The Application of Dialectical Behavior Therapy to Eating Disorders

1
The Application of Dialectical Behavior Therapy
to Eating Disorders

• Melissa Freizinger, Ph.D.
• Laurel Hill Inn, Medford, MA

2
Objectives for Today

• Briefly outline of Dialectical Behavior Therapy
  (DBT) basics.
• Explain how ED behaviors fit into the DBT
  framework.
• Discuss case examples for each DBT module and the
  applicable DBT skills.
• Discuss barriers to use of DBT skills.
• QA

3
What is DBT?

• A comprehensive treatment approach that was
  developed by Marsha Linehan for the treatment of
  people with borderline personality disorder (BPD)
  and parasuicidal behaviors also including self
  injurious behaviors.

4
What is DBT (continued)

• DBT is an empirically - supported treatment.
• DBT is based on biosocial theory of emotion
  dysregulation model of symptoms and theory of
  invalidating environments.
• DBT utilizes a complete array of cognitive and
  behavioral techniques.
• DBT incorporates acceptance-based philosophies
  and strategies, primarily Zen Buddhism practices,
  in the context of a dialectical philosophy.

5
The Dialectics of DBT Therapy

• Is the tension between promoting change (behavior
  therapy) and acceptance (Zen).

6
A Dialectical View of Our Patients

• Balancing Acceptance,
• Validation, and Change
• We know you have suffered a great deal and your
  life is really terrible right now, but you must
  work harder to recover

Validate the Valid Understand and
Accept Validation is not agreeing dont
validate the invalid
7
Why DBT for ED Patients?

• Comorbid BPD and parasuicidal behaviors are
  common among patients w/EDs.
• Suicide is one of the leading causes of death in
  patients w/AN.
• Many patients with EDs engage in high risk
  behaviors.
• Substantial numbers of patients w/EDs are
  refractory to front line treatments.
• DBT is a concrete and cost effective treatment.
• People with eating disorders often have the same
  type of issues with managing overwhelming
  emotions.

8
Traditional DBT Treatment

• Individual Psychotherapy
• Group Skills Training
• Team Consultation
• Telephone Consultation

9
Integrating DBT into Therapy

• Balance change with acceptance.
• Therapist must have strong, positive relationship
  with patient.
• Therapist responsible for helping patient replace
  maladaptive behaviors with skillful adaptive
  behaviors.
• Orient client to DBT and elicit commitment to
  therapy and collaborate on goals for treatment.

10
Possible DBT Solutions

• Solve the problem.
• Change your emotional reaction to the problem.
• Tolerate the problem.
• Stay miserable.
• Make things worse.

11
Treatment Hierarchy

• Target One
• Life Threatening Behaviors
• Target Two
• Therapy Interfering Behaviors (anything that
  threatens the continuation of therapy)
• non-compliance
• Target Three
• Quality of Life Interfering Behaviors
  (inconsistent with a meaningful life)
• Substance abuse or housing problems
• Employment issues
• Target Four
• Increasing Behavioral Skills to facilitate a life
  worth living

You can set treatment goals for each of these
targets but you always focus on resolving the
highest target before moving on to another target.
12
DBT Four Modules

• Acceptance Skills
• 1. Mindfulness
• 2. Distress Tolerance
• Change Skills
• 3. Emotional Regulation
• 4. Interpersonal Effectiveness

DBT is effective because it breaks down complex
concepts into teachable skills that patients can
understand and access when in crisis.
13
Behaviors treated by DBT Skills

• 1. Mindfulness inability to identify cues of
  hunger and satiety, mindless eating
• 2. Distress Tolerance impulsivity, anxiety,
  tolerating re-feeding, using ED to manage
  emotions
• 3. Emotional Regulation labile or no affect,
  inability to identify emotions
• 4. Interpersonal Effectiveness interpersonal
  chaos, saying no, asking for help, passivity

