For many people suffering from eating disorders (EDs), disordered eating behaviors can become coping mechanisms to deal with big, overwhelming emotions. By regularly using these behaviors, they can offer an illusion of control and comfort, creating a vicious cycle where the eating disorder becomes a refuge. While the ED may “feel safe”, the negative consequences (both short- and long-term) can quickly become apparent, and without the tools to manage emotions or difficult situations in other ways, it can be difficult to break the cycle.
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 offers an alternative for ED behaviours (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: a 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. The skills help soothe our emotions sufficiently for the wise mind to intervene.
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
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- 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
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- 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 positive relationships, set boundaries, and communicate effectively.
Practicing Interpersonal Effectiveness Skills
Below are some examples of interpersonal effectiveness skills that may be helpful to practice:
Conclusion
DBT skills offer a valuable framework for eating disorder recovery. With practice, it’s possible to build emotional resilience and adopt healthier behaviors. For personalized support, contact the Sööma team at (514) 437-4260 or by e-mail at info@sooma.ca. You can also book an appointment with one of our professionals directly by clicking this link.
By: Justine Chriqui, Registered Dietitian
Sööma est une entreprise bilingue qui fonctionne en anglais et en français. Nous fournissons des articles de blogue, des recettes et des articles de diverses sources qui sont parfois écrits en anglais et parfois en français. Si vous vous sentez incapable d’accéder à un article ou à un sujet spécifique en raison d’une barrière linguistique, veuillez nous contacter à info@sooma.ca et nous serons heureux de traduire le contenu pour vous.
Sööma is a bilingual company that operates in both English and in French. We will provide blog posts, recipes and articles from various sources that are sometimes written in English and sometimes in French. If you feel unable to access a specific article or topic due to a language barrier, please reach out to us at info@sooma.ca and we will be happy to translate the content for you.
References
(1) Herrin, M., & Larkin, M. (2013). Nutrition counseling in the treatment of eating disorders (2nd ed.). Routledge/Taylor & Francis Group.
(2) Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). Guilford Press.
(3) 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.
