Dialectical Behaviour Therapy for Eating Disorders

DBT was originally developed by American psychologist Marsha M. Linehan in the 1970s and 1980s as a therapy for people with a diagnosis of borderline personality disorder (BPD). Over time, researchers and clinicians began to recognise that DBT could also be adapted to support people with other mental health difficulties that involve emotional dysregulation and unhelpful ways of coping, such as eating disorders. Since the early 2000s, DBT has been increasingly used to support people with eating disorders, including anorexia nervosa, bulimia nervosa, and binge eating disorder.

Principles of Dialectical Behaviour Therapy for Eating Disorders

There are several key principles underlying the application of DBT for eating disorders.

Dialectical Thinking

DBT encourages clients to recognise and accept the inherent contradictions and tensions in their: 

• Thoughts
• Feelings
• Behaviours 

Related to their eating disorder. For example, on one hand, the person might desperately want to get better, but on the other hand, they find themselves actively protecting their eating disorder and resisting change. Dialectical thinking seeks to accept and incorporate both of these truths as a necessary step towards change.

A key skill in DBT for eating disorders is dialectical abstinence. Dialectical abstinence means making a full commitment to stopping all eating disorder behaviours. Because the urges to engage in these behaviours can be so strong, the commitment needs to be 100%, and it is kept at the front of your mind.

At the same time, you also hold in mind - way, way back, so that it never weakens your resolve - that if a slip happens, you’ll meet it without judgement and recommit to full abstinence. 

Emotional Regulation

Many people with eating disorders find intense emotions hard to manage, and may cope through restrictive eating, bingeing, overexercising, or purging. DBT aims to help people develop other ways of regulating their emotions by teaching skills related to mindfulness, distress tolerance, and emotion regulation. 

Validation and Support

DBT emphasises the importance of validating clients' experiences and emotions, while also providing a supportive environment in which they can take steps towards change. This approach helps reduce feelings of shame and self-blame often associated with eating disorders, which can be barriers to change.

Techniques Used in Dialectical Behaviour Therapy for Eating Disorders

Key features of DBT for eating disorders are:

• Chain analysis - This involves taking a detailed account of all the different thoughts, feelings, behaviours, and situations that led up to engaging in an eating disorder behaviour as a way to understand the function (or purpose) of the behaviour and target the triggers
• Daily diary cards - This is a daily record of DBT skills used, emotions, and urges to engage in eating disorder and other unhelpful behaviours

DBT for eating disorders typically involves a combination of individual therapy, group skills training, and phone coaching. Some of the key techniques used in DBT for eating disorders include:

Mindfulness

Clients learn to observe and describe their thoughts, feelings, and sensations without judgement. This practice helps build self-awareness and emotion regulation, which can be particularly helpful for people with eating disorders. 

A key part of DBT for eating disorders is applying mindfulness to eating to notice and accept difficult feelings that come up around eating, and to ease preoccupation with food.

Distress Tolerance

This aspect of DBT teaches people how to tolerate and cope with distressing emotions and situations without turning to behaviours that cause harm. Skills learned may include distraction, self-soothing, and radical acceptance.

Emotion Regulation

DBT helps people learn to identify, understand, and manage their emotions more effectively, which can be important in working with the emotional dysregulation often present in eating disorders.

Effectiveness of Dialectical Behaviour Therapy for Eating Disorders

A growing body of research suggests that DBT can be an effective therapy for eating disorders. Several studies have found that DBT can lead to significant reductions in eating disorder behaviours and thoughts, as well as improvements in emotion regulation and overall psychological wellbeing. Some studies have also found that DBT can reduce how often binge eating and purging happen, and support weight restoration for some people with anorexia nervosa.

Benefits and Limitations

Benefits of DBT for eating disorders include:

Comprehensive Approach: DBT addresses both the emotional and behavioural aspects of eating disorders, making it a more comprehensive option than some other forms of therapy.

Skills-Based Focus: By teaching concrete skills for managing emotions and behaviours, DBT can help people with eating disorders build a stronger foundation for lasting change.

Evidence-Based: DBT is supported by a growing body of research showing it can help people with eating disorders.

While DBT has been shown to help many people with eating disorders, it may not be the best fit for everyone. Some people find other therapeutic approaches a better fit, or need additional support for co-occurring difficulties such as trauma.