Dialectical Behavior Therapy Groups for Individuals with Eating Disorders

By Craig Boas, LCSW-C, and Kate Clemmer, LCSW-C

Dialectical Behavioral Therapy (DBT) has proven to be a very effective and beneficial modality of treatment. The overarching goal of this treatment is to help people manage and regulate overwhelming or intense emotions that can lead to destructive impulses and behaviors, what is often referred to as emotion dysregulation. Dr. Marsha Linehan developed DBT in 1993 with the primary aim of treating people who were diagnosed with Borderline Personality Disorder. Since that time, an enormous amount of research has been conducted providing evidence of its efficacy in reducing dangerous behaviors and improving global functioning for individuals with BPD.1 While DBT remains the treatment of choice for this 
population, it has also been applied and studied in the treatment of others impacted by mood disorders, trauma, substance abuse, suicidality, self-harm behaviors, ADHD and eating disorders. Specifically, two small-scale and one larger study have looked at the effects of DBT Skills Training for individuals with bulimia and binge eating disorder.2 All three found DBT skills led to significant reductions in binges or binge/purge behaviors.3, 4, 5 More extensive research could help clinicians to increase efficacy and determine which specific skills are most important for behavior change among those with eating disorders.

An extensive summary of the research on DBT is available from The Linehan Institute.

In addressing this topic, it’s helpful to understand that symptoms such as restricting calories, bingeing, purging and over-exercising, are often used by individuals with eating disorders to cope with painful or unpleasant emotional states. Unfortunately, eating disorders are progressive illnesses and typically worsen over time. As one becomes more and more ill, he or she develops a sort of tolerance to the symptoms, eventually needing to go to more extreme measures, or use symptoms more frequently, to experience the same level of emotional numbing or temporary relief from overwhelming feelings like anxiety, anger or loneliness. As you might imagine, developing skills to help regulate these emotional states and endure them without turning to harmful behaviors becomes invaluable during the recovery process. That’s where DBT comes in. Participating in DBT groups helps individuals with eating disorders to develop the skills to identify, tolerate, and validate painful emotions that could otherwise foster maladaptive behaviors around food and weight.

The Four DBT Modules: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness

At The Center for Eating Disorders at Sheppard Pratt, DBT skills are utilized in individual therapy and in groups at all levels of care, from our outpatient department to our partial hospital and inpatient settings. Our weekly outpatient groups for adults provide the most comprehensive training of the skills within the context of structured DBT practice. Prior to beginning this treatment modality, it is recommended and requested that each group member commit to attending the group for at least 10 months in order to go through two rotations of each of the four skill sets. This time commitment builds competency and, ultimately, mastery in utilization of the skills. The groups are open during this time period providing there is availability, and potential new members may join the groups at the beginning of each new skill to be taught. Here’s a brief look at each of the skill sets we cover in DBT group.

Mindfulness Skills

Mindfulness skills are the first set of skills taught in the groups because they are considered the foundation of DBT and are vital to the effectiveness of the other three skill sets. Mindfulness is a state of active, open attention to the present moment. Commonly, individuals with eating disorders have automatic or intrusive thoughts driven by perfectionism, ambivalence, and low self-esteem. Practicing mindfulness can help to diffuse those thoughts and raise awareness of one’s judgments about them. Through mindfulness, an individual can gain more flexibility and freedom in their thoughts.

Mindfulness skills are actually derived from Buddhist practices of non-judgment, acceptance, and focusing on the present moment. Thus, the goal behind the Mindfulness module is not to change, but rather to notice and accept whatever one is feeling in any given moment. Mindfulness can help eating disordered clients to tolerate anxiety that directs their behavior. For example, someone might struggle with tolerating fullness after eating a challenging meal or with negative body image thoughts while on a date. In these moments it can be helpful for an individual to engage in a deep breathing exercise where the person focuses on breathing through their diaphragm as they inhale and exhale slowly. Some clients feel that counting their breaths as they engage in this exercise makes it easier to stay focused on the present moment.

