DBT for Eating Disorders: How it Works, Effectiveness & Examples

What Is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT) is a comprehensive and evidence-based treatment developed by Marsha Linehan.¹ DBT generally consists of individual and group therapy, crisis coaching, skills training, and a therapist consultation team.¹ Goals of DBT include enhancing life skills, generalizing skills to life outside therapy, reducing maladaptive behaviors, and improving patient motivation.¹ There is also an emphasis in DBT to provide routine structure and boundaries for the individuals in treatment.¹

DBT focuses on teaching four major life skills:¹

1. Mindfulness
2. Emotional regulation
3. Interpersonal effectiveness
4. Distress tolerance

How Can DBT Help With Eating Disorder Symptoms?

DBT skills have been adapted for the treatment of eating disorders with promising results. People with eating disorders often have trouble regulating their emotions and engage in disordered eating to cope with difficult emotions.^2,3 Therefore, DBT for eating disorders focuses on emotion regulation and distress tolerance to help the person learn to manage their emotional experience without using disordered eating behaviors.³

It is important to recognize that different types of eating disorders can have different emotional struggles. While those diagnosed with anorexia nervosa might struggle with episodes of emotional overcontrol (leading to restrictive behaviors), individuals diagnosed with binge eating disorder or bulimia nervosa may struggle with episodes of emotional undercontrol (leading to use of purging or over-eating to regulate emotions).² Therefore, additional research is needed to understand what DBT adaptations are most effective for different types of eating disorders.

DBT Vs. RO-DBT for Eating Disorders

There is a newer DBT approach for eating disorders called radically open dialectical behavior therapy (RO-DBT).⁵ RO-DBT targets emotional loneliness, rather than emotion dysregulation, as the primary problem for those struggling with disordered eating.⁵ Treatment focuses on learning to feel safe in social bonds with others.⁵

In addition to teaching core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills, RO-DBT also teaches radical openness. Radical openness skills teach the person how to open themselves to new perceptions of their world.⁵

Radical openness involves three core components:⁵

1. Acknowledging the environmental trigger
2. Self-inquiring into urges
3. Flexibly responding

DBT Skills for Eating Disorders

Although general DBT skills remain the same with DBT for eating disorders, skills may be tailored to focus on disordered eating behaviors. For example, distress tolerance may focus on the distress that happens after eating a feared meal. Similarly, mindfulness may be utilized during a meal to focus on the sensory experience of engaging with food and how it feels in the body.

Mindfulness Skills

DBT mindfulness skills are focused on paying attention to and accepting the present moment. DBT for eating disorders may help the individual focus on a mindful approach to eating and experiencing meals. Through developing mindfulness, someone can learn to build a better mind-body connection, which the eating-disordered behaviors may have damaged.

DBT mindfulness skills that are used in eating disorder treatment include:

• Utilizing the five senses to eat a meal: Calling on the five senses to fully experience your meal can help you attend to the present moment. You may be used to tasting your meal but stopping to notice the sight of your food or the smell of it can help you recognize each meal as a unique experience.
• Reflecting on the motivation for hunger: Humans eat for all sorts of valid reasons—social reasons, cultural reasons, boredom, or celebration, just to name a few. Reflecting on your motivation for a meal may help you mindfully consume what feels right for your body.
• Checking in with hunger cues before a meal: Checking in with hunger cues before a meal can help you have an understanding of the intensity of your hunger.
• Checking in with fullness cues during and after a meal: Checking in with fullness cues during and after a meal can help you scale how food is digesting and feeling as you consume.
• Slowing down the overall experience of preparing food and eating: Slowing down the overall experience of preparing and consuming food may help you appreciate the full experience of having a meal.
• Developing a spiritual connection or appreciation of food: Some people may have a religious or spiritual connection to food that helps them re-focus on consuming mindfully. For example, some individuals pray before a meal or thank their Higher Power after consuming to show appreciation for the experience.
• Mindfully eat with others: Eating with others who are committed to consuming food mindfully can help encourage you to do the same. DBT for eating disorders can help you recognize how relational connections are important to the recovery process.

