For many people with eating disorders (EDs), disordered eating behaviours can develop as coping mechanisms for managing big, overwhelming emotions. Over time, by consistently turning to these behaviours, one can start to feel comforted and supported by them and their eating disorder can feel like a safe-haven. While the eating disorder may “feel safe”, one may begin to notice how engaging with these behaviors may lead to consequences (either short term and long term), but not know how to cope with emotional discomfort or challenging situations without their eating disorder.
What is Dialectical Behavior Therapy (DBT)?
As one of the newer therapeutic modalities used in the treatment of eating disorders, Dialectical Behaviour Therapy, or DBT, uses evidence-based practice to support the development of new coping skills that can replace eating disordered behaviours (1). The “dialectic” aspect of DBT aims to explore the balance between acceptance and change. Acceptance allows one to validate their experiences and behaviours, while change allows the individual to move away from depending on their ED for managing emotions (1, 2). DBT has shown promising results in the treatment of eating disorders, including bulimia nervosa, binge-eating disorder, and anorexia nervosa (1, 3).
The Goal of DBT and How it’s Used
The goal of DBT, according to its creator Dr. Marsha M. Linehan, is to “help individuals change behavioural, emotional, thinking, and interpersonal patterns associated with problems in living” (2). In order to do this, the following four skills are practiced:
- Mindfulness
- Emotion Regulation
- Distress Tolerance
- Interpersonal Effectiveness
Let’s explore what each of these skills means and examples of how we can practice them in eating disorder recovery.
Mindfulness
The core of mindfulness is paying attention to the present moment. Mindfulness involves being curious and attentive without passing any judgement or criticism onto ourselves. In this practice, we become a witness to our own thoughts, feelings, and emotions so that we can better identify them, accept them and respond in a meaningful way.
Within mindfulness, DBT presents three main states of mind:
- Logical mind: ruled by reason, facts and control and ignores emotion and empathy in order to be practical.
- Emotional mind: ruled by emotions, feelings and urges; logical thinking is difficult, and facts are skewed toward how the person is feeling
- Wise mind: the balance between logical mind and emotional mind, while acting toward one’s values. Wise mind adds an intuitive component of understanding one’s emotional experience and logical analysis.
Practicing Mindfulness Skills
Below are some examples of mindfulness skills that may be helpful to practice:
- Diaphragmatic breathing: For slowing down breathing and heart rate.
- Before starting, rate your level of stress on a scale of 1-10 (10 being the most stressed)
- Either sitting or laying down, place one hand on your chest and the other just below your rib cage. The hand on your chest should move as little as possible, with your hand on your rib cage moving with your breath
- Breathe in slowly and deeply through your nose (for example for up to 10 seconds), thinking or whispering a soothing word like “calm”
- Breathe out slowly through pursed lips (making your lips as narrow as possible for the air to be exhaled)
- Repeat these breaths for at least 1 minute and reassess your stress level. Continue this exercise for as long as necessary
- Mindful Questions: Ask yourself questions that help you explore your experience and awareness around your meal or snack. Examples include:
- How does my food look, smell, and taste?
- What is my hunger level (asked at different points in the meal)
- How do I feel about myself while I’m eating? Are there any ED thoughts present? What can I tell myself to distract or ignore the ED voice?
Emotion Regulation
Practicing emotion regulation can help us reach a state of Wise Mind. It helps us learn how to navigate emotions so that they don’t take charge of thoughts and behaviours, and it can be especially helpful in cases where one might feel “out of control” or that their eating disorder takes the reins after an emotional trigger (aka during times of emotional dysregulation).
Practicing Emotion Regulation Skills
Below are some examples of emotion regulation skills that may be helpful to practice:
- Understand your emotions: Take time to name emotions and explore (especially with your psychotherapist or psychotherapy-informed dietitian!) how your emotions, thoughts and behaviours influence each other
- HALT: To prevent turning to ED behaviours during vulnerable times, practice self-care when you feel you’re getting too:
- Hungry
- Angry
- Lonely
- Tired
Distress Tolerance
Just as it sounds, distress tolerance skills help us learn to tolerate distress. For example, let’s say someone feels like they’re at an 8/10 for how stressed or emotionally dysregulated they feel. Instead of trying to scramble to navigate the stress once it has reached an 8/10 (and possibly continuing to climb), distress tolerance skills can be practiced to help return to one’s window of tolerance by managing the stress with mindfulness and emotion soothing before feeling the need to turn to an ED behaviour.
There are a variety of techniques that can be used to practice distress tolerance, so finding the one(s) that work best for you is important – and can take some time. Distress tolerance skills should not be used to avoid emotions, but should help turn your attention to something else so you can tolerate and soothe emotions to be further processed in Wise Mind.
Practicing Distress Tolerance Skills
Below are some examples of distress tolerance skills that may be helpful to practice:
- Distraction techniques: Prevent or avoid harmful behaviours with distractions, like: playing games, going for a walk, watching TV, reading an emotional book when you’re angry, or removing yourself from the situation for a while.
- TIP skills: When distress starts to take over and your emotion mind is really taking control, TIP skills can help quickly soothe them:
- Tip the temperature*: quickly calm the nervous system by dunking your face in a bowl of ice water, or hold an ice pack to your eyes and cheeks for 10-30 seconds
- Short bursts of intense exercise*: expend pent-up energy by doing bursts of movement like jumping jacks, sprints or punching a pillow to release your big emotions
- Paced breathing: slow your breathing to slow your heart rate with diaphragmatic breathing, or other strategies like breathing out slower than you breathe in (ex. Inhaling for 5 seconds and exhaling for 7 seconds
- Paired muscle relaxation: pair your breathing with the tensing of your body muscles, like making a fist (without causing a cramp) and noticing the tension release as you exhale
*Before practicing the starred TIP skills, consult your healthcare provider if you have a heart or medical condition that could be affected by heart rate fluctuations
Interpersonal Effectiveness
Interpersonal effectiveness skills can support us in finding and creating the relationships we want, while ending the relationships we don’t want. It helps us interact with others, strengthen relationships (including that with ourselves), and balance change with acceptance.
Practicing Interpersonal Effectiveness Skills
Below are some examples of interpersonal effectiveness skills that may be helpful to practice:
- Objectives Effectiveness: Enhance your relationship with others and get your needs met with communication tools like the DEARMAN skill. This can help with setting boundaries, and sharing your needs and how others can respect them.
- Self-Respect Effectiveness: Act in a way that maintains or enhances your self-respect after a social interaction and allows you to ask what you want while still respecting yourself afterwards. Using the FAST skill can be especially helpful with this.
Conclusion
Introducing DBT skills into treatment can be very powerful in eating disorder recovery. And just as recovery isn’t linear, mastering DBT skills can take a lot of practice. By continuing to practice and accepting the challenges we experience with change, we can learn to be more tolerant with ourselves, our emotions and the recovery process. If you’re interested in including DBT skills in your treatment, or are looking for overall support with your relationship with food, feel free to contact the Sööma team by phone at (202) 738-4726 or by email at info@fuelingforrecovery.com.
References
- Herrin, M., & Larkin, M. (2013). Nutrition counseling in the treatment of eating disorders (2nd ed.). Routledge/Taylor & Francis Group.
- Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). Guilford Press.
- Wisniewski L, Ben-Porath DD. Dialectical Behavior Therapy and Eating Disorders: The Use of Contingency Management Procedures to Manage Dialectical Dilemmas. Am J Psychother. 2015;69(2):129-40. doi: 10.1176/appi.psychotherapy.2015.69.2.129.
