Therapy Models for Treating Eating Disorders
The rationale for applying DBT to the treatment of eating disorders (EDs) has been described comprehensively in the literature. The rationale proposed suggests that alternative approaches are necessary for eating disorders because current empirically founded treatments (e.g. cognitive behavioral therapy and interpersonal psychotheray) may only be partially effective or ineffective for a select number of patients. DBT can be considered a logical alternative because, unlike other approaches, it is based on an affect-regulation model of treating ED symptoms. Eating pathology (e.g. binge-eating, self-induced vomiting, restriction, etc.) may now be understood as mechanisms to cope with emotional vulnerability (Telch et al., 2000), as opposed to errors in cognition or faulty interpersonal relationships alone ( Fairburn et al., 1993).
DBT Applied to Clients Diagnosed with Eating Disorders: A Review
Those articles presenting efficacy data have consistently shown great promise for the adaptation of DBT theory and techniques to treat clients with eating disorders. For example, a case report published by Safer, Telch and Agras (2001a) applied a DBT approach to treat a previously unresponsive adult female with a long history of bulimia nervosa (BN) symptoms. This approach consisted of an abridged DBT skills training program to address ED symptoms, as well as consultation team meetings for the support of the clinician. This treatment did not include all the traditional elements of standard DBT: individual therapy sessions were seen as a proxy for group skills training, and the Interpersonal Effectiveness Skill module and telephone skills coaching were not included. Nonetheless, this patient experienced a rapid decline in both binge-eating and purging behaviors, showing drastic change at both post-treatment and at six-month follow-up. Safer and colleagues have also evaluated the effects of another DBT adaptation (20 weeks of skills training) for the treatment of bulimia nervosa (Safer, Telch & Agras, 2001b) and binge eating disorder (Safer, Robinson & Jo, 2010). In both studies, significant improvements on measures of binge-eating and related eating pathology were found post-treatment. A limitation of these studies, however, is that they primarily included individuals presenting with low to moderate levels of ED symptoms and excluded those suffering from anorexia nervosa (AN) and multiple treatment targets.
The treatment of clients with more significant ED symptoms and multiple problem behaviors requires more comprehensive treatment models (Ben-Porath, Wisniewski & Warren, 2009; Chen, Mathews, Allan, Kuo & Linehan, 2008; Kroeger et al. 2010). Our group has published detailed descriptions outlining the rationale and use of DBT for complex clients with comorbid Axis I and II disorders (Federici, Wisniewski & Ben-Porath, 2012; Wisniewski, Bhatnagar, & Warren, 2009; Wisniewski, Safer, & Chen, 2007). Although still considered preliminary, examinations of more comprehensive DBT programs (weekly consultation team and all four traditional DBT skills modules) appear to be effective in treating both eating disorder and self-harm behaviors (Bankoff et al., 2009; Chen, Matthews, Allen, Kuo, & Linehan, 2008; Kröger, Schweiger, Sipos, Kliem, Arnold, Schunert, & Reinecker, 2010; Palmer et al., 2003).
Anorexia nervosa (AN), the ED most resistant to treatment, has received considerably less attention in the DBT literature. In an effort to close this gap, one group explored the effectiveness of DBT in six adolescents diagnosed with AN and six adolescents diagnosed with BN (Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, & Miller, 2008). In their 25-week program, the six women diagnosed with anorexia demonstrated an appreciable weight gain post-treatment. Another group has been developing a model to use a DBT adaptation to treat the over-control that is a signature of individuals whose primary eating disorder symptom is restriction (Lynch, Gray, Hempel, Titley, Chen and O’Mahen (2013).
Continued research in the DBT and ED field is needed to develop a stronger base of studies evaluating the effectiveness of DBT for the treatment of EDs.
When is it appropriate to use DBT with clients diagnosed with an eating disorder?
Not all eating disorder clients are appropriate for comprehensive DBT and comprehensive DBT is not appropriate for all clients with eating disorder. DBT should be considered with eating disorder clients for whom standard, evidence-based treatments have not helped, for clients who have a co-morbid diagnosis, or for when emotion regulation issues are central to a client’s illness.
Advice for clinicians
A common pitfall that DBT clinicians may experience when they begin treating eating disorders is they assume that the disorder is NOT about the food. Clinicians must understand that it is not about the food until it is! It is not about the food until you ask a client with restrictive behaviors to eat or one with binge eating to refrain from eating. More specifically, a patient may be using restrictive behaviors to “numb” emotions and to feel “in control,” yet when faced with a granola bar that contains more than a predetermined number of calories, the anxiety and fear are really about THAT granola bar in THAT moment (not about being in control or numbing emotions).
Also, it is standard in ED treatment for the therapist to take the individual’s weight at the start of each session. DBT therapists without ED experience may find this uncomfortable.
My advice to any clinician: if you are going to choose to see patients who suffer from an eating disorder, get trained! There is a heavy dose of cognitive behavioral treatment for EDs that is needed as part of the treatment. Training and supervision in EDs is necessary to successfully treat these clients.
If you are interested in learning more about DBT and eating disorders, Dr. Wisniewski has prepared an Eating Disorder Reading List for clinicians who would like to read more about the topic.
Lucene Wisniewski, PhD, FAED, is the owner and founder of Lucene Wisniewski, PhD, LLC, and DBTOHIO, as well as an Adjunct Assistant Professor of Psychological Sciences at Case Western Reserve University. From 2006-2014, she served as Clinical Director and co-founder of the Cleveland Center for Eating Disorders, a comprehensive eating disorder treatment program offering evidenced based care. Wisniewski served as the Chief Clinical Integrity Officer of the Emily Program, a multi-state eating disorder program from 2014-2017. Her research and clinical interests center around program development and using empirically founded treatments to inform clinical practice. She provides workshops on the CBT and DBT treatment of eating disorders internationally and publishes in peer reviewed journals as well as invited book chapters. Dr. Wisniewski has been elected fellow, has served on the board of directors, and as the co-chair of the Borderline Personality Disorder special interest group of the Academy for Eating Disorders (AED). In 2013 the AED awarded Dr. Wisniewski the Outstanding Clinician Award to acknowledge her contribution to the field of eating disorder treatment.