The term ‘dialectical’ is derived from classical philosophy. Dialectical Behavior Therapy (DBT) was originally developed by Marsha Linehan for treating borderline personality disorder, and has subsequently been adapted for binge eating disorder. Typically clients with BPD, as defined in DSM-IV, are notoriously difficult to treat (Linehan 1993a). They often do not attend regularly, frequently fail to respond to therapeutic efforts and make considerable demands on the emotional resources of the therapist (particularly when suicidal and parasuicidal behaviors are prominent). The effectiveness of DBT has been demonstrated in many controlled studies across different research groups. Because of this success and due to similar behavior patterns, DBT is now being used in many settings as a viable therapy for the treatment of bipolar disorder.
How it works
Dialectical Behavioral Therapy (DBT) consists of two parts:
- Once-weekly psychotherapy sessions in which a particular problematic behavior or event from the past week is explored in detail, beginning with the chain of events leading up to it, going through alternative solutions that might have been used, and examining what kept the client from using more adaptive solutions to the problem:
Both between and during sessions, the therapist actively teaches and reinforces adaptive behaviors, especially as they occur within the therapeutic relationship. . . the emphasis is on teaching patients how to manage emotional trauma rather than reducing or taking them out of crises. . . . Telephone contact with the individual therapist between sessions is part of DBT procedures.
(Linehan, 1991) DBT targets behaviors in a descending hierarchy:
- decreasing high-risk suicidal behaviors
- decreasing responses or behaviors (by either therapist or patient) that interfere with therapy
- decreasing behaviors that interfere with/reduce quality of life
- decreasing and dealing with post-traumatic stress responses
- enhancing respect for self
- acquisition of the behavioral skills taught in group
- additional goals set by patient
- Weekly 2.5-hour group therapy sessions in which interpersonal effectiveness, distress tolerance/reality acceptance skills, emotion regulation, and mindfulness skills are taught (see summaries of sample worksheets). Group therapists are not available over the phone between sessions; they refer patients in crisis to the individual therapist.
There are four modules in DBT group skills training:
- Core Mindfulness Skills – These are derived from Buddhist meditation techniques to enable the client to become aware of the different aspects of experience and to develop the ability to stay with that experience in the present moment.
- Interpersonal Effectiveness Skills – These focus on effective ways of achieving one’s objectives with other people: to ask for what one wants effectively, to say no and be taken seriously, to maintain relationships and to maintain self-esteem in interactions with other people (comparable to assertiveness training).
- Emotion Modulation Skills – These skills are ways of coping with intense emotional experiences and their causes. They also allow for an adaptive experience and expression of intense emotions.
- Distress Tolerance Skills – These include techniques for putting up with, finding meaning for, and accepting distressing situations if there is no conceivable solution at present.
DBT for Binge Eating Disorder Techniques
- Mindfulness training: Learning to fully experience thoughts, emotions, and action urges without attempting to suppress them or judge them, and without experiencing secondary emotions such as guilt or shame.
- Identifying the antecedents and consequences of emotions.
- Becoming aware of the bodily responses that accompany negative emotions.
- Understanding the relationship between cognitions and emotions, and modifying cognitions that evoke negative emotions.
- Learning adaptive methods of coping with negative emotions: relaxing, taking walks, socializing, taking a warm bath, listening to soothing music.
- Getting adequate sleep and reducing excessive exercise and the use of drugs and alcohol.
- Reducing negative emotions, for example by facing rather than avoiding feared situations, and by revealing rather than hiding feelings of shame.