Dialectical behavior therapy (DBT) is a type of cognitive-behavioral therapy developed by Marsha Linehan, Ph.D. Originally, DBT was used to treat borderline personality disorder (BPD). However, it has since been used to treat other mental illnesses with symptoms of emotional dysregulation, including eating disorders.
The word "dialectical" refers to the concept of being able to hold onto two seemingly different ideas at once. For instance, it is considered important in DBT for clients to accept themselves as they are and also to be motivated to change.
The components of DBT typically consist of individual therapy sessions, skills-training sessions (usually done in a group therapy setting) and telephone consultations as needed (available 24 hours a day). Unfortunately, many therapy settings are not able to provide for all three components at once. For instance, one therapist may offer a skills-training group but not be available for telephone consultations. An individual therapist may teach specific skills to clients based on their clinical judgment. This type of treatment may still be helpful but may not be as helpful as receiving all three components of the treatment. DBT has also been adapted for use in residential and inpatient treatment settings.
The skills-training component of DBT consists of four modules:
- Core Mindfulness Skills: Based on Eastern meditative practices, mindfulness skills encourage the client to fully experience the world around them, in the moment. Many therapists use this principle to treat eating disorders by teaching clients "mindful eating." This allows a person to fully experience the tastes and textures of their food and cultivate awareness of hunger and fullness signals.
- Interpersonal Effectiveness Skills: The goal of this module is to teach people how to express their needs and set boundaries to build healthy relationships.
- Emotion Regulation Skills: These skills teach how to identify and name emotions, reduce vulnerability and decrease suffering.
- Distress Tolerance Skills: These are skills to help clients survive painful emotions when the situation cannot be changed in the moment.
Each skill is taught in a session and then throughout the following days or weeks clients keep track of situations in which they were able to practice each skill. Using diary cards, clients keep a record of urges, such as urges to use alcohol or drugs; urges to harm themselves; urges to restrict, exercise, binge and/or purge. In a telephone consultation, a therapist prompts the client to use a specific skill in the situation as needed.
Does Dialectical Behavior Therapy Work?
DBT is the first psychotherapy shown to be effective in treating BPD. Although results are promising for using DBT to treat eating disorders, the research consists mainly of case studies and studies that do not compare DBT to other treatments (or no treatment at all). One randomized controlled trial that compared DBT to active comparison group therapy for binge eating found no significant differences in outcomes (although both groups showed improvement).
The majority of research studies have been done on DBT and the treatment of binge-eating disorder and bulimia nervosa. There are no randomized controlled trials on the treatment of anorexia nervosa with DBT.
Who Is an Appropriate Candidate for Dialectical Behavior Therapy?
Given the current research on DBT and eating disorders, it is likely to be most helpful for people suffering from bulimia nervosa or binge-eating disorder. It is also likely to be helpful for clients who are suffering from BPD in addition to an eating disorder.
Feigenbaum, J. (2008). Dialectical behavior therapy. Psychiatry, 7(3), 112-116.
Harriet Salbach-Andrae, H., et al. (2008). Dialectical behavior therapy of anorexia and bulimia nervosa among adolescents: A case series. Cognitive and Behavioral Practice, doi:10.1016/j.cbpra.2008.04.001.
Linehan, M.M. (1993). Skills training manual for treating borderline personality disorder. New York, NY: Guilford Press.
Safer, D.L., Robinson, A.H., & Jo, B. (2010). Outcome from a randomized controlled trial of group therapy for binge eating disorder: Comparing dialectical behavior therapy adapted for binge eating to an active comparison group therapy. Behavior Therapy, 41, 106-120.
Safer, D.L., Telch, C.F., & Agras, W.S. (2001). Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry, 158(4), 632-634.
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.
Wisniewski, L. & Kelly, E. (2003). The application of dialectical behavior therapy to the treatment of eating disorders. Cognitive and Behavioral Practice, 10, 131-138.