The Use of Arts In Awareness & Prevention of Eating Disorders

A 3-part series by Robyn Hussa Farrell, Founder and CEO of mental fitness

This is the third and final part in a series (View Part 1 View Part 2)

Summary: It has been an 8-year journey to evolve an evidence-based model of building and delivering award-winning prevention-focused programs in collaboration with educators, researchers and practitioners.

These arts-infused programs are created with five main elements:

- documentary style films featuring the nation’s researchers in prevention

- handouts written by researchers and practitioners

- resources

- strategies for finding CEDS and FAED specialists

- links to validated screeners and more.

Most importantly, creating and delivering the programs requires a community effort and multiple collaborations.

Today we offer an array of online and live courses. A complete listing is available here. Mental Fitness live programs have been implemented in the following school districts across the country:

• Greendale, Wisconsin
• Central Wisconsin (in collaboration with WI American Academy of Child and Adolescent Psychiatrists and Wisconsin School Nursing Association)
• Spartanburg, South Carolina (in collaboration with Veritas Collaborative, Judy Bradshaw Children’s Foundation and Mary Black Foundation)
• Columbia, South Carolina (in collaboration with Hearth Center and SCEDA)
• Weston, Connecticut (in collaboration with Weston, CT Youth Services)
• Western Suffolk, New York (in collaboration with NY AHPERD)
• Reading, Pennsylvania (in collaboration with Veritas Collaborative, Perfect as You Are and Reading Hospital)

But leading professional development workshops that educate about disordered eating awareness and prevention is only the beginning. As with many things, the more we know, the more we learn what we don’t know. The real work still lies ahead of us …

(PLEASE NOTE: the remainder of this article contains confidential information that is property of Robyn Hussa Farrell, Mental Fitness, Inc., and various research teams. For permissions or more information, please contact Robyn Hussa Farrell at rfarrell@mentalfitnessinc.org.)

Inspired by Dianne Neumark-Sztainer’s research[1], in 2012 we began to further investigate the shared risk and protective factors that underlie serious mental illnesses, eating disorders, obesity and addictions. We pulled together research from developmental psychology, looking at the overlap between prevention and kindergarten readiness. Gathering publications from multiple areas of science, we located validated assessments, evidence-based interventions and put them together into our Mental Fitness Map. This has become our mechanism for linking evidence-based prevention programs to schools and universities.

To help us bring together these resources, we built a prevention site (BResilient.co) and the NOURISH prevention center (NOURISHSpartanburg.com), where parents and children can take classes and attend workshops.

Generally, we are in the process of investigating and learning that communities can improve behavioral health, overall health and improve kindergarten readiness by focusing on the shared protective factors that can be taught to children ages 0-5 and their parents. In addition to Mental Fitness’s findings in Spartanburg schools in 2013-2014 (see Part 2 for complete detail), the below appendix contains supporting data emphasizing the overlap in four key areas. The below hypotheses have led to our key research and design projects for 2015-2016 which are available on our website at MentalFitnessInc.org.

We are especially grateful to the primary researchers with whom we have had the privilege of collaborating on the below report; including, Christina Anderson, Ph.D., Cynthia Bulik, Ph.D., Deb Burgard, Ph.D., Melissa DeRosier, Ph.D., Camden Elliott, MD., and Christine Peat, Ph.D.

1. The Mental Fitness “Map” is based on the below research at University of Minnesota, emphasizing the importance of focusing on the shared risk and protective factors for mental health and obesity as the new way for preventing obesity, mental illnesses, and improving health outcomes. [2]

o   “A major challenge to developing interventions that are able to prevent both obesity and eating disorders is the identification of potent and modifiable factors that have relevance for both conditions[3]. Identification of appropriate risk factors for the condition being targeted is essential to developing effective prevention interventions[4].”

o   “Other potential shared risk and protective factors that may be worthy of further etiologic inquiry include self-esteem, depression, dietary intake patterns (e.g. meal patterns), the role of parental encouragement or role modeling of weight-related behaviors and the role of a home environment that is supportive of healthy eating and physical activity behaviors.[5]” (these have all been integrated into our Mental Fitness map)

