Dialectical Behavior Therapy for Clients With Complex and Multidiagnostic Eating Disorder Presentations

Anita Federici and Lucene Wisniewski

There is a great deal of interest in and discussion about how to improve treatment for clients with complex and multidiagnostic eating disorders (EDs) and, specifically, how dialectical behavior therapy (DBT) might be applied. In the past decade, numerous book chapters and articles have been published on the topic (see review by Bankoff, Karpel, Forbes, & Pantalone, 2012; Safer, Telch, & Chen, 2009). Most of the literature describes treatment adaptations (specifically 20 weeks of DBT skills training) for individuals with bulimia nervosa (Safer, Telch, & Agras, 2001) and binge eating disorder (Safer, Robinson, & Jo, 2010; Telch, Agras, & Linehan, 2001) who present with low or moderate illness severity. Thus, therapists treating clients with primary bulimia nervosa and binge eating disorder (e.g., those with moderate illness severity and little or no diagnostic comorbidity) are directed to these resources.

The treatment of clients with complex EDs and multiple problems is, however, more complicated. The literature to date has recommended more comprehensive treatment models for clients with chronic anorexia nervosa and for clients with multiple problem behaviors (Ben-Porath, Wisniewski, & Warren, 2009; Chen, Mathews, Allan, Kuo, & Linehan, 2008; Kroger et al., 2010; Palmer et al., 2003). Detailed descriptions outlining the rationale and use of DBT for complex clients with comorbid Axis I and II disorders have previously been published (Fox, Federici, & Power, 2012; Wisniewski, Bhatnagar, & Warren, 2009; Wisniewski & Kelly, 2003; Wisniewski, Safer, & Chen, 2007). Thus, in this chapter we expand on several key foundational concepts described in the literature in an effort to provide further guidance to clinicians working with multidiagnostic and complex ED presentations. After a brief review of the affect regulation model and the rationale for using DBT with this population, we focus the bulk of the chapter on the therapeutic stance, ways to prioritize multiple problem behaviors, strategies to increase commitment, and methods to manage therapy-interfering behaviors.