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131

The Application of Dialectical Behavior Therapy


to the Treatment of Eating Disorders
L u c e n e Wisniewski, U H H S / Laurelwood Hospital a n d Counseling Center
E l i z a b e t h Kelly, Private Practice

Dialectical behavior therapy (DBT) is a treatment that was originally designed to treat patients diagnosed with borderlinepersonality
disorder (BPD). Recent empirical evidence suggests that this treatment may also have some promise for the treatment of eating dis-
order patients. We propose that appropriately trained therapists may use the standard DBT model with some adjustments for an
eating disorder diagnosis. These adjustments are both theoretical and practical and include broadening the biosocial theory, develop-
ing eating disorder-specific dialectics, highlighting eating disorder behaviors in the treatment targets, expanding the diary card, and
adding a nutrition skills module.

IALECTICALBEHAVIORTHERAPY(DBT; Linehan, 1993a) vosa (Safer, Telch, & Agras, 2001). The results of these in-
D is a treatment that was originally developed to treat
chronically suicidal, adult patients diagnosed with bor-
vestigations demonstrate that 20 sessions o f DBT skills
training is effective in decreasing eating disorder symp-
derline personality disorder (BPD). DBT blends cognitive- tomatology in patients who binge eat. These studies pro-
behavioral approaches and acceptance-based strategies vide preliminary evidence suggesting that DBT may be an
to help patients function more effectively. Linehan (2001) effective model for the treatment o f binge-eating dis-
developed DBT on the premise that patients used sui- order and bulimia nervosa. There are no known data,
cidal and self-harm behaviors as a way to solve their prob- however, on the effectiveness o f DBT for treating patients
lems, and that the problem most c o m m o n l y faced by diagnosed with anorexia nervosa.
these patients is emotional dysregulation. Several research In this article, we present a case for applying DBT to
studies have demonstrated that DBT is effective in treat- the treatment of patients who suffer from eating dis-
ing w o m e n diagnosed with BPD (Linehan, Armstrong, orders and outline how this might be accomplished.
Suarez, Allmon, & Heard, 1991; Linehan, Heard, & Arm-
strong, 1993). Interest in DBT has grown rapidly since
S t a n d a r d DBT
the 1993 publication of Linehan's b o o k detailing the
treatment, and researchers and clinicians alike have DBT was designed to treat adult patients with chronic
begun to apply DBT to other clinical populations both suicidality and seff-injury--a multiproblem, difficult-to-
with a n d without Axis II symptoms (e.g., Dimeff, Rizvi, treat population. In DBT, four basic modes o f treatment
Brown, & Linehan, 2000; Miller, Rathus, Linehan, are provided concurrently in order to meet the treatment
Wetzler, & Leigh, 1997). goals. First, a weekly skills training group provides didac-
The eating disorder community has also begun to take tic material as per the Skills Training Manual for Borderline
notice of DBT. There are several eating disorder pro- Personality Disord~or(Linehan, 1993b). The goal of the group
grams in the U.S. and Europe that have begun to use DBT is to ensure skill acquisition, strengthening, and general-
in their clinical practice (e.g., M. Marcus, personal com- ization in order to enhance the patient's capabilities.
munication, April 10, 2001; R. Palmer, personal commu- There are four categories of skills, each with a specific tar-
nication, April 25, 2001). In addition, research on the ap- get: emotion regulation, distress tolerance, interpersonal
plication of DBT to eating disorders has begun to appear effectiveness, and mindfulness. In general, the emotion
in the literature. For example, the DBT skills training regulation and interpersonal effectiveness modules are
model has been adapted and applied to the treatment of designed to teach the skills that address change in order
patients diagnosed with binge-eating disorder (Telch, to improve one's life and current situation, while core
1997; Telch, Agras, & Linehan, 2000) and bulimia ner- mindfulness and distress tolerance skills focus on the ac-
ceptance of reality. Specifically, emotion regulation skills
target m o o d - d e p e n d e n t behavior as well as impulsivity.
Cognitive and Behavioral Practice 10, ! 3 1 - 1 3 8 , 2003
1077-7229/03/131-13851.00/0 The goal of interpersonal effectiveness is to reduce inter-
Copyright © 2003 by Association for Advancement of Behavior personal chaos and increase balance in one's relation-
Therapy. All rights of reproduction in any form reserved. ships. The mindfulness skills--considered the "core skills"
132 Wisniewski & Kelly