2. Studies that look at the long-term impact on individuals who benefitted from early childhood education at ages 0-5, show profound improvement in social and emotional learning skills, less crime, higher graduation rates and increased employment.[6]

o   “The High/Scope Perry Preschool study followed 123 children from preschool well into adulthood. … the study found a persistent effect on achievement tests through middle school, a finding consistent with results from the meta-analysis of all relevant research literature. In addition, the preschool group had better classroom and personal behavior as reported by teachers, less involvement in delinquency and crime, fewer special education placements, and a higher high school graduation rate.[7] Through age 40, the program was associated with increased employment and earnings, decreased welfare dependency, and reduced arrests. Long-term effect sizes are in the range from 0.30 to 0.50 standard deviations. High school graduation increased from half to two-thirds, the number of arrests by age 27 fell by half, and employment at age 40 showed an increase of 14 percentage points.[8]”

o   “Multiple meta-analyses conducted over the past 25 years have found preschool education to produce an average immediate effect of about half (0.50) a standard deviation on cognitive development.[9] This is the equivalent of 7 or 8 points on an IQ test, or a move from the 30th to the 50th percentile for achievement test scores. For the social and emotional domains, estimated effects have been somewhat smaller but still practically meaningful, averaging about 0.33 standard deviations.[10] To put these gains in perspective, it’s important to realize that on many measures, a half standard deviation is enough to reduce by half the school readiness gap between children in poverty and the national average.”

3. Social and emotional learning skills, similar to those taught through the Mental Fitness programs, contribute to the prevention of obesity.[11]

o   “There is tremendous overlap between the social skills targeted in Social Skills Training programs and the skills necessary to produce lifelong change in obesogenic habits. For example, in order to change dietary habits, children need to have nutritional knowledge, as well as impulse control to resist energy dense foods. The impulse control strategies used for maintenance of a healthy diet are parallel to the impulse control and emotion regulation strategies used in social interactions wherein children may need to resist aggressive impulses and maintain a calm and cooperative attitude. In addition, learning respect for oneself and others, improving perspective taking ability, maintaining a positive attitude, understanding responsibility, and learning to use action plans to achieve short and long-term goals are important skills for obesity prevention and the development of positive peer relations and provide benefit when used in an independent social skill intervention[12] or when used in conjunction with other intervention program components[13]. Given the strong evidence supporting the positive and reinforcing effect of peers on diet and activity, the novel, collaborative approach combining the best practices in obesity prevention with complimentary social skill training can provide potent, long-lasting effects for all children, regardless of weight, and therefore can contribute to the prevention of obesity.”

4. Emotional well-being, social competence, and cognitive abilities – together – are the brick and mortar that comprise the foundation of human development.[14] These have been linked to improving mental fitness, obesity prevention and children’s readiness for school.

o   “Being able to regulate emotion, pay attention, work independently and with peers, and make good choices are paramount in determining children’s readiness for school[15]. These early SEB skills are critical prerequisites for school entry [16]. Young children with low SEB skills are more likely to display antisocial behaviors, dislike school, perform poorly on academic tasks, and experience grade retention and drop out [17], and are more likely to be inattentive, disruptive, or withdrawn in the classroom[18].”

The Mental Fitness national nonprofit is devoted to prevention research that expressly serves children, educators and families. We hope that you will join us in our mission of building mental fitness in all youth through evidence-based prevention programs.

• mentalfitnessinc.org – main website 
• bResilient.co – prevention tools, curricula and trainings by national prevention researchers
• ThinkEatPlay.org – optimizing athlete health
• WeAreTheRealDeal.com – top rated body image site featuring 40+ contributors
• NOURISHSpartanburg.com – live prevention center in Spartanburg’s Chapman Cultural Center
• SelfEsteemStomp.com – an annual fun walk for families

Watch the 3-minute trailer of NORMAL (the musical that began this process), featuring Robyn Hussa Farrell by clicking here.

About the author:

ROBYN HUSSA FARRELL is an award-winning New York producer and performer, educator and author. She is co-Adaptor of the Jonathan Larson award-winning musical, NORMAL, which she has been producing and performing in for 7 years to educate about mental fitness in schools … and which is the inspiration for forming mentalfitness, inc. (formerly called NORMAL In Schools).  As a writer, she re-imagined and is Author/Editor of the award-winning body image blog site WeAreTheRealDeal.com, she is Author of the books Healthy Selfitude and Meditation & Mindfulness For Eating Disorder Recovery.  Hussa Farrell also has collaborated as investigator and author on several research publications.  Her work in this area is in collaboration with more than 50 researchers; including those from Harvard School of Public Health, UNC Chapel Hill, Coastal Carolina University, MUSC and others.

As an E-RYT yoga instructor, Hussa created eating disorder recovery yoga programs for inpatient, partial and outpatient treatment programs and has offered free recovery yoga to patients (and their families) in recovery for over a decade in Wisconsin, New York City and in Spartanburg, South Carolina.  The “NOURISH” recovery yoga workshops infuse arts, writing, poetry and movement to support the recovery journey.  She has led seminars for treatment professionals to highlight how to lead safe and effective recovery yoga and mindfulness workshops.  She was invited to provide a chapter in a new book by Carolyn Costin about yoga for recovery that will be published in 2016 by Routledge.