14
DBT can be helpful to

• Increase
• Structured eating
• Awareness of hunger/fullness
• Non-judgmental approach toward food and body
• Skill use when emotionally dysregulated
• Decrease
• Unstructured eating
• Food avoidance
• Food/body obsessions
• Judgments about weight, shape, appearance
• Compensatory behaviors
• Use of ED to cope with difficult emotions

15
Mindfulness

• Mindfulness means paying attention in a
  particular way on purpose,in the present
  moment, andnonjudgmentally.
• Jon Kabat-Zinn

16
Mindfulness Works in Tandem with the Other DBT
Skills

• Mindfulness is incompatible with ED behaviors
  because one cannot be mindful and engage in
  behaviors that decrease affect.
• Patients become mindful of their avoided emotions
  and self-judgments.
• Mindfulness provides a framework for teaching the
  difference between thoughts, emotions, and the
  values of each and prepares patients to use
  other DBT skills.

17
Three Primary States of Mind
Wise Mind is the integration of Reasonable Mind
and Emotion Mind
Emotion Mind emotions Override logical
thought And control thinking
Reasonable Mind devoid of emotion, emphasizes
use of logic
18
Mindfulness Skills

• The What Skills
• Observe
• Describe
• Participate
• The How Skills
• Non-judgmentally
• One-mindfully
• Effectively
• States of Mind

Emotional mind
Rational mind
Wise mind
19
Mindfulness Applied

• Handout
• Handout 2

• Examples
• Im so full. Im gross.
• Thats it, Im going on a 10 miles run!
• When my Dad says Why dont you just eat - I
  want to restrict more.

• DBT Skills
• Describe non-judgmentally

20
MINDFULNESS HANDOUT 2
Taking Hold Of Your Mind "What"
Skills Observe Just notice the experience without
getting caught in the experience. Experience
without reacting to your experience.Notice what
comes through your senses your eyes, ears, nose,
skin, tongue. Describe Put words on the
experience. Describe to yourself what is
happening. Call a thought just a thought, a
feeling just a feeling. Don't get caught in
content. Participate Enter into your experience.
Let yourself get involved in the moment, letting
go of ruminating. Do just what is needed in each
situation - neither willful nor sitting on your
hands.
21
Distress Tolerance

• Goal of DT to help patients tolerate pain and
  accept life as it is in the moment rather than
  using impulsive behaviors.
• Four sets of crisis survival skills are taught
• Distracting
• Self-soothing
• Improving the moment
• Pros and cons
• Acceptance skills are taught radical acceptance,
  turning the mind willingness vs. willfulness.

22
Distress Tolerance Applied

• Handout
• Handout 1

• Examples
• My mom told me I look healthy.
• Im going to restrict dinner tonight.
• Im gaining weight and I cant stand it!

• DBT Skills
• Managing crisis
• Distraction, Accepting Reality
• Distraction

23
Distress Tolerance Handout 1

• Crisis Survival Strategies DISTRACT - Wise Mind
  ACCEPTS
• With ACTIVITIES
• With CONTRIBUTING
• With COMPARISONS
• With EMOTIONS (Opposite Emotions)
• With PUSHING AWAY
• With THOUGHTS
• With SENSATIONS

24
Emotion Regulation

• Goal Emotion regulation skills focus on
  improving control over emotions and learning
  techniques for modulating emotions.
• Skills
• Understand emotions
• Reduce emotional vulnerability
• Decrease emotional suffering
• Act opposite to painful emotions
• Identify and label emotions vs. hunger/fullness
• Increase pleasant activities

25
Emotional Regulation Applied

• Handout
• Handout 10

• Examples
• Im so depressed I dont want to go to the
  movies.

DBT Skills Changing Emotions by Acting Opposite
to Current Emotion
26
Emotional Regulation Handout 10

• Changing Emotions by Acting Opposite to Current
  Emotion
• FEAR Do what you are afraid of doing....OVER AND
  OVER AND OVER.
• GUILT OR SHAME
• When guilt or shame is JUSTIFIED (emotion FITS
  your wise mind values) Repair the transgression,
  say you are sorry.
• When guilt or shame is UNJUSTIFIED (emotion DOES
  NOT fit your wise mind values) Do what makes you
  feel guilty or ashamed....OVER AND OVER AND OVER.
  
