This feature by Leslie Karwoski Anderson, PhD is Part 1 of 2 in a series about DBT for eating disorders. In this first part, Leslie addresses her experience working with DBT as an eating disorder clinician and the first of five Eating Disorder skills she will discuss in this blog.
Like many eating disorders clinicians, I was drawn to the field because of my own personal experience. Growing up, I felt the societal expectations for my body and appearance were pervasive and inescapable. I felt helpless watching several friends battle severe eating disorders. I simultaneously dabbled in disordered eating and exercise practices as I tried to figure out who I was growing up in a culture that tells young women that their worth lies primarily in their appearance and thinness. And I know that I have a great deal of privilege here; I can only imagine how much more significant this societal pressure may be for those in marginalized groups or identities.
On internship, I coincidentally worked for the first time in both a primary eating disorders (ED) clinic and a DBT clinic. As a new intern, I have a distinct memory of asking my supervisor what qualities made for a good ED therapist. I had this vague awareness that when treating EDs, it is important to model certain qualities, values, and behaviors, although I had not figured out exactly how to do that. I suppose as a therapist it is always helpful to be mindful of the influence your image has on your clients. If you are a substance abuse therapist, it is probably not helpful to casually refer to the great bottle of wine you enjoyed with last night’s dinner, and it is probably even less helpful to have an active substance abuse disorder yourself. Sometimes it feels even more critical in the world of eating disorders. On my internship, I began to understand and appreciate how DBT can help us shape our therapeutic identity. I quickly learned to appreciate that in DBT we have permission to be radically genuine and use self-disclosure when effective. And, that means there is a lot riding on us to model skillful behavior.
My clinical work these days is using DBT to treat serious EDs at a PHP level of care. Much has been written about the basic philosophy of this approach, and how to adapt DBT for the ED population specifically. I want to use this blog to explore on a more personal level how DBT for ED can help us personally as clinicians treating EDs.
The vast majority of the ED clients I have treated report they have been surrounded by people who emphasize the importance of appearance. Maybe their parents role modeled yo-yo dieting or criticized their children’s bodies. Or perhaps they had a coach who insisted on them maintaining a certain body size in order to compete in a sport. Or their friends go out to eat with them and pick at dressing-less salads. It is not uncommon for my clients to say that I am the first person they have encountered that does not do these things. I feel that it is uniquely important when treating EDs that I “practice what I preach.”
In this blog, I am sharing some of the DBT for Eating Disorders skills that we teach our clients, and some thoughts about how we, as clinicians, might apply them in our own lives. This is easier said than done of course! And, I consider this transaction of us helping our clients change, while our clients and the treatment help us change, to be one of the most rewarding parts of being a DBT clinician. Let’s start with Radical genuineness.
Radical genuineness. I want my clients to emerge from ED treatment in a healthier physical state, and also equipped with the skills that will allow them to maintain their health. I want them to understand and believe that life doesn’t have to revolve around food, dieting, over-exercise and other disordered practices. I imagine that our clients look to us not just to tell them that it’s possible to have a life that is not focused on appearance, but to show them that that is possible. Much of the treatment of EDs revolves around instructing our patients to make lifestyle changes: “Don’t skip meals,” “Accept yourself as you are,” “Focus your energy on things that make life worth living rather than on your weight.”
So, what does this mean for us as clinicians? On a really basic level, it means modelling the behaviors you want them to adopt: not consuming diet foods or drinks in front of clients, not talking about being on a diet, and not making comments that are critical of your own or others’ bodies. It is probably even better if you live according to these principles even when your clients aren’t around: eat according to the philosophy that all foods are good foods, and drop not just the external self-critical remarks, but the inner self-judgment as well.
Leslie Karwoski Anderson, PhD, FAED, is an Associate Clinical Professor and the Training Director at the UC San Diego Eating Disorders Center for Treatment and Research. She trains nationally and internationally on DBT and DBT for Eating Disorders. Read her full bio here.