Courageous Conversations in Evidence Based Treatment

The nuances of Eating Disorders and DBT

As a field, we have been interested in applying Dialectical Behavior Therapy to the treatment of eating disorders for about the past 20 years, with the first writings on the topic appearing in the literature in the late 1990s. The rationale for applying DBT to the treatment of eating disorders centers around two basic concepts:

1. Current evidence-based treatments for eating disorders, such as cognitive behavioral or interpersonal psychotherapy, are not wholly effective for all patients.
2. DBT’s treatment of eating disorders is based in an affect-regulation model, which addresses eating disorder symptoms differently than other approaches.

The field has been slowly accruing research and clinical papers on the application of DBT to eating disorders, including a special series due for publication in early 2020 in Eating Disorders, The Journal of Treatment and Prevention. This special series, co-edited by Dr. Leslie Anderson, Dr. Tiffany Brown and myself, will include articles written by experts from all over the world.

It will include papers summarizing the most up-to-date data on DBT’s effectiveness with adult and adolescent eating disorders, as well as recommendations for which DBT to use with which ED diagnosis.

This latter part is important, given that the treatment for Binge Eating might be different than the treatment for Anorexia Nervosa, which also might be different from the treatment for individuals who suffer from eating disorders that co-occur with other psychiatric conditions.

The significant results from the reviewed studies are encouraging and support further research for the use of DBT with individuals who suffer from eating disorders. The findings suggest that DBT, if adapted correctly, could serve as a powerful treatment for such clients – especially those who have traditionally been difficult to treat or who have been previously unresponsive to the more standard treatment approaches.

Please, if you are treating eating disorder cases using DBT, collect data! We need to better understand and refine the treatment for this population

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 an eating disorder. DBT should be considered with 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 DBT clinicians may experience when they begin treating eating disorders is assuming that the disorder is not about the food. Clinicians must understand that it is not about the food – until it is!

It’s 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 – and not about being in control or numbing emotions.

Also, it is standard in eating disorder treatment for the therapist to take the individual’s weight at the start of each session. DBT therapists without eating disorder 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. Training and supervision in eating disorders is necessary to successfully and effectively treat these clients.