• SADNESS OR DEPRESSION Get active, approach,
  don't avoid. Do things that make you feel
  competent and self-confident.
• ANGER Gently avoid the person you are angry with
  rather than attacking them (Avoid thinking about
  him or her rather than ruminating).

27
Interpersonal Effectiveness

• Goal To help patients learn to use their voice
  rather than using their ED behaviors to become
  socially effective.
• Skills
• Obtaining changes one wants while maintaining the
  relationship and self-respect
• Negotiating conflict
• Asking for what one needs
• Assertiveness and saying no
• Dealing with interpersonal conflict
• Staying emotionally regulated while in conflict

28
Interpersonal Effectiveness Applied

• Handout
• Handout 8

• Examples
• I need to ask my school for a leave of absence
  to get treatment and Im scared.
• My roommate posted on her Facebook page that I
  have an eating disorder!
• My husband thinks Im in recovery but Ive
  relapsed.

• DBT Skills
• Situations for Interpersonal Effectiveness,
  Getting What You Want - DEARMAN

29
Interpersonal Effectiveness Handout 8

• Guidelines for Objective Effectiveness Getting
  What You Want DEAR MAN
• DESCRIBE Describe the situation when necessary -
  stick to the facts and no judgmental statements
• EXPRESSExpress feelings/opinions about the
  situation clearly.
• ASSERT Assert your wishes. Ask for what you want
  or say no clearly.
• REINFORCE Reward people who respond positively
  to you when you ask for something, say no or
  express an opinion.
• STAY MINDFUL 1. Broken Record 2. Ignore
• APPEAR CONFIDENT Use confident tone of voice
  confident physical manner.
• NEGOTIATE Be willing to give to get Offer and
  ask for alternate solutions.

30
Structuring the Session

• First address Target One issues
• Burning issues? (yours and mine)
• Homework Review
• Summarize
• Goal Setting
• Homework

31
Barriers to Treatment

• What do you do if your client rejects the skill?

1. Commitment and Motivation work with patient
- What are you willing to do? 2. Refer to
Possible DBT solutions. 3. Play devils advocate
to engender counter argument from patient It is
really difficult to change Maybe now is not
the time..
32
Q A

• Thank you for your time!

33
Resource list

• Cognitive-Behavioral Treatment of Borderline
  Personality Disorder. Marsha Linehan. The
  Guilford Press. (May 14, 1993).
• http//behavioraltech.org
• Skills Training Manual for Treating Borderline
  Personality Disorder. Marsha M. Linehan. The
  Guilford Press. (May 14, 1993).
• Dialectical Behavior Therapy in Clinical
  Practice Applications across Disorders and
  Settings. Linda A. Dimeff, Kelly Koerner. Marsha
  M. Linehan (Foreword). The Guilford Press.
  (August 14, 2007).
• Dialectical Behavior Therapy with Suicidal
  Adolescents. Alec L. Miller, Jill H. Rathus,
  Marsha M. Linehan. The Guilford Press (November
  16, 2006).
• Helping Teens Who Cut Understanding and Ending
  Self-Injury. Michael Hollander. The Guilford
  Press. (June 10, 2008).
• The High Conflict Couple A Dialectical Behavior
  Therapy Guide to Finding Peace, Intimacy,
  Validation. Alan Fruzzetti, Ph.D. (Foreword-
  Marsha M. Linehan). New Harbinger Publications.
  (December 3, 2006).
• Dialectical Behavior Therapy Workbook Practical
  DBT Exercises for Learning Mindfulness,
  Interpersonal Effectiveness, Emotion Regulation,
  Distress Tolerance. Matthew McKay, Jeffrey C.
  Wood, Jeffrey Brantley. New Harbinger
  Publications. (July 2007).
• Depressed and Anxious The Dialectical Behavior
  Therapy Workbook for Overcoming Depression
  Anxiety. Thomas Marra. New Harbinger
  Publications. (May 2004).