Since Mindfulness is also the most challenging of the skills to master, each group begins with a five-minute mindfulness exercise. Most of the exercises are guided meditations. An example of an exercise we use frequently in group is, “Leaves on a Stream.” In this exercise, group members are encouraged to visualize placing their thoughts, emotions, and sensations on leaves as they visualize them floating beside them and then gradually away from them. This is known as a thought defusionexercise that reinforces the impermanence of particularly unpleasant thoughts and emotions, and steers us away from rigid and absolute forms of thinking.

Distress Tolerance

Some individuals are naturally prone to be hyper sensitive to negative emotions, and even mild levels of stress may be experienced as unbearable or overwhelming.  If someone with an eating disorder is not able to tolerate distressing feelings without acting on symptoms, then those impulsive actions will continually interfere with efforts at recovery. This is where Distress Tolerance, the second module covered in our DBT groups can be helpful. This skill set helps individuals distinguish between pain which is an inevitable part of life, and suffering – the result of continued resistance to or non-acceptance of pain. While both pain and suffering can be unpleasant, pain is more tangible and short-lived. Suffering, on the other hand, is more pervasive because of the shame and denial that it encompasses.

In the distress tolerance module of DBT, group participants learn that there will be times when pain is unavoidable and that learning to accept and tolerate the short-term distress can help mitigate longer-term emotional suffering. A major concept taught during this module is radical acceptance which invites group members to stop fighting against reality or resisting painful emotions, and to instead accept that in life which is outside of their control. For example, practicing radical acceptance of the body can help to create a powerful shift away from negative body image thoughts to statements of truth such as “I have the body I have” or “I am living in this body”.

Other skills in the Distress Tolerance module include distraction, self-soothing skills, and crisis survival skills. Often times when Eating Disorder patients are struggling with food challenges or experiencing what feels like overwhelming fullness after a meal, distraction or self-soothing are among the most effective ways to ride out that discomfort. DBT participants have an opportunity to develop each of these skills during the group and to practice on their own between each session.

Emotion Regulation

The goals of the third DBT module, Emotion Regulation, are to help clients identify and validate emotions, decrease emotional vulnerability and to decrease emotional suffering. People with eating disorders often have difficulty validating their own emotions because of a genetic predisposition coupled with invalidating environmental factors such as lack of social support and peer pressure. This heightens one’s vulnerability to acting on eating disorder symptoms which becomes preferable to tolerating and experiencing painful emotions.

One of the primary objectives in Emotion Regulation is to get clients to first validate their emotional pain, which is a necessary step to regulating emotions. Another key component of Emotion Regulation is addressing and reducing one’s vulnerability factors. In applying this to eating disorders, some typical vulnerability factors include avoidance of adequate nutrition, social isolation, over-exercise, and other destructive behaviors such as substance abuse or self-harm.

The cultivation of one’s values is a vital part of participation in the DBT group and can also play an integral role in recovery from an eating disorder. This is based on the principle that emotions alone provide a flimsy foundation for action in comparison to values. During DBT group, clients learn about and practice living their lives in accordance with what they value. Some of the more commonly identified values among group members include family, work, religious or spiritual beliefs, volunteer work, or hobbies and talents.

Interpersonal Effectiveness

Difficulties with self-esteem, perfectionism, impulsive reactions to distress, and the drive to please others are some traits commonly shared by individuals with eating disorders. These traits can also negatively interfere with the development of healthy relationships. Interpersonal Effectiveness, the fourth and final module addressed during DBT groups, covers this aspect of relationships and teaches the skills needed to ensure they are balanced and fulfilling instead of toxic or destructive.

A major part of the interpersonal effectiveness module includes assertiveness skills, or asking for what you want and need from others. Another important aspect is setting boundaries, or learning to say no and resist pressure from others. During this module, members learn how to be strategic in getting their emotional needs met and practice specific strategies for resolving conflicts. This often involves learning how to assess and prioritize the objective needs, relationship needs and individual needs (self-respect).