Distress Tolerance Skills

DBT distress tolerance skills are focused on teaching the individual to cope with distressing situations without reverting back to self-destructive coping mechanisms and compensatory behaviors. Distress tolerance skills encourage the person to respond in a flexible manner to frustrations. Skills may be used either during a crisis or during a moment where intense emotions are making it difficult to accept the reality of a situation.

Distress tolerance skills for eating disorders may focus on tolerating difficult sensations felt in the body during a meal, when grocery shopping, or when eating around others. They may also focus on encouraging the individual to think about the short-term and long-term consequences of engaging in an eating-disordered behavior versus using a distress tolerance skill to stabilize recovery.

DBT distress tolerance skills that are used in eating disorder treatment include:

• S.T.O.P.: The STOP skill stands for Stop, Take a step back, Observe, and Proceed mindfully. Using this skill during moments of intense negative emotion may help the individual to avoid impulse reactions.
• Pros and Cons: This skill asks the individual to consider the short- and long-term consequences of engaging in reactionary behaviors in the moment, and to weigh those with the benefits of using distress tolerance skills to stabilize the situation.
• T.I.P.P.: TIPP skills focus on techniques to bring the body back to a baseline level and can be used during feelings of fight-or-flight. TIPP stands for temperature, intense exercise, paced breathing, and paired muscle relaxation.
• A.C.C.E.P.T.S.: ACCEPTS stands for Activities, Contributions, Comparisons, Emotions, Pushing away thoughts, and Sensations. These coping techniques allow you to distract from the present moment when it is too distressing to bear.
• 5 senses self-soothing: This skill, otherwise known as the 54321 method, asks you to use your five senses to engage in self-soothing in the present moment. It can be used during moments of dissociation or racing thoughts to slow down and feel safe in the body.
• I.M.P.R.O.V.E.: IMPROVE is focused on improving the quality of a moment through challenging negative beliefs and emotionality. IMPROVE stands for Imagery, Meaning, Prayer, Relaxation, One thing in the moment, Vacation, and Encouragement.

• Emotion Regulation Skills

  DBT emotion regulation skills are used to tolerate and manage difficult emotional experiences. Emotion regulation skills allow individuals to identify, accept, and regulate emotions. Through developing strategies for emotion regulation, someone may better understand how their thoughts influence their emotions.

  People with eating disorders often have a disrupted link between their mind and body, which can make their emotions either blunted or heightened. Recognizing how emotions are felt in the body and slowing down the process of experiencing an emotion are a couple of ways that DBT for eating disorders may foster this mind-body connection for individuals.

  DBT emotion regulation skills that are used in eating disorder treatment include:

  • Opposite action: Opposite action encourages the individual to identify the behavior generally associated with the emotion they are experiencing and perform the opposite behavior. For example, if you are feeling the need to isolate due to sadness, Opposite Action would encourage you to seek support.
  • Check the facts: This skill involves carefully reviewing the facts behind an emotional situation and separating them from the thoughts of the emotional mind.
  • Identifying emotion myths: DBT encourages the individual to understand that the stories we tell ourselves about emotions influence how we experience them. Identifying myths about emotions, such as “It is not polite to show any of my emotions” can help sort through the myths that trigger strong emotions.
  • P.L.E.A.S.E.: This skill focuses on improving physical well-being to improve overall emotional health. PLEASE stands for treating Physical iLlness, balancing Eating, Avoiding mind-altering substances, getting enough Sleep, and keeping up with physical Exercise.
  • Paying attention to positive events: This skill draws on mindfulness to help with emotion regulation by drawing attention to the positive events in life. Through recognizing and appreciating these events, positive emotional experiences tend to follow.
  • Engaging in a pleasant activity: This skill encourages you to build a list of pleasant activities and engage in one when you are experiencing a distressing emotional experience.
  • Ride the wave: This skill focuses on riding out the wave of emotion, observing and accepting each piece of the emotional experience without acting on urges.