because familiarity with these skills is a prerequisite to A n o t h e r reason that DBT may be a useful intervention
many of the skills taught in the other modules--emphasize for eating disorder patients is that DBT was designed for
taking control of one's attention. The distress tolerance patients with multiple problems. Patients who suffer from
skills include crisis survival strategies, designed to tolerate eating disorders often present with high rates of both
difficult situations without engaging in self-destructive be- Axis I and Axis II comorbidiv/(Braun, Sunday, & Halmi,
haviors, as well as acceptance strategies to reduce suffering. 1994; Herzog, Keller, Sacks, Yeh, & Lavori, 1992), and the
The group begins with a review of the assigned homework eating disorders themselves usually have a significant ef-
from the skill taught the previous week, followed by the fect on interpersonal and vocational functioning. This is
introduction of a new skill for which a h o m e w o r k assign- especially true for patients who have suffered with the dis-
m e n t is given. Second, patients attend weekly individual order over many years. Furthermore, personality disorder
therapy sessions. The focus of these sessions is to address symptoms have been shown to predict poor treatment out-
and improve motivation and desire for change. Third, come for some eating disorder patients (Rossiter, Agras,
patients receive telephone consultation as needed (the Telch, & Schneider, 1993).
therapist's in vivo coaching of a patient to use skills in DBT's inherent structure also provides a g o o d model
daily living helps with generalizing skills). Finally, a weekly for treating patients diagnosed with an eating disorder.
consultation team is held for all of the professionals work- For example, skills coaching via telephone helps patients
ing together within the DBT framework. The rationale avoid engaging in problematic behaviors such as binge
for the consultation team is to enhance the therapist's eating, purging, or restricting. In addition, weekly consul-
motivation as well as her ability to provide quality care to ration team meetings help to keep therapists motivated
these often challenging patients. and provide valuable input and feedback a r o u n d treat-
These treatment components are considered the gold m e n t approach. Because therapists of eating disorder pa-
standard in DBT; however, it is important to note that re- tients can experience isolation, frustration, a n d / o r burn-
search has yet to be conducted to determine which com- out as a result of the difficulty and tenacity of the eating
ponents are necessary a n d / o r sufficient to produce change disorder, the weekly team m e e t i n g - - a s well as the multi-
in these patients. disciplinary treatment team a p p r o a c h - - r e c o m m e n d e d
in DBT is considered to be the treatment of choice for
eating disorder patients. DBT also provides a clear behav-
Why Apply DBT to Patients ioral hierarchy that may guide clinicians in targeting in-
With Eating Disorders? terventions. Finally, the emphasis on balancing change
The treatments for eating disorders that have received procedures with acceptance of the patient and her behav-
the greatest degree of empirical support are cognitive be- iors in the m o m e n t may be effective in maintaining ther-
havioral therapy (CBT) and interpersonal psychotherapy apeutic alliance and progress in treatment with this chal-
(IPT). However, it is well known that these treatments are lenging population.
not successful with all patients (Wilfley & Cohen, 1997).
DBT is considered an e n h a n c e d cognitive-behavioral
Theoretical/Conceptual Adaptations
treatment that includes a focus on addressing and improv-
of DBT for Eating Disorders
ing relationship deficits. This foundation, as well as the
treatment structure and additional emphasis on acceptance We propose some theoretical adaptations to the stan-
strategies, may make DBT a viable, effective treatment ap- dard DBT model in order for the treatment of eating dis-
proach for patients suffering from eating disorders. order patients to occur smoothly. Specifically, it may be
Patients with eating disorders often have difficulty reg- useful to b r o a d e n the standard bio-social theory to in-
ulating emotions, and eating pathology (i.e., binge eat- elude eating disorders and to develop dialectic tensions
ing, vomiting, restricting) may be viewed as a way to cope that are faced by eating disorder patients.
with that emotional vulnerability (e.g., Stice, Nemeroff, &
< Shaw, 1996; Telch et al., 2000). From a DBT perspective, The Biosocial T h e o r y
it could be said that eating disorder behaviors assist pa- Linehan developed the biosocial theory to help ex-
?: tients in "solving their problems," as these individuals plain why a particular individual might develop BPD.
lack skills to solve these problems otherwise. It has been This theory states that the primary deficit evidenced in
,i
suggested that DBT's focus on emotion regulation may be patients diagnosed with BPD is emotion dysregutation.
particularly helpful to eating disorder patients in that nei- According to the theory, the borderline client has a bio-
ther CBT nor IPT have specific components that address logical temperament that results in an increased sensitiv-
emotion regulation (Telch, 1997). We propose that DBT's iv/to emotional stimuli, an intensity in the emotional re-
focus on helping patients more effectively regulate emo- sponse itself, as well as a slow return to emotional
:i tions makes it particularly useful to eating disorder patients. baseline (Linehan, 1993a). It is believed that this vulner-
:')I
DBT and Eating Disorders 133