For years Robyn has also been co-creating and producing documentary films with her husband Tim Farrell, through their production company whitelephant.  Some of the documentary films she has co-directed; include, Speaking Out About Edand ED 101 – and both are the result of her interviewing national experts in the fields of neurobiology, eating disorders, obesity and nutrition.  Their next documentary film is Beneath The Floorboards – a commissioned project through ANAD and BEDA.  Hussa Farrell is also responsible for creating and implementing the more than 25 award-winning mentalfitness programs that serve as content to more than 20 national nonprofits, corporations and that are created in collaboration with more than 50 national researchers in medicine, nutrition, mental health and wellness. She recently co-created the ThinkEatPlay program to optimize health in athletes and created the 5 Minute Mindfulness program for classroom educators.

In 2014, Hussa Farrell and her husband launched Resiliency Technologies to provide mental health prevention tools to corporations.  More information is available at BResilient.co.

For her work creating mentalfitness, inc. and its programs and initiatives, Robyn received the 2014 Peace Award from Converse College Westgate Family Therapy and 2010 Champion in Women’s Health award from Wisconsin First Lady, Ms. Sue Ann Thompson.

Prior to her work with mentalfitness, inc., Robyn was co-Founder of the award winning New York Theatre Company, Transport Group.  During her six year tenure as Founding Executive Director, the company won the 2007 Drama Desk award for the company’s breadth of vision and challenging productions and more than 20 nominations from Drama Desk, Obie and others.  Transport Group continues to thrive in the West Village of Manhattan.  Please visit them at TransportGroup.org.

Robyn holds an MFA-Acting from the University of Virginia, is a member of AEA, AFTRA/SAG, the Academy for Eating Disorders (AED), The International Association for Eating Disorders Professionals (IAEDP), Women In Film and Television (NYWIFT), and is an E-RYT Certified Yoga Teacher with the Yoga Alliance.  She and her husband recently relocated to Spartanburg, SC where she runs the Mental Fitness NOURISH prevention center and is a proud board member of the Spartanburg Philharmonic Orchestra.

References:

[1] Haines, J., and Neumark-Sztainer, D. (2006). Prevention of Obesity and Eating Disorders: A Consideration of Shared Risk Factors. Published by Oxford University Press. Health Education Research Vol. 21 no. 6, p. 770-782. Retrieved from: http://her.oxfordjournals.org/content/21/6/770.abstract

[2] Haines, J., and Neumark-Sztainer, D. (2006). Prevention of Obesity and Eating Disorders: A Consideration of Shared Risk Factors. Published by Oxford University Press. Health Education Research Vol. 21 no. 6, p. 770-782. Retrieved from: http://her.oxfordjournals.org/content/21/6/770.abstract

[3] Neumark-Sztainer D. Can we simultaneously work toward the prevention of obesity and eating disorders in children and adolescents. Int J Eat Disord 2005; 38: 220–7.

[4] Perry C. Creating Health Behavior Change: How to Develop Community-Wide Programs for Youth. Thousand Oaks, CA: Sage Publications, 1999.

[5] Haines, J., and Neumark-Sztainer, D. (2006). Prevention of Obesity and Eating Disorders: A Consideration of Shared Risk Factors. Published by Oxford University Press. Health Education Research Vol. 21 no. 6, p. 770-782. Retrieved from: http://her.oxfordjournals.org/content/21/6/770.abstract

[6] From Barnett, W. S. (2008). Preschool Education and Its Lasting Effects: Research and Policy Implications. Boulder and Tempe: Education and the Public Interest Center & Education Policy Research Unit. Retrieved 8/1/2014 from: http://nieer.org/resources/research/PreschoolLastingEffects.pdf

[7] Berrueta-Clement, J.R., Scwheinhart, L.L., Barnett, W.S., Epstein, A.S., & Weikart, D.P. (1984). Changed lives: The effects of the Perry Preschool program on youths through age 19. Ypsilanti, MI: High/Scope Press.

Schweinhart, L.J, Barnes, H.V., Weikart, D.P. (1993). Significant benefits: The High/Scope Perry

Preschool study through age 27. Ypsilanti, MI: High/Scope Press.

[8] Schweinhart, L.J., Montie, J., Xiang, Z., Barnett, W.S., Belfield, C.R., & Nores, M. (2005). Lifetime effects: The High/Scope Perry Preschool study through age 40 (Monographs of the High/Scope Educational Research Foundation, 14). Ypsilanti, MI: High/Scope Press.

