Dialectical Behavior Therapy for Complex Eating Disorder Presentations: Rationale and Overview
DBT is a comprehensive treatment intervention that is celebrated for its success in treating suicidal and self-injurious behaviors in a population once considered treatment resistant (e.g., individuals with borderline personality disorder; Linehan, 1993a). The past decade alone has witnessed the rapid growth and application of DBT to a wide variety of mental disorders. Randomized trials have shown that DBT is associated with fewer hospital admissions, lower rates of substance abuse and angry outbursts, increased client commitment to therapy, fewer dropouts, and decreased therapist burnout (see reviews by Lynch, Trost, Salsman, & Linehan, 2006; Robins & Chapman, 2004). Applied in its standard format, DBT involves a 1-year commitment to weekly individual therapy, group skills training, telephone skills coaching, and a therapist consultation team (Linehan, 1993a, 1993b). DBT uses a combination of behavioral principles, cognitive modification techniques, Eastern meditative practices, and acceptance-based strategies, with the aim of helping clients eliminate impulsive and self-destructive behaviors while building a life worth living (Harned, Banawan, & Lynch, 2006).
Affect Regulation Model and Biosocial Theory
DBT is based on an affect regulation model. From this perspective, problematic and self-destructive behaviors (e.g., self-injury, food restriction, vomiting) are primarily caused by deficits in one's ability to adaptively regulate emotion (Harned et al., 2006; Linehan, 1993a). Individuals with emotion regulation deficits typically have difficulty experiencing or tolerating emotions, accurately identifying various feeling states, and adaptively communicating their emotional needs. Without the ability or skills to regulate emotions in a reliable and consistent manner, emotionally sensitive individuals often feel unstable and unsure of their needs and often have difficulty in relationships. Thus, symptoms become a way of reducing emotional distress (Chapman, Gratz, & Brown, 2006). Individuals with EDs consistently report that symptoms provide relief from emotions that are perceived as threatening or overwhelming or that exceed existing coping abilities (Haynos & Fruzzetti, 2011; Heatherton & Baumeister, 1991). Symptoms such as binge eating and purging have been described as coping strategies, physical escapes, and ways of withdrawing from emotional pain and discomfort (Cockell, Zaitsoff, & Geller, 2004). Similarly, food restriction and excessive exercise often subdue intense emotions by providing a sense of numbness, control, or self-soothing or by their ability to generate positive feelings (Overton, Selway, Strongman, & Houston, 2005).
Linehan (1993a) proposed that emotion regulation deficits are the result of two interconnected systems: (a) a biological vulnerability to emotions and (b) chronically invalidating environments. According to this theory, some individuals are naturally (or biologically) more sensitive to their emotions from birth. Their genetic temperaments are such that they tend to have a low emotional threshold, respond to situations with greater emotional intensity, and take longer to return to baseline once activated. Clinicians who work in the ED field are well acquainted with the pervasiveness of emotion regulation deficits in their clients. Studies have shown that individuals with EDs have difficulty accurately recognizing and labeling emotional states in themselves and others (Bydlowski et al., 2005), have greater difficulty accepting their emotions, and report greater affect dysregulation than control groups (Svaldi, Griepenstroh, Tuschen- Caffler, & Ehring, 2012).
A biological emotional sensitivity alone, however, may not be predictive of problem behavior. The risks increase when an emotionally sensitive person is repeatedly exposed to an invalidating environment (Linehan, 1993a). Invalidating environments communicate subtly or overtly that an individuals feelings and internal experiences are in some way incorrect, unacceptable, or otherwise inappropriate. Instead of providing nurturance for and tolerance of individual differences, such environments dismiss, punish, or otherwise fail to accept the experiences or needs of the individual. Over time, some individuals cope by dismissing or judging their own emotions, doubting their internal feelings and gut reactions, and ultimately never learning self-acceptance or ways to adaptively manage their emotions and needs.