  Interpersonal Effectiveness Skills

  DBT interpersonal effectiveness skills are used to teach someone how to initiate, maintain, and regulate relationships. These skills help the individual with understanding how to obtain an objective, build and manage healthy relationships, and maintain self-respect.

  DBT interpersonal effectiveness skills that are used in eating disorder treatment include:

  • D.E.A.R.M.A.N: This skill allows the individual to develop healthy communication with others and work through any interpersonal conflicts. This skill helps the individual understand how to get their needs met during conflict, while still balancing the needs of the other person.
  • G.I.V.E.: This skill is focused on how to maintain healthy relationships. It focuses on being Gentle, acting Interested, Validating others, and using an Easy manner.
  • F.A.S.T.: This skill focuses the individual on using their values to guide healthy communication with others. FAST focuses on being fair, not over-apologizing, sticking to values, and being truthful.
  • Boundary building: Another important component of interpersonal effectiveness skills is the ability to identify and maintain boundaries with others. Eating disorders sometimes develop in families with poor boundaries, and re-learning how to set and regulate boundaries is an essential part of DBT for eating disorders.
  • T.H.I.N.K.: This skill helps to regulate negative emotional affect toward others. THINK stands for Thinking about the situation, developing empatHy, Interpreting behaviors, Noticing the other person, and being Kind in your response.
  • Assertiveness training: Part of interpersonal effectiveness is learning how to present as assertive and communicate needs effectively. People with eating disorders often use their behaviors to avoid healthy communication with others, and assertiveness training can help with the how-tos behind facilitating communication.
  • Dialectics: Dialectics are about understanding how two seemingly opposite things can be true. Utilizing this approach during conflict can help the individual accept another person’s reality without compromising their own values.

Can DBT Effectively Treat Eating Disorders?

Current research into DBT techniques for eating disorders shows promising results, which vary by particular diagnosis.³ One study showed that DBT is an effective treatment for binge eating disorder in women, with an 89% success rate.⁴ In another study, 90% of adult individuals with anorexia nervosa responded positively to DBT treatment.⁵ A different study found that people with bulimia had fewer binging and purging symptoms after 20 weeks of DBT therapy.⁶

How Quickly Does DBT for Eating Disorders Work?

Some studies have found evidence of DBT treatment working to reduce eating-disordered symptoms in as little as 20 weeks for adult populations.^4,5,6 It is important to note that further research is needed to support these results in larger demographics of people across gender, race, and age differences. Additionally, different diagnoses under the umbrella of eating disorders may require different adaptations of DBT.

Who Should Try DBT for Eating Disorders?

Research has supported DBT for eating disorders as a promising intervention for adult populations diagnosed with binge eating disorder, bulimia, and anorexia.^4,5,6 Additional research has supported DBT as helpful for treating anorexia and bulimia nervosa in adolescents.⁷

Some studies have found that people who were resistant to traditional methods of eating disorder treatment, such as CBT-E, might benefit from trying DBT.⁸ Additionally, those who have a co-morbid diagnosis of an eating disorder and borderline personality disorder may also benefit.⁸ It is important to consult with your care team, such as a primary care physician, psychiatrist, and therapist, to consider this decision around your unique needs.

Who Is Not a Good Candidate for DBT for Eating Disorders?

Eating disorders come with an imminent risk of physical harm or death. It is important for stabilization of the individual’s physical health to occur (at least to a certain degree) prior to utilizing any therapy approach—including DBT for eating disorders. If an individual’s eating disorder is severe enough to cause them harm, they may not be able to participate in a DBT program and they should seek residential treatment or hospitalization instead.

What to Expect During DBT Treatment

DBT for eating disorders will likely involve weekly individual therapy sessions, group skills training sessions, and access to phone coaching or crisis sessions. Also, programs may use a weekly consultation team to provide additional support. The standard length of treatment for DBT for eating disorders may vary by treatment program or per individual but could range from 20 weeks to over 6 months.