Karoly, L.A., Kilburn, M.R., & Cannon, J.S. (2005). Early childhood interventions: Proven results, future

promise. Santa Monica, CA: Rand Corporation.

[9] Camilli, G., Vargas, S., Ryan, S., & Barnett, W.S. (in press). Meta-analysis of the effects of early education interventions on cognitive and social development. Teachers College Record.

Gorey, K. M. (2001). Early childhood education: A meta-analytic affirmation of the short- and long-term benefits of educational opportunity. School Psychology Quarterly, 16 (1), 9-30.

Guralnick, M.J., & Bennett, F.C. (Eds.),(1987). The effectiveness of early intervention for at-risk and handicapped children. New York, NY: Academy Press.

McKey, R.H., Condelli, L., Ganson, H., Barrett, B.J., McConkey, C., & Planz, M.C. (1985). The impact of Head Start on children, families, and communities. Washington, DC: Head Start Evaluation Synthesis and Utilization Project.

Nelson , G., Westhues, A., & MacLeod, J. (2003). A meta-analysis of longitudinal research on preschool prevention programs for children. Prevention and Treatment, 6, 1-34.

Ramey, C.T., Bryant, D.M., & Suarez, T. M. (1985). Preschool compensatory education and the modifiability of intelligence: A critical review. In D. Detterman (Ed.) Current topics in human intelligence (pp.247-296). Norwood, NJ: Ablex.

White, K., & Casto, G. (1985). An integrative review of early intervention efficacy studies with at-risk children: Implications for the handicapped. Analysis and Intervention in Developmental Disabilities, 5, 7-31.

[10] Camilli, G., Vargas, S., Ryan, S., & Barnett, W.S. (in press). Meta-analysis of the effects of early education interventions on cognitive and social development. Teachers College Record..

McKey, R.H., Condelli, L., Ganson, H., Barrett, B.J., McConkey, C., & Planz, M.C. (1985). The impact of Head Start on children, families, and communities. Washington, DC: Head Start Evaluation Synthesis and Utilization Project.

White, K., & Casto, G.(1985). An integrative review of early intervention efficacy studies with at-risk children: Implications for the handicapped. Analysis and Intervention in Developmental Disabilities, 5, 7-31.

[11] From Sarah Salvy, Ph.D., University of Southern California, California Obesity Prevention Program

[12] Brightwood LH, DeRosier ME. LifeStories for Kids: Enhancing character development and social skills through storytelling (Grades 3-5). Cary, NC: 3-C Institute for Social Development. 2007.

DeRosier ME. Social Skills GRoup INtervention (S.S. GRIN) – Parent Guide (S.S. GRIN – PG). Cary, NC: 3-C Institute for Social Development. 2006.

DeRosier, M. E. Social Skills GRoup INtervention (S.S.GRIN): Group interventions and exercises for enhancing children’s communication, cooperation, and confidence (Grades K-2) (4th Edition). Cary, NC: 3-C Institute for Social Development. 2007.

DeRosier ME. Social Skills GRoup INtervention (S.S.GRIN): Group interventions and exercises for enhancing children’s communication, cooperation, and confidence (Grades 3-5) (4th Edition). Cary, NC: 3-C Institute for Social Development. 2007.

DeRosier ME, Brightwood LH. LifeStories for Kids: Enhancing character development and social skills through storytelling (Grades K-2). Cary, NC: 3-C Institute for Social Development. 2007.

Harrell A, DeRosier ME. Social Skills GRoup INtervention – Adolescents (S.S. GRIN – A). Cary, NC: 3-C Institute for Social Development. 2007.

[13] Botvin GJ. Preventing drug use in schools: Social and competence enhancement approaches targeting individual-level ecological factors. Add Behav. 2000; 25: 887-897.

[14] National Scientific Council on the Developing Child, Harvard University (2007). The Science of Early Childhood Development: Closing the Gap Between What We Know and What We Do.

[15] Pianta, R. C., Cox, M.J., Taylor, L., & Early, D. (1999). Kindergarten teachers’ practices related to the transition to school: Results of a national survey. The Elementary School Journal, 100, 71-86.

[16] Pianta, R. C., & Kraft-Sayre, M. (2003). Successful Kindergarten Transition: Your Guide to Connecting Children, Families, & Schools. Baltimore, MD: Paul H Brookes Pub Co.

[17] Raver, C., & Knitzer, J. (2002). Ready to enter: What research tells policy makers about strategies to promote social and emotional school readiness among three- and four-year-old children. NY: NCCP.

[18] Raver, C., & Knitzer, J. (2002). Ready to enter: What research tells policy makers about strategies to promote social and emotional school readiness among three- and four-year-old children. NY: NCCP.