ability interacts with an invalidating e n v i r o n m e n t to re- tions make sense o r have validity. This invalidation can
sult in the d e v e l o p m e n t o f BPD. T h e invalidating envi- occur across a s p e c t r u m from severe physical o r sexual
r o n m e n t is generally characterized by a chronic a n d abuse to a p o o r fit between the t e m p e r a m e n t o f the indi-
pervasive c o m m u n i c a t i o n to the individual t h a t h e r re- vidual a n d h e r environment (e.g., extreme t e m p e r a m e n t a l
sponses a n d reactions are n o t a p p r o p r i a t e a n d do n o t differences between the patient a n d h e r environments).
m a k e sense (i.e., are invalid). F u r t h e r m o r e , this theory assumes that the e n v i r o n m e n t
We suggest that the biosocial theory can aid o u r un- does n o t teach the individual the necessary skills to regu-
d e r s t a n d i n g of how s o m e individuals develop an eating late h e r emotions. T h e result is an individual who is unable
disorder. If we e x p a n d the biosocial theory to include eat- to pay attention to a n d trust h e r own responses a n d reac-
ing d i s o r d e r patients, t h e n it c o u l d be stated that an eat- tions b u t instead learns to rely on the e n v i r o n m e n t for
ing d i s o r d e r develops because o f the transaction between cues b o t h a b o u t what to feel a n d what is accurate or true.
a person's biological vulnerability (emotional, nutritional, With respect to patients who suffer f r o m eating disor-
o r both) a n d the invalidating e n v i r o n m e n t . However, in ders, attempts to c o n t r o l weight in response to stress, dif-
o r d e r to fully e n c o m p a s s issues u n i q u e to eating d i s o r d e r ficult emotions, o r invalidation from the e n v i r o n m e n t
patients, we p r o p o s e that the c u r r e n t biosocial theory may seem to be a "valid" solution in this culture that typi-
would n e e d to include a nutrition vulnerability a n d a cally rewards weight loss a n d ( a p p a r e n t ) self-control. T h e
b r o a d e n e d view o f the invalidating e n v i r o n m e n t . emotionally vulnerable individual may t u r n to dieting to
Emotion and nutrition vulnerability. Consistent with the initially feel b e t t e r a n d to feel "in control." T h o u g h diet-
biosocial theory o f BPD, m a n y patients with eating dis- ing generally leads to low m o o d - - a n d , if excessive, lack
orders also r e p o r t suffering f r o m an inability to regulate o f c o n t r o l - - d i e t i n g behaviors have the potential to pro-
e m o t i o n s effectively. These deficits in e m o t i o n m o d u l a - vide short-term relief a n d r e i n f o r c e m e n t from others.
tion are wide in scope a n d may vary significantly by diag- Nutritional deficits can t h e n f u r t h e r complicate the pic-
nosis. F o r a n o r e x i a nervosa patients, the p r o b l e m with ture. T h e eating d i s o r d e r is the p r o b l e m b u t also be-
e m o t i o n s may manifest itself as difficulty with identifica- comes the solution for the p a t i e n t who t h e n engages in
tion a n d awareness o f e m o t i o n , e x t r e m e avoidance o f eating d i s o r d e r e d behaviors to cope with biological deft-
e m o t i o n s , a n d i n h i b i t e d e m o t i o n a l e x p r e s s i o n (i.e., tits a n d to m a n a g e the invalidating environment.
over c o n t r o l o f e m o t i o n ; e.g., Casper, H e d e c k e r , & Mc- Patients who suffer from eating disorders may experi-
Clough, 1992). O n the o t h e r h a n d , patients d i a g n o s e d ence o t h e r levels o f invalidation in a d d i t i o n to the ones
with b u l i m i a nervosa a n d b i n g e - e a t i n g d i s o r d e r may described above. First, we live in a culture that invalidates
struggle with e m o t i o n intensity a n d dyscontrol (e.g., a healthy, accepting stance toward o n e ' s b o d y a n d ap-
Telch & Agras, 1996). pearance. Research has shown that very few A m e r i c a n
In a d d i t i o n to e m o t i o n vulnerability, eating d i s o r d e r w o m e n are as thin as the average fashion m o d e l a n d that
patients may also suffer from nutrition-related vulnerabil- as the A m e r i c a n p o p u l a t i o n gets fatter, Playboy center-
ity. For example, there is some evidence o f a biological folds a n d Miss A m e r i c a contestants b e c o m e t h i n n e r (Gar-
d i s r u p t i o n in the body's ability to a p p r o p r i a t e l y signal ner, Garfinkel, Schwartz, & T h o m p s o n , 1980). O u r cul-
h u n g e r a n d satiety (e.g., Wisniewski, Epstein, Marcus, & ture is t h e r e f o r e clearly invalidating as its standards o f
Kaye, 1997). In addition, overeating as well as u n d e r e a t - beauty are n o t obtainable for the majority o f women. We
ing can exacerbate a patient's vulnerability to e m o t i o n also live in a culture that tends to equate physical appear-
dysregulation. Moreover, if a p a t i e n t does n o t experi- ance with self-worth, especially for w o m e n a n d increas-
e n c e p r o b l e m s with satiety r e g u l a t i o n b e f o r e the o n s e t ingly for men. A t t e m p t s to control eating a n d weight may
o f h e r disorder, the effects o f severe restriction, b i n g e function to provide some patients with an identity o r
eating, o r p u r g i n g often m a k e d e t e c t i o n o f h u n g e r or sense o f a c c o m p l i s h m e n t . Second, patients are often in-
fullness problematic. validated with respect to their eating disorder s y m p t o m s - -
Taken together, o u r a d a p t a t i o n of the biosocial theory challenged, for example, with statements such as, "What
for eating disorders t h e r e f o r e poses that persons who de- d o you m e a n you c a n ' t eat it, it's only a piece o f bread?"
velop eating disorders may have some biological vulnera- o r "Why c a n ' t you j u s t stop eating" or "Don't you see how
bility in regulating e m o t i o n s or in the h u n g e r / s a t i e t y sys- you are h u r t i n g yourself by purging?" Finally, for some
tem (i.e., n u t r i t i o n vulnerability) or both. We p r o p o s e eating d i s o r d e r patients, the invalidation may also occur
that if this biological vulnerability interacts with a certain when the e n v i r o n m e n t makes excessive attempts to re-
type of e n v i r o n m e n t (i.e., invalidating), the patient may move stress (i.e., overprotection). T h e i n a d v e r t e n t mes-
develop an eating disorder. sage b e c o m e s that the individual c a n n o t adequately han-
Invalidating environment. S t a n d a r d DBT hypothesizes dle life's problems. These o t h e r examples o f invalidation
that an invalidating e n v i r o n m e n t is o n e that fails to com- m a y be m o r e subtle, b u t can l e n d s u b s t a n t i a l l y to a
m u n i c a t e to the individual that h e r responses a n d reac- patient's sense of alienation.
134 Wisniewski & Kelly

