myfastpregnancy.com.

Almost immediately after he was born, my son needed food. He was naturally driven to nourish himself and I felt so lucky to help him grow and experience this fundamental human need and pleasure…eating. Over the last few months, I have responded to him as he communicates his hunger with cries and other cues. I’ve thought more about how this innate drive becomes so complicated as we grow. What starts as a simple relationship becomes clouded with other factors outside of our bodies.

As life goes on, it is often not just hunger that drives us to eat. Social, emotional, and environmental factors work their way into our relationship with food. And unfortunately, so do guilt, judgment, and labels like “good” and “bad.” I think that maintaining an intuitive and forgiving relationship with food is a challenge for most, whether the relationship is officially “disordered” or not. Movements such as health at every size (HAES) and intuitive eating encourage people to begin to move closer to the simpler relationship with food that I’ve observed in my son.

In the case of eating disorders, the process of feeding one’s self moves beyond the complexity of what most of us experience in our daily relationship with food. With a myriad of potential causes and triggers, the eating disorder highjacks the brain and body in more ways than one. Thoughts and perceptions become distorted, hunger cues become erratic or in some cases nonexistent, and levels of key neurotransmitters and hormones are affected. Depression and anxiety commonly run alongside the eating disorder. The result is a serious, sometimes life-threatening illness that couldn’t be further removed from the pure relationship with food we are all born with.

Carrying and feeding my son, and watching him nourish himself so instinctually have been a reminder for me personally to continue to work toward eating intuitively. I am also reminded of how difficult this can be for those of us who are no longer newborns!

It is tragic the way eating disorders attack the fundamental act of nourishing oneself in a healthful, intuitive way, which is why it is so important to continue to fight eating disorders with early identification and treatment. It’s a fight I am privileged to be a part of.

Mindful Eating

The definition of binge eating is “the consumption of large amounts of food associated with a feeling of loss of control over eating.”  Individuals who binge eat describe the experience as almost dissociative.  They are frantically eating large amounts of food which they are barely tasting.  They feel unable to stop until they are uncomfortably full.

One skill that I teach clients who binge eat and overeat is mindful eating.  Mindfulness is a Buddhist principle that involves being fully aware of what is going on both inside yourself and in your environment at the moment.  Mindfulness is a skill that anyone can develop.

Continue reading “Mindful Eating”