Dialectical Behavior Therapy for Binge Eating and Bulimia
The treatment of eating disorders is often discussed as being complicated with few manual-based approaches. The most frequent treatment approach recommended has been cognitive-behavioral therapy (CBT), with over 20 published controlled trials. One approach that falls under the broad CBT umbrella and that has empirical support for effectiveness is dialectical behavior therapy (DBT). DBT was originally developed by Marsha M. Linehan, PhD, to treat chronically suicidal individuals who met criteria for borderline personality disorder. DBT combines cognitive and behavioral techniques for emotion regulation and reality-testing with concepts of distress tolerance, acceptance, and mindfulness. Dialectical strategies offer a way for clients to balance and accept change in the context of their own worldview while helping them to develop new strategies or skills to change dysfunctional behavior.
The authors present an approach to treating bulimia nervosa and binge eating disorders based on an empirically supported and modified version of DBT. Their presentation develops a set of guidelines to work effectively with these 2 eating disorders. The authors caution, as a guideline, that there is limited information about the effectiveness of DBT with anorexia nervosa. Also, they strongly recommend training and supervision when implementing DBT skills.
The authors present a well-written and practical approach to the treatment of bulimia nervosa and binge eating. They cover rationale for the use of DBT in this population and clearly define assessment and implementation of the skills of Mindfulness, Emotion Regulation, and Distress Tolerance. Each of these skills has an excellent description of how to present material in a group format, including potential exercises.
Briefly, DBT for eating disorders is based on a broadly defined affect regulation model. The basic theoretical conceptualization is that eating disorder behavior (ie, binge eating, purging) serves to regulate intolerable emotions in individuals with few or no adaptive strategies to cope with affect. Bingeing functions to change attention and cognitive focus from uncomfortable thoughts, as well as provide immediate escape or avoidance from uncomfortable physiologic and emotional experiences. Bulimic behaviors become overlearned dysfunctional reactions to dysregulated emotions. The longer-term effects of bingeing or bulimic behaviors are emotional experiences such as guilt or shame that can contribute to and maintain eating-disordered behavior. DBT emphasizes evaluating the specific pattern of emotions, their source, and their meaning in the individual’s world. These are considered in the context of the individual’s skills to cope with the emotional experience. DBT targets disordered eating behaviors directly, and as emotions are generated by efforts to regulate eating, treatment targets the increase of distress tolerance and emotion regulation.
The material in this book is based on a model developed at Stanford University with an emphasis on stopping (1) therapy-interfering behavior and (2) binge eating and decreasing (3) mindless eating; (4) cravings, urges, and preoccupation with food; (5) capitulating; and (6) apparently irrelevant behaviors (eg, weighing). This model involves didactics as described but also application of mindfulness to eating (eg, mindfully planning, regular eating), problem-solving and distress tolerance skills for urges to binge and purge, and radical acceptance of body image.
Interventions described may be similar in each session such as diary cards (including ratings of urges to binge, binge eating, mindless eating, apparently irrelevant behavior [eg, easy access to binge foods], goal capitulation, food cravings, food preoccupation, and weekly weight), chain analysis, and solution analysis (what skills the client has used or will use in the future). Within each session, the therapist establishes reasons for skills failure, reinforces approximations of skills, and ensures broad skills use rather than overreliance on one skill.
The use of didactic strategies to cope effectively is based on teaching 3 skills modules (Mindfulness, Emotion Regulation, and Distress Tolerance). Mindfulness is presented as living with awareness in the moment, being nonjudgmental without attachment to the moment. Specific Mindfulness skills are elaborated in the book and continue throughout treatment. Distress Tolerance focuses on acceptance and involves acknowledging what is without bitterness, resentment, or undue shame or guilt. In DBT for eating disorders, every change strategy is paired with an acceptance-based validation strategy. Validation involves responding in a genuine way to the client’s thoughts and feelings as understandable given his or her current situation, learning history, and beliefs and in terms of the model of eating disorder behavior. Emotional Regulation skills are designed to develop and implement adaptive skills to effectively manage negative emotions. This includes identifying, labeling, and understanding the function of emotions; reducing vulnerability to intense emotions; increasing positive experiences; and using mindfulness to change emotions when doing so would be effective.
The authors also interject excellent case material throughout the book that helps the reader understand how the strategies can be successfully administered. Additionally, the final chapters review the potential for DBT with eating disorders such as anorexia nervosa and the future directions of this intervention. Overall, this is a highly readable and well-organized book that helps those interested in treating bulimia nervosa and binge eating disorder to develop new skills in treatment. The one caveat concerning this book is that it does not have a DVD for the reader to see how specific intervention may be presented in the context of treatment.
Author affiliation: University of Iowa Carver College of Medicine, Iowa City. Potential conflicts of interest: None reported.
doi:10.4088/JCP.10bk06689
© Copyright 2011 Physicians Postgraduate Press, Inc.