Dialectics d i l e m m a while providing a potentially less frustrating


Dialectics inform b o t h the theory as well as many treat- framework u n d e r which the therapist can work. Dialecti-
m e n t strategies used in DBT (Linehan, 1993a, 1993b). cal strategies (e.g., irreverence a n d extending) have the
Dialectics stress the i n t e r c o n n e c t e d n e s s o f reality, the potential to move t r e a t m e n t forward when c h a n g e strate-
truth as constantly evolving, a n d the tension a n d resolu- gies have n o t b e e n effective. A d d i t i o n a l dialectical dilem-
tion o f opposites to p r o d u c e change. T h e p r i m a r y dialec- mas will likely e m e r g e as DBT is e x p a n d e d to treat the
tic, or tension, in DBT is between acceptance a n d change. eating d i s o r d e r p o p u l a t i o n . Specific d i l e m m a s for the dif-
DBT emphasizes finding a balance a n d searching for ferent subgroups o f eating disorders (i.e., a n o r e x i a ner-
what is missing when l o o k i n g for a solution. It challenges vosa vs. b u l i m i a nervosa vs. binge-eating disorder) may
the therapist a n d p a t i e n t to entertain m a n y possible ver- also be indicated.
sions o f reality a n d to assume a n d search for some truth In summary, we p r o p o s e that some theoretical a n d
in all o f them. T h e therapist n o t only uses a dialectical ap- c o n c e p t u a l a d a p t a t i o n s to s t a n d a r d DBT may be n e e d e d
p r o a c h in h e r stance toward the p a t i e n t in o r d e r to main- in the process o f applying this t r e a t m e n t to patients with
tain a collaborative relationship, b u t also attempts to eating disorders. These changes include e x t e n d i n g the
teach a n d m o d e l dialectical t h i n k i n g a n d behavior in biosocial theory to include nutritional vulnerabilities as
every interaction with the patient. well as a b r o a d e r view o f the invalidating e n v i r o n m e n t
L i n e h a n (1993a) has described the following behav- a n d the d e v e l o p m e n t o f dialectic tensions specifically for
ioral p a t t e r n s as b e i n g in f r e q u e n t tension for patients eating disorders.
with BPD: e m o t i o n dysregulation vs. self-invalidation, in-
hibited grieving vs. u n r e l e n t i n g crisis, a n d a p p a r e n t com-
Practical Adaptations to Standard
petence vs. active passivity. The resolution o f these tensions
DBT to Treat Eating Disorders
is consistently addressed b o t h in t r e a t m e n t in general a n d
in the m o m e n t - t o - m o m e n t interactions with the patient. We p r o p o s e that in actual practice, DBT as a p p l i e d t o
We p r o p o s e that for eating d i s o r d e r patients, the pri- an eating d i s o r d e r p o p u l a t i o n would n o t l o o k very differ-
m a r y dialectical d i l e m m a may be c o n c e p t u a l i z e d as over- e n t f r o m traditional DBT. However, we outline below the
c o n t r o l l e d e a t i n g vs. absence o f an eating plan. Patients changes that would n e e d to be c o n s i d e r e d when using
with eating disorders may swing from o n e e x t r e m e o f the DBT with a p a t i e n t who has an eating disorder.
d i a l e c t i c - - o b s e s s i n g over every detail o f f o o d a n d eating
(e.g., when, what, how m u c h ) , to the o t h e r extreme: a Treatment Targets
mindless a p p r o a c h toward eating. Patients often s p e n d It is i m p o r t a n t to reiterate that the p r i m a r y t r e a t m e n t
an e n o r m o u s a m o u n t o f time a n d energy deciding, plan- goal for a p a t i e n t with an eating d i s o r d e r who is receiving
ning, a n d m o n i t o r i n g what they will a n d will n o t eat. This DBT t r e a t m e n t would be to resolve the dialectical di-
overcontrol may be reflected in such behaviors as ex- l e m m a between rigid, o v e r c o n t r o l l e d eating a n d the ab-
t r e m e food avoidance, calorie counting, excessive weigh- sence o f eating structure o r plan. This would i n c l u d e
ing, a n d obsessive thinking a b o u t food a n d weight. O n h e l p i n g the p a t i e n t to achieve a b a l a n c e d a p p r o a c h to-
the o t h e r hand, a n d n o t u n r e l a t e d , when patients are un- ward eating a n d f o o d a n d h e l p i n g h e r to e m b r a c e a life
able to m a i n t a i n this rigid, o v e r c o n t r o l l e d pattern, they worth living without an eating disorder. In o r d e r to
often move to the o t h e r side o f the dialectic. T h e m i n d - achieve the resolution o f the dialectical dilemma, patients
less a p p r o a c h may manifest as binge eating o r as e x t r e m e will l e a r n skills that will increase behaviors consistent with
efforts to avoid the body's e x p e r i e n c e o f hunger. their goals a n d decrease those behaviors in o p p o s i t i o n to
Dialectics a n d a dialectical a p p r o a c h have m u c h to their goals. In general, the behaviors that patients will at-
c o n t r i b u t e to the t r e a t m e n t o f eating disorders. F i n d i n g t e m p t to increase include following a structured meal
"the m i d d l e path" is critical to this p o p u l a t i o n , whose ex- plan, eating a wide r a n g e o f foods, increased self-identifi-
t r e m e a p p r o a c h to food, a n d frequently themselves, is cation of h u n g e r a n d fullness, a n d increased awareness
central to their p r o b l e m behaviors. A dialectical a p p r o a c h o f eating. Moreover, patients will a t t e m p t to develop a
to the "wisdom" o f the patient's c u r r e n t situation is also b a l a n c e d a n d n o n j u d g m e n t a l a p p r o a c h toward food, eat-
helpful in e n c o u r a g i n g flexibility a n d r e d u c i n g frustra- ing, a n d b o d y image. Patients wilt a t t e m p t to decrease re-
tion for the therapists treating these patients. strictive eating, avoidance o f specific food(s), compensa-
Dialectics can foster a m o m e n t - t o - m o m e n t explora- tory behaviors, unstructured eating, obsessing a b o u t food,
tion a n d u n d e r s t a n d i n g of the complexity of the patient's as well as j u d g m e n t s a b o u t weight, shape, o r a p p e a r a n c e .
situation (e.g., wanting to give u p their eating d i s o r d e r In DBT, the establishment o f t r e a t m e n t targets assists
b u t n o t wanting "to get fat"). For m a n y patients, eating o r the therapist in designating what behaviors to prioritize
n o t eating b e c o m e s a way o f e x e r t i n g control, a n d a dia- in each interaction with the patient. Targeted behaviors
lectical a p p r o a c h highlights the many sides o f the patient's outline the goals for t r e a t m e n t a n d the o r d e r in which
DBT and Eating Disorders 135