Art Therapy in the Treatment of Eating Disorders

By Jennie J. Kramer, MSW, LCSW
Founder and Director of Metro Behavioral Health Associates Eating Disorders Centers Scarsdale and New York City, NY

At Metro Behavioral Health Associates, we are enthusiastic about our use of creative arts therapy to help patients access some of the very complicated feelings at the root of their struggles with anorexia, bulimia and bingeing. Though most people find the idea intriguing, many seem to have misperceptions about the role of art therapy in treating eating disorders.

For instance, though making art can certainly be a nice way to spend time and explore and express one’s feelings, it also happens to be serious therapy. Art therapists are licensed, clinical professionals who have completed extra rigorous training.

Also, many people think art therapy can only be effective for people who are artistic or especially talented – in fact, the opposite is often true.  It is probably a more effective tool for people who don’t regularly express themselves through the arts. It can provide access to feelings and emotions that have long been repressed or suppressed.  Think of it like the difference between drawing something with your dominant hand and then doing it with your non-dominant hand. With the latter, unless you are particularly ambidextrous, you’ll likely produce something seemingly childlike and unpolished. What one creates is then raw, real, unfiltered and also has the potential to bring back thoughts and ideas from childhood.

How Art Therapy Helps Treatment Progress

I asked our creative arts therapist Caren Sacks to share insights about how art therapy helps a patient with an eating disorder progress through treatment and recovery. Here are some of the common ways people benefit from it:

As a communication tool. Art therapy can be helpful in the assessment phase as a way to gather information about a patient. It is also helpful in treatment since making art can be a way to access deeply buried feelings and emotions and (for a few minutes at least) to get past their overwhelming tendency to be self-critical.

To create metaphors that enhance self-awareness.  Art making can be a treatment alternative when a patient finds traditional talk therapy too painful or uncomfortable. It can also help when a patient feels stuck and/or is unable to make changes or develop self-awareness. They can make images that both express their worries and serve as a vehicle for addressing these uncomfortable feelings.

As a starting point for group interaction. In making and sharing art in a group setting, members give and get support from others. Rather than criticizing, group members discuss what feelings are evoked when they look at something someone else has created. The art-makers get to see things from a different perspective and also learn to feel safe expressing themselves.

As a tool for relaxation and meditation. Research supports the idea of art making as an excellent form of mindfulness that taps into the part of the brain that allows you to relax. Making art can be a mindful respite from feelings of anxiety, self-criticism and fear.

The Medium Can Be the Message

With art therapy, the process of making art is as important – often more so – than whatever gets produced in the session. Even the materials used to create art shape the experience in important ways. For instance, colored pencils and markers are typically used in a very controlled way. Paints, especially watercolors, and clay offer far less structure and, Sacks says, may be an inappropriate choice for a person whose strengths needs to be shored up.

As for the assignment, she will sometimes ask people to produce something they want to explore or discuss, while at others times she will offer a specific “prompt.” “It is important to hear what is going on in the moment, to see what feelings people are coming in with,” she explains. “From there I might offer a prompt or directive.” Depending on the mood of the patient or group, she may ask for a depiction of what the eating disorder looks like or, perhaps, ask for a portrayal of the promise (like perfection, for anorexia, or escape, for binge eating disorder) the eating disorder holds out, along with a depiction of the reality it actually delivers.

The real goal, Sacks explains, “is to be able to support someone in doing their own work, so they begin to address their own experiences.” She encourages people to begin trying to look at their emotions in a visual way.  “If you are feeling a particular emotion or have had an experience, we want to see what it looks like.  What colors do you see? What shapes are you choosing? What forms? Are they in conflict with one another or do they flow together? Are they similar or opposites? Is there a sense of turmoil in the image or is it calm?”

A Thoughtful Process

In the hands of an experienced art therapist, what happens in a therapeutic session is not in the least random. “Just as it is in verbal therapy, where the interventions are thoughtful and you’re not just speaking off the cuff, in art therapy we are shaping an experience in a very meaningful way. Everything, from the choice of materials to the words we use to help patients reframe their experiences, is done in a very thoughtful, in-the-moment way.” In the hands of an experienced art therapist, art making is a way to help people communicate their thoughts, feelings and emotions through images. At its core, the basic tenet is to use the process to help people develop better communication skills.

About the author:

Jennie J. Kramer, MSW, LCSW, is the Founder and Executive Director of Metro Behavioral Health Associates, with offices in New York City and Scarsdale, NY.  She is also the co-author of the book, “Overcoming Binge Eating for DUMMIES,” (2014).

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.