Adults and adolescents who suffer from eating disorders (ED) also commonly present with Nonsuidical Self-Injury disorder (NSSI). With so much at stake, treating both at the same time is a scary proposition for many therapists and counselors.
At CEBT, as specialists both in Dialectical Behavior Therapy (DBT) and the treatment of eating disorders, we have a certain comfort level in addressing the co-occurrence of self-harm and complex eating disorder presentations. Given that Self-harm Awareness Month and Eating Disorders Awareness Week both occur in March, it feels timely to address this challenge.
For providers of DBT, self-harm is considered a Target 1 behavior – meaning it has the capacity to be life-threatening. Research has shown that self-harm has a meaningful purpose: It functions as an escape from emotional pain. But it’s still harmful and can increase vulnerability toward higher risk-taking and life-threatening behaviors.
Best practices require that providers have sufficient training in managing self-harm and eating disorder behaviors before addressing these concerns directly with clients.
Such training will emphasize the importance of working with the client to build his or her own commitment to changing the behaviors. But what if a client says they’re not interested in reducing or stopping self-harm?
A DBT therapist will focus with a client on motivation and commitment to reducing self-harming behaviors before moving on to another target.
Therapists will work with behavioral interventions to build understanding and awareness of the pattern of thoughts, emotions and interactions with others that create the urge toward self-harm. From there, the goal is to replace self-harming behaviors with ones that aren’t life threatening and have lesser consequences.
Of course, eating disorders themselves have life threatening complications, which are also Target 1 behaviors. So, when working with a client who engages in self-harming behaviors and presents with life threatening medical conditions, which do we address first?
It depends.
Strictly speaking, in DBT, life-threatening medical complications require an intervention before reviewing self-harming behaviors. In practice, however, even a commitment to address immediate medical concerns may be elusive.
If there is an imminent life-threatening medical concern stemming from eating-disorder behaviors, the therapy focuses only on seeking medical treatment. Using collaborative behavioral interventions, client and therapist work on attending to – and being accountable for – stabilizing medical concerns.
If the medical concerns aren’t life threatening and there are self-harming behaviors, conducting a collaborative behavioral analysis on the self-harming behaviors happens next.
Accomplishing these goals is no small feat.
By obtaining training in both DBT and complex eating disorders, providers can acquire the tools to navigate the uncertainties around such complex cases. These tools help the clinician to manage the balance between acceptance and change – allowing more effective collaboration with clients on the journey to a better life.
While the steps on that journey often feel uncertain – sometimes to the clinician as well as the client – there is comfort in knowing that the very structure of DBT means that behaviors with life-ending potential are addressed, allowing the treatment to focus on creating a life worth living.
Image by 愚木混株 Cdd20 from Pixabay
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About the Author:
Jennifer Campbell, LISW/LISW-S, is a DBT LBC Certified Clinician™ and has several years of experience delivering evidence based treatments, including comprehensive DBT, CBT-E, ACT, and DBT-PE for clients across various levels of care.