Traditional DBT approaches generally emphasize the use of worksheets and homework during psychoeducation portions. In DBT for eating disorders, there is often an emphasis on eating group meals together. Some groups may also add on art or other forms of creative expression. Since DBT for the treatment of eating disorders is a relatively newer approach, variations in treatment may occur until there is a generalized approach developed.

DBT sessions for eating disorders will involve:

• Checking symptom severity: The therapist may check in on eating disorder behaviors used during the past week. The therapist may assess for how often or how intensely behaviors are occurring,
• Skills training: DBT generally involves skills training in a group setting, but individual therapists may check in on how the person is applying the skills to current situations. The therapist may provide further psychoeducation if needed, or ask the client to review how they are using skills outside sessions.
• Transparent discussion of motivators for treatment: Sessions may involve frank discussions of the motivators for recovery, which are generally established at the beginning of treatment. The therapist may use these motivators to encourage the person to think about the short- and long-term consequences of engaging in impulsive disordered behaviors.
• Discussion of goals and values: A core component of DBT treatment and eating disorder recovery are knowing and living out core values, which are often in opposition to eating-disordered behaviors. Therapists may discuss what core values the person is living through in daily life, and how those relate to goals for recovery.
• Challenging black-and-white thinking patterns: People with eating disorders often have inflexible and rigid views and thinking patterns. A DBT therapist would encourage the individual to balance these thoughts using dialectical strategies.

How to Find a DBT Therapist for Eating Disorders

Therapists at the outpatient level may use DBT interventions for eating disorders in their treatment approach. Some places to start looking might be an online therapist directory or online therapy platform. If you are looking for a standard treatment for DBT for eating disorders, you may benefit from seeking care from a facility at an in-patient, partial hospitalization, or intensive outpatient level. You can also look into an online eating disorder recovery program, such as Equip Health.

Alternative Treatment Options for Eating Disorders

Many treatment options exist for People diagnosed with eating disorders. The right treatment option will vary based on an individual’s unique needs and accessibility in their location. A comprehensive treatment plan for an eating disorder can vary based on the severity of symptoms.

Eating disorder treatment can be inpatient or outpatient. Some individuals may need in-patient services to stabilize enough to receive outpatient treatments. Other individuals may function well enough to create an outpatient care team by visiting with a therapist, physician, and registered dietician routinely. Recovery might look different for each individual.

Alternative treatment options for eating disorders include:

• Psychodynamic therapy: Psychodynamic therapy helps individuals review their past and childhood upbringing to determine the root causes of their problems. Psychodynamic therapy puts an emphasis on insight and the subconscious as the source of answers for afflictions.
• Enhanced cognitive behavioral therapy (CBT-E): CBT-E is a structured treatment for eating disorders that incorporates psychoeducation and cognitive behavioral therapy principles. CBT-E helps the individual understand how their thoughts influence their moods and behaviors to maintain symptoms and how to disrupt this cycle.
• Group therapy: Group therapy for eating disorders could occur at either an in-patient or out-patient level. Groups can provide structure and peer support in a validating environment where relational skills can also be practiced.
• Intensive outpatient program (IOP): IOP for eating disorders would offer a higher level of care than a once-a-week therapy session. IOP allows the person to continue living their daily life while receiving more intensive care such as therapy sessions, group therapy, and skills groups that might be offered in a structured environment several times a week.
• Partial hospitalization program (PHP): PHPs are one step up from IOP in that they would offer a similar type of support, but more frequently than IOP. Some people who are involved in PHP may attend programs for half of their days and then continue with regular life outside of those hours.
• Family therapy: Eating disorders often have roots in the family system. Seeking a family therapist can help the family explore how intergenerational belief systems have contributed to the symptoms of the individual and improve social bonds.
• Eye movement desensitization and reprocessing (EMDR): Individuals with eating disorders sometimes have experienced a trauma which resulted in the development of their symptoms. EMDR uses bilateral stimulation to help the individual re-process and integrate traumatic memories.
• Interpersonal therapy: Interpersonal therapy focuses on overcoming interpersonal conflicts that maintain eating disorder symptoms. Four components of treatment include unresolved grief, role disputes, role transitions, and interpersonal deficits.