behaviors will b e a d d r e s s e d w h e n they occur. T h e behav- i m p o r t a n t to have an a g r e e d u p o n p l a n for b o t h how


iors to b e targeted, their priority, a n d their rationale are medical information will b e c o m m u n i c a t e d a n d how, what,
m a d e clear to the p a t i e n t at the start o f treatment. More- a n d who will d e c i d e w h e n medical i n t e r v e n t i o n n e e d s to
over, the p a t i e n t is asked to m a k e a c o m m i t m e n t to work occur. Examples o f situations that would move eating dis-
o n these specific goals in a p a r t i c u l a r o r d e r (e.g., life- o r d e r behaviors to Target I status include, b u t are n o t lim-
t h r e a t e n i n g behavior will be a d d r e s s e d p r i o r to quality-of- ited to, evidence o f bradychardia, orthostatic b l o o d pres-
life issues). This is n o t to say that a higher-level target will sure, electrolyte imbalances, EKG abnormalities, a n d syrup
b e addressed to the exclusion o f lower target behaviors, o f ipecac use.
b u t simply that the highest priority target will n o t go un- Target II: Therapy-interfering behaviors. T h e active atten-
noticed. F o r instance, if a p a t i e n t has an increase in sui- tion to behaviors that interfere with t r e a t m e n t compli-
cidal i d e a t i o n a n d severe p u r g i n g b e h a v i o r o n h e r diary ance a n d progress is o n e o f several features o f DBT that
card, b o t h would likely b e addressed. This w o u l d be espe- has the potential to c o n t r i b u t e to the t r e a t m e n t o f e a t i n g
cially true if t h e quality-of-life i n t e r f e r i n g b e h a v i o r disorders, given the longevity o f the n e e d for t r e a t m e n t
( p u r g i n g ) was l i n k e d in any way to i n c r e a s e d t h o u g h t s d o c u m e n t e d for this p o p u l a t i o n . Target II is b a s e d on the
o f self-harm. assumption that a p a t i e n t has to be in t r e a t m e n t in o r d e r
Before actual t r e a t m e n t can begin, however, patients to b u i l d a life worth living without an eating disorder. Ac-
m u s t agree to c o m m i t to the t r e a t m e n t a n d its targets. It tive attention is given b o t h to p a t i e n t a n d / o r therapist
is assumed that patients e n t e r DBT t r e a t m e n t voluntarily, behaviors, in o r o u t o f session, that interfere with the pa-
agreeing to work o n certain goals in a specific o r d e r with tient receiving treatment. T h e attention to Target II be-
their therapist (e.g., r e d u c i n g b i n g e i n g a n d p u r g i n g be- haviors works to p r e v e n t p a t i e n t d r o p o u t as well as thera-
haviors p r i o r to resolving vocational goals). It is t h e r e f o r e pist b u r n o u t . DBT emphasizes the i m p o r t a n c e o f e a c h
i m p o r t a n t to distinguish patients who are in active treat- therapist observing his o r h e r own limits r a t h e r t h a n set-
m e n t f r o m those who are in a p r e t r e a t m e n t stage o f DBT ting arbitrary limits or b o u n d a r i e s in interactions with pa-
for eating disorders. tients. These limits may b e different f r o m therapist to
D u r i n g the p r e t r e a t m e n t stage, patients are o r i e n t e d therapist a n d may vary within an individual over time. F o r
a n d m a k e a c o m m i t m e n t to t h e i r individual targets (e.g., example, therapists may differ in their limits a r o u n d rate
weight gain, d e c r e a s e d p u r g i n g ) . This p r e t r e a t m e n t o f weight gain o r decision to hospitalize a p a t i e n t with sig-
phase is crucial, as a p a t i e n t may be asked for a commit- nificant p u r g i n g behaviors. T h e rationale for this individ-