Although, many group members may initially be resistant to role playing, this strategy can be particularly valuable in not only learning this skill but in providing an opportunity for group members to work through fears of asserting themselves. 

Creating a Life Worth Living

The term “dialectical” in Dialectical Behavior Therapy, is defined as an integration of opposites. This duality is central to DBT as clients are encouraged to practice the acceptance-oriented skills of mindfulness and distress tolerance, while also working towards positive change through emotion regulation and improved interpersonal effectiveness. This can be a difficult concept for clients to grasp initially, however most group members go on to appreciate both the emotional validation they receive and the changes they are able to make as a result of new skills learned. It’s not uncommon for group members to say “I wish I had learned these skills a long time ago.” Perhaps it’s because they are embracing the overarching tenet of DBT which is to build a life worth living. In doing so, clients learn to accumulate positive emotions and to build mastery. To “build mastery” is to set yourself up for success as opposed to taking on too much, to cope with potentially difficult emotions ahead of time and to take care of your body. When it comes to healing from eating disorders, these skills can be invaluable.

To learn more about Marsha Linehan and DBT visit behavioraltech.org/

To learn more about DBT treatment options at The Center for Eating Disorders at Sheppard Pratt in Baltimore, Maryland click here.

About the authors:

CRAIG BOAS, LCSW-C received his Master of Social Work degree from the University of Connecticut in 1995. Prior to joining the Center for Eating Disorders at Sheppard Pratt in 2009, Craig worked in multiple inpatient and outpatient settings in a variety of roles, including time as a family therapist with the Center for Eating Disorders in 2005. Craig’s current focus is in Dialectical Behavioral Therapy. Before rejoining the Center for Eating Disorders staff in 2009, Craig provided treatment at the Retreat at Sheppard Pratt where he was instrumental in the development and implementation of DBT as one of the core treatment modalities. Craig currently works in the Center’s outpatient department providing individual and family therapy and facilitating several outpatient DBT groups.

Kate Clemmer, LCSW-C

Community Outreach Coordinator, The Center for Eating Disorders at Sheppard Pratt

Kate Clemmer earned her Master of Social Work degree from the University of Maryland, Baltimore in 2005 with a focus on Management & Community Organization and a specialization in Child, Adolescent & Family Health. Before joining the Center for Eating Disorders at Sheppard Pratt staff in 2008, Kate provided individual and family therapy to children and adolescents through The University of Maryland’s School-Based Mental Health Program where she also coordinated a multi-site health education and prevention initiative. As the CED Outreach Coordinator, Kate facilitates professional trainings and community workshops, provides outreach to schools, and coordinates The Center’s annual community events including a symposium for treatment providers, the Love Your Tree Body Image Campaign, and National Eating Disorders Awareness Week. Kate also facilitates The Center’s weekly support group for individuals with eating disorders and maintains the CED website and blog.

References:

1. Chen, E.Y. & Safer, D.L. (2010). Dialectical Behavior Therapy for Bulimia Nervosa and Binge Eating Disorder In C.M. Grilo & J.E. Mitchell (Eds.), The Treatment of Eating Disorders: A clinical handbook (pp. 294-316). New York, NY: The Guilford Press.

2. Linehan, M.M. (2015) DBT Skills Training Manual, Second Edition. New York, NY: The Guilford Press.

3. Safer, D.L. & Jo, B. (2010). Outcome from a randomized controlled trial of group therapy for binge eating disorder: Comparing dialectical behavior therapy for binge eating to an active comparison group therapy. Behavior Therapy, 41(1), 106-120.

4. Safer, D.L., Telch, C.F., & Agras, W.S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158(4), 632-634.

5. Telch, C.F., Agras, W.S., & Linehan, M.M. (2001). Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology, 69(6), 1061-1065.