Is DBT Effective for the Treatment of Eating Disorders?

Dialectical-behavioral therapy (DBT), as developed by Dr. Marsha Linehan, is a type of therapy that helps patients reduce emotional reactivity and improve thought patterns and interpersonal interactions. The therapy, a hybrid of cognitive-behavioral therapy and tenets from eastern philosophies (primarily Buddhism), was created to help those who struggle with borderline personality disorder and chronic suicidality. However, DBT has also shown promise in the treatment of substance use disorders and eating disorders.

DBT is a problem-solving, but accepting approach – one that helps patients change, while accepting them for who they are. This duality (or “dialectical” view) seems to sit well with many patients as they struggle on the road toward recovery. The avoidance of either/or thinking (e.g., “I’m either recovered or I’m a failure”) can help patients restructure other black-or-white thought patterns common in those with eating disorders.

DBT offers an affect-regulation approach to eating disorders – helping sufferers to cope less pathologically with some of the challenging emotions that might precipitate eating disorder symptoms. Patients who are treated with DBT learn four broad, overlapping sets of skills in the areas of: 1) mindfulness 2) distress tolerance 3) emotion regulation and 4) interpersonal effectiveness.

Individual skills in the mindfulness module include learning how to use one’s “wise mind” and engaging in non-judgmental awareness. In the distress tolerance module, patients hone crisis coping skills, such as distracting and self-soothing. With emotion regulation, patients learn how to identify and label emotions, as well as how to create a life that is less vulnerable to intense emotional shifts. In the interpersonal effectiveness module, patients learn assertiveness skills, such as asking for what they need and saying no to others’ request.

Research into the efficacy of using DBT to treat eating disorders has been encouraging, though additional, broader research is warranted. In an early study of women with binge eating disorder, participants treated with DBT showed significant reduction in binge eating behavior, with 89 percent of the sample binge-free at the end of the study and 56 percent abstinent at the six-month follow-up. In a similar study of women with bulimia nervosa, results showed “highly significant decreases” in bulimic symptoms following DBT treatment.

More recently, researchers piloted the use of DBT with adult patients with anorexia, and the treatment showed promise. DBT was associated with increased BMI in participants, evident at six- and twelve-months.

A number of eating disorder treatment centers offer DBT as a complement to other types of therapies. Patients typically learn DBT in group settings, where the modules are introduced cyclically so that new patients can join the discussion at any time. Patients often report that DBT provides a helpful, solution-oriented adjunct to their treatment. Particularly when distressed, they can rely on their DBT skills to cope with emotional challenges in the moment.

Take the case of Eddie, a 45-year-old man with binge eating disorder. Learning DBT was helpful in reducing his binge episodes through various pathways. He became more mindful of his hunger and mood states through a consistent mindfulness practice. He learned how to better insulate himself against emotional distress – behaviors like consistent sleep hygiene and sufficient food intake helped protect him against any emotional waves he encountered. (Eating enough, too, helped protect him against over-hunger, which often triggered a binge).

Eddie had earmarked some tools from his distress tolerance module so that when he did experience distress, he had some alternatives to bingeing. Some of his go-to self-soothing skills included going for a drive or spending time with his dog. Finally, Eddie had learned that a significant trigger for his binges was feeling overwhelmed by life’s demands and promises to others at work and home. In the interpersonal module, Eddie learned how to say no skillfully to others’ requests, a practice that previously evaded him. These skills collectively helped Eddie experience a significant reduction in binge eating episodes and an improvement in overall wellbeing.