m e n t to c h a n g i n g ego-syntonic behaviors (e.g., maintain- ualized limit setting is for the therapist to m o d e l self-care
ing a low weight). This is especially true for patients suf- a n d to preserve the t h e r a p e u t i c relationship. This active
fering from a n o r e x i a nervosa, for w h o m c o m m i t m e n t attention to preserving the t h e r a p e u t i c relationship is es-
(which in m a n y ways is the treatment) is often difficult. It pecially critical with eating disorder patients who may n e e d
is n o t u n c o m m o n to r e t u r n to the c o m m i t m e n t stage p r o l o n g e d treatment in o r d e r to recover a n d for therapists
m a n y times over the course o f active treatment. who often feel frustrated a n d are at risk for b u r n o u t .
O n c e a c o m m i t m e n t - t o - t r e a t m e n t goal is o b t a i n e d , ac- Therapy-interfering behaviors that can occur in the
tive t r e a t m e n t can begin. As in s t a n d a r d DBT, t h e r e are t r e a t m e n t o f eating d i s o r d e r patients include the follow-
t h r e e groups o f behaviors, o r targets, a d d r e s s e d in active ing: n o t c o m p l e t i n g f o o d diary cards; an inability to focus
treatment. T h e following describes the s t a n d a r d DBT tar- in session as a result of m a l n o u r i s h e d state; refusing to be
get hierarchy a n d the a p p l i c a t i o n o f behaviors o f dis- weighed; e n g a g i n g in behaviors to surreptitiously alter
o r d e r e d eating to these targets. weight; an absence f r o m t r e a t m e n t because o f the n e e d
Target 1."Life-threatening behaviors (suicide, parasuicide). for medical intervention; e n g a g i n g in p u r g i n g that inter-
Target I focuses o n those behaviors that are likely to e n d feres with m e d i c a t i o n efficacy; substance abuse.
in death. DBT is based o n the n o t i o n that (a) failure to Target III: Quality-of-life interfering behaviors. Behaviors
address these behaviors is inconsistent with the goals o f t h a t severely interfere with the patient's c h a n c e o f having
psychotherapy a n d (b) a p e r s o n who is d e a d c a n n o t re- a life worth living are a d d r e s s e d in Target III. These in-
ceive t r e a t m e n t (Linehan, 1993a). As in s t a n d a r d DBT, clude most Axis I disorders. F o r eating d i s o r d e r patients
suicidal i d e a t i o n (with p l a n a n d / o r i n t e n t ) a n d self- who are n o t suicidal a n d whose eating d i s o r d e r does n o t
injury are the first targets to address. Active eating dis- pose an i m m i n e n t risk, the majority of the t r e a t m e n t will
o r d e r behaviors in this t r e a t m e n t are the p r i m a r y targets occur within Targets II a n d III. In addition, behaviors
addressed in quality-of-life i n t e r f e r i n g behaviors (Target that increase the l i k e l i h o o d o f t a r g e t e d behaviors occur-
III). Eating d i s o r d e r behaviors may be m o v e d to Target I ring are addressed. For instance, if restricting increases
w h e n they p r e s e n t an i m m i n e n t t h r e a t to the patient's every t i m e a p a t i e n t b e g i n s a r e l a t i o n s h i p , this w o u l d
life. Moving eating d i s o r d e r behaviors to Target I ahnost b e a n a l y z e d a n d a d d r e s s e d in t r e a t m e n t . T a r g e t III
always reflects a m e d i c a l e m e r g e n c y a n d it is t h e r e f o r e t r e a t m e n t also addresses behaviors that are "apparently
136 Wisniewski & Kelly

Table ! disorder. F u r t h e r m o r e , r e c o r d i n g intake can be consid-


Quality-of-Life Interfering Behaviors for Patients With Eating Disorders e r e d a form o f exposure. Finally, the i n f o r m a t i o n ob-
tained via the diary card can assist the therapist in effi-
Eating Disorder Behaviors Other Quality-of-Life Behaviors
ciently setting session a n d t r e a t m e n t goals.
Restrictive or unstructured eating Financial problem
Binge eating/purging Interpersonal isolation/difficulties Additional Skills Modules
Diet pill~diuretic~laxative abuse Other Axis I, especially substance
Skills training is o n e o f five c h a n g e p r o c e d u r e s used in
Excessive exercising abuse
Calorie counting s t a n d a r d DBT. DBT assumes that skill deficits are a m a j o r
Body checking i n t e r f e r e n c e in the patient's ability to g e n e r a t e m o r e
Water loading adaptive solutions in their lives. We believe that these
Avoiding food-related events m o d u l e s can be helpful to patients suffering from eating
Buying clothes that are too small
disorders. We propose, however, that it may be necessary
Planning to diet
to use an additional nutrition skills as well as an ex-
p a n d e d mindfulness m o d u l e in o r d e r to achieve the mid-
dle p a t h of b a l a n c e d eating with awareness. To adminis-
u n i m p o r t a n t " (i.e., behaviors that seem u n i m p o r t a n t b u t ter this information, we suggest the use o f a skills-based
inevitably lead to eating d i s o r d e r behaviors). Examples o f g r o u p where weight o r weight loss in n u m b e r s is n o t dis-
these include driving past a particular fast f o o d restau- cussed. This g r o u p should have skill acquisition as its pri-
r a n t in which b i n g e f o o d is typically b o u g h t o r trying on m a r y target a n d emphasize a n o n j u d g m e n t a l a p p r o a c h in
clothes that are a smaller size. Table 1 lists examples o f o r d e r to increase s u p p o r t a n d skills r a t h e r than competi-
Target III behaviors. tion a m o n g patients. Empirical evidence is clearly n e e d e d
to evaluate the effectiveness o f this model. If a DBT skills
Expanded Diary Card g r o u p specifically for eating d i s o r d e r patients is n o t avail-
In s t a n d a r d DBT, diary cards are the b a c k b o n e of the able to a patient, a s t a n d a r d skills g r o u p (i.e., with a
treatment. We suggest that the s t a n d a r d diary card, a varied p a t i e n t p o p u l a t i o n ) with the individual therapist
daily self-monitoring form k e p t by the patients, needs to or a DBT-informed nutritionist teaching the nutrition
be a d a p t e d in o r d e r to m e e t the needs o f the eating dis- m o d u l e could be a reasonable s e c o n d choice.
o r d e r patient. Between each therapy session, eating dis- Nutrition module. T h e nutrition m o d u l e that we pro-
o r d e r patients c o m p l e t e a diary card on which they mon- pose is one that can provide basic e d u c a t i o n r e g a r d i n g
itor intake, targeted behaviors (e.g., binge eating, purging, nutrition a n d can address specific myths a b o u t dieting
laxative use, exercise), emotions, a n d the use o f skills. Pa- a n d weight control. We believe that this m o d u l e is neces-
tients are asked to c o m p l e t e the self-monitoring form sary even for patients for w h o m e m o t i o n regulation is a
daily. Similar to a s t a n d a r d food diary typically used in p r i m a r y deficit. In o u r experience, patients' eating disor-
most CBT treatments, patients d o c u m e n t f o o d intake or d e r behaviors c a n n o t be d i s r u p t e d without the structure
the failure to c o m p l y with their f o o d p l a n as well as track a n d skills to specifically teach b a l a n c e d eating. It is also
their urges a n d active eating d i s o r d e r behaviors. Patients i m p o r t a n t to p o i n t out that many eating d i s o r d e r patients
are also asked to track their use o f DBT skills a n d the ef- have a p p a r e n t c o m p e t e n c e with respect to p r o p e r nutri-
fectiveness o f the skills in h e l p i n g to control d i s o r d e r e d tion. In o t h e r words, patients often a p p e a r as if they have
eating behaviors. T h e diary card includes a section for accurate i n f o r m a t i o n r e g a r d i n g the "healthiness" o f a
m o n i t o r i n g a range o f emotions; this section emphasizes f o o d o r facts a r o u n d dieting, a l t h o u g h they do n o t (e.g.,
the core c o n n e c t i o n o f e m o t i o n s to eating behaviors a n d knowledge o f fat c o n t e n t in a variety o f f o o d b u t lack o f
targets increased mindfulness o f the e m o t i o n a l experi- kiaowledge about the necessity o f fat in one own's diet). It
ence. T h e diary card t h e n provides the focus for the next may therefore be erroneously assumed by the therapist that
therapy session. Patient a n d therapist discuss the prob- a patient has the prerequisite skills a n d is not using them.
lematic behaviors that have o c c u r r e d since the last ses- In reality, patients may e i t h e r lack accurate i n f o r m a t i o n
sion a c c o r d i n g to the designated targets. o r the i n f o r m a t i o n they d o have (e.g., accurate knowl-
We wish to u n d e r s c o r e the i m p o r t a n c e of the e x p a n d e d edge o f a food's caloric content) actually reinforces the eat-
diary card. Although the card can be quite lengthy, its use ing disorder rather than guides effective eating behaviors.
is i m p o r t a n t for several reasons. First, it provides the ther- We believe that a nutrition m o d u l e is essential to edu-
apist a n d p a t i e n t with i m p o r t a n t information. Use o f the cate o r r e e d u c a t e eating d i s o r d e r patients a b o u t topics
diary card assists in accurate assessment a n d reinforce- such as p o r t i o n size, meal planning, metabolism, the
m e n t o f progress. Second, use o f the diary card p r o m o t e s function o f a varied diet, as well as the effects o f f o o d re-
m i n d f u l eating. Cognitive avoidance o f what is eaten can striction a n d c o m p e n s a t o r y behaviors on weight c o n t r o l
be a significant p r o b l e m for many patients with an eating a n d m o o d . As p a r t o f the nutrition m o d u l e , a p p r o p r i a t e
DBT and Eating Disorders 137

meal plans can be established. Patients are expected to eating disorders. Preliminary empirical evidence suggests
follow their meal plans daily. It can b e helpful to use be- that DBT is a n effective t r e a t m e n t for patients diagnosed
havior chain analyses, a step-by-step analysis of the tar- with binge-eating disorder or b u l i m i a nervosa. Additional
geted behavior a n d its antecedents a n d consequences, in research is n e e d e d to replicate these studies a n d to evalu-
o r d e r to identify the barriers to following a meal plan a n d ate whether DBT is helpful to patients diagnosed with
to be able to p i n p o i n t skills that can be used in the future anorexia nervosa as well.
to ensure successful c o m p l e t i o n of the meal plan. The We have o u t l i n e d how a therapist with the requisite
n u t r i t i o n m o d u l e can also address myths a b o u t dieting, t r a i n i n g can apply DBT to eating disorder patients with
advertising, a n d cultural reinforcers for dieting behaviors. only some small adaptations to the standard DBT model.
T h e skills group can be used to identify the behaviors that However, as Robins (2000) has also noted, we are mind-
lead to p r o b l e m eating as well as those that lead to bal- ful there is limited empirical support of the use of stan-
a n c e d eating. T h e goal would be to increase behaviors dard DBT with borderline patients, a n d the move to adapt
that lead to balanced eating a n d to avoid the "apparently the t r e a t m e n t may be premature. We therefore h o p e that
u n i m p o r t a n t behaviors" o n the path toward mindful eating. this article will move others to consider using DBT with
As stated above, a nutritionist can be brought in to teach eating disorder patients a n d to empirically evaluate its
this module b u t it is also essential that the therapist have a effectiveness with this population.
solid u n d e r s t a n d i n g of basic n u t r i t i o n in o r d e r to assist
the p a t i e n t in m a k i n g behavioral changes in their eating.
Mindfulness module. T h e core mindfulness skills in References
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• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Food Refusal by Infants and Young Children:


Diagnosis and Treatment
I r e n e C h a t o o r , Children's National Medical Center, Washington, DC, a n d The George Washington University
J o d y G a n i b a n , The George Washington University

Parents report that 25 % of toddlers exhibit food refusal. A subgroup of these children demonstrate such severefood refusal that their
nutritional status is compromised, leading to the diagnosis of a feeding disorder. Although food refusal is common, and can pose a
significant health risk for some children, few researchers and clinicians have described the different farms food refusal may take, or
have relatedfood refusal subtype to feeding disorders subtypes. Such critical issues must be addressed and discussed because different
types offood refusal and feeding disorders may necessitate different treatment approaches. This review proposes that food refusal can
be expressed in qualitatively different ways, including (a) unpredictable food refusal; (b) selectivefood refusal; and (c) fear-based
food refusal. Furthermore, it is proposed that each farm offood refusal gives rise to a qualitatively different feeding disorder: Unpre-
dictable food refusal is associated with infantile anorexia; selectivefood refusal is related to sensory food aversions; and fear-based
food refusal is central to a posttraumatic feeding disorder. Implications for the treatment of each type offeeding disorder are discussed.

T IS ESTIMATED THAT 25% o f otherwise n o r m a l l y devel- children c o n t i n u e d to exhibit serious eating p r o b l e m s at


I o p i n g infants a n d u p to 80% o f those with develop-
mental handicaps have feeding problems (Chatoor, Ham-
4 a n d 6 years o f age (Dahl, Rydell, & Sundelin, 1994;
Dahl & Sundelin, 1992).
burger, Fullard, & Rivera, 1994; Lindberg, Bohlin, & In spite o f the serious implications o f early f e e d i n g dif-
Hagekull, 1991; Reilly, Skuse, Wolke, & Stevenson, 1999). ficulties, research a n d clinical practice have b e e n ham-
Additional studies indicate that early feeding problems are p e r e d by an inconsistent n o m e n c l a t u r e a n d by diagnostic
associated with behavioral problems, anxiety disorders, a n d criteria that do n o t adequately describe the range o f feed-
eating disorders during later c h i l d h o o d a n d adolescence ing p r o b l e m s that exist. F o r example, in 1994, the Amer-
(Marchi & Cohen, 1990; Timimi, Douglas, & Tsiftsopoulou, ican Psychiatric Association (APA) a d d e d "Feeding Disor-
1997). Accordingly, f e e d i n g p r o b l e m s are c o m m o n a n d d e r o f Infancy a n d Early C h i l d h o o d " to the Diagnostic and
m a y f o r e s h a d o w l o n g - t e r m e a t i n g a n d behavioral p r o b - Statistical Manual of Mental Disorders (DSM-IK,', APA, 1994).
lems. Food refusal is a key symptom o f several feeding dis- F e e d i n g disorders were d e l i n e a t e d by the following crite-
orders. Dahl a n d S u n d e l i n (1986) r e p o r t e d that 1% to ria: (a) persistent failure to eat adequately with signifi-
2% o f infants u n d e r 1 year o f age d e m o n s t r a t e d severe cant failure to gain weight o r significant loss o f weight
food refusal a n d p o o r growth. Seventy p e r c e n t o f these over at least 1 m o n t h ; (b) the disturbance is n o t due to an
associated gastrointestinal o r o t h e r medical condition;
(c) the disturbance is n o t a c c o u n t e d for by a n o t h e r men-
tal d i s o r d e r o r by lack o f available food; a n d (d) the onset
Cognitive and Behavioral Practice 10, 138-146, 2003
is b e f o r e the age of 6 years. However, these diagnostic
1077-7229/03/138-14651.00/0
Copyright © 2003 by Association for Advancement of Behavior criteria exclude whole groups o f c h i l d r e n who p r e s e n t
Therapy. All rights of reproduction in any form reserved. with p r o b l e m a t i c f e e d i n g behaviors a n d show a d e q u a t e