Applying Dialectical Behavioral Therapy to the Treatment of

Applying Dialectical Behavioral Therapy to the Treatment of Eating Disorders Advanced Recovery Systems CE Presentation Series Friday, February 9 th, 2018 Elizabeth Carges, Ph. D Licensed Clinical Psychologist Clinical Director, Orlando & Tampa Outpatient Treatment Programs Center for Discovery

Learning Objectives • Identify four major DBT skills • Understand why DBT is an appropriate treatment modality for patients with eating disorders • Learn methods to implement DBT skills within an eating disorder treatment program or within individual therapy scenarios

Imagine a world where you could fully accept yourself and simultaneously want to change and grow • Imagine a treatment during which you could accept where you are in the recovery process but still be encouraged and hopeful for change • These seemingly opposite ideas can exist in union when applying the principles of dialectical-behavioral therapy or DBT

Outline • Brief overview of three major eating disorders • Brief overview of DBT • Applying DBT to the treatment of eating disorders

Eating Disorder Basics General • Genetics, environmental factors, co-occurring disorders, medical complications and personality traits all combine to create risk factors for the creation and maintenance of an eating disorder • Hard to treat • Relapse is common • CBT considered the “gold standard” • What about DBT • Can we make treatment better? Can we improve patient resiliency? Can we decrease episodes of relapse? http: //www. anad. org/get-information/about-eating-disorders/eating-disorders-statistics/

Three Most Common Presentations • Anorexia Nervosa • Bulimia Nervosa • Binge Eating Disorder

Anorexia Nervosa-Statistics • Close to 1% of American women are diagnosed with anorexia in their lifetime. • 50 -80% of the risk for anorexia is genetic. • 33 -50% of patients have a comorbid mood disorder, such as depression. • About half of anorexia patients have comorbid anxiety disorders, including generalized anxiety disorder and social anxiety disorder. • Obsessive-compulsive disorder

Anorexia Nervosa: DSM-5 • 1. Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health. Significant low weight is defined as weight that is less than minimally normal • 2. Intense fear of gaining weight or becoming fat even though underweight • 3. Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on selfevaluation, or denial of the seriousness of the current low body weight

Anorexia Nervosa-DSM-5 Subtypes • Two subtypes: • Restricting • Low body weight and no history of binging or purging in the last three months • Often co-morbid with depression and anxiety disorders and OCD • Binge-eating/purging type • Still characterized by restriction • History of binging or purging in last three months • May purge even small amounts of food consumed • Modes: restriction, exercise, laxatives, vomiting • Needs differential diagnosis with regard to deciding between this, Bulimia Nervosa, or Purging disorder • Mild, Moderate, Severe, or Extreme severity rating based on BMI

Bulimia Nervosa-Statistics • 1. 5% of American women suffer from bulimia nervosa in their lifetime • Approximately half of bulimia patients have a comorbid mood and/or anxiety disorder • Patients can be of normal weight, above normal weight, and sometimes are obese • Nearly 1 in 10 patients with bulimia have a comorbid substance abuse disorder, usually alcohol use.

Bulimia Nervosa: DSM-5 1. Recurrent episodes of binge eating characterized by BOTH of the following: a. Eating in a discrete amount of time (within a 2 hour period) large amounts of food that is definitely larger than what normal people eat b. Sense of lack of control over eating during an episode 2. Recurrent inappropriate compensatory behavior in order to prevent weight gain (purging, misuse of laxatives, excessive exercise, fasting). 3. The binge eating and compensatory behaviors both occur, on average, at least once a week for three months 4. Self-evaluation is unduly influenced by body shape and weight 5. The disturbance does not occur exclusively during episodes of anorexia nervosa

Binge Eating Disorder-Statistics • 2. 8% of American adults suffer from binge eating disorder in their lifetime • Binge eating disorder affects women slightly more often than men • Estimates indicate that about 60% of people struggling with binge eating disorder are female, 40% are male • Approximately half of BED patients have comorbid mood and/or anxiety disorders • Nearly 1 in 10 BED patients have a comorbid substance abuse disorder • Binge eating may be as high as 25% in postbariatric patients

Binge Eating Disorder: DSM-5 1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: • Eating, in a discrete period of time (e. g. , within any 2 -hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances • A sense of lack of control over eating during the episode (e. g. , a feeling that one cannot stop eating or control what or how much one is eating. ) 2. Binge-eating episodes are associated with: • • • Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because of feeling embarrassed by how much one is eating Feeling disgusted with oneself, depressed, or very guilty 3. Marked distressed regarding binge eating is present 4. Occurs at least once a week for three months 5. Not associated with recurrent use of inappropriate compensatory behavior

Overview of DBT What is Dialectical Behavior Therapy? • Dialectical behavior therapy (DBT) provides clients with new skills to manage painful emotions and decrease conflict in relationships • DBT is a cognitive behavioral treatment developed by Marsha Linehan, Ph. D, ABPP • It emphasizes individual psychotherapy and group skills training classes

Overview of DBT • DBT establishes a “dialectical” view, one that allows us to hold two mutually exclusive positions at one time • The opposite of all-or-nothing thinking • “Dialectical” a synthesis or integration of opposites • DBT therapists accept clients as they are while also acknowledging that they need to change in order to reach their goals. • All of the skills and strategies taught in DBT are balanced in terms of acceptance and change • Two sets of acceptance-oriented skills (mindfulness and distress tolerance) • Two sets of change-oriented skills (emotion regulation and interpersonal effectiveness)

Overview of DBT • The theory behind the approach is that some people are prone to react in a more intense manner toward certain emotional situations: • primarily those found in romantic, family and friend relationships • DBT theory suggests that arousal levels for certain people, in such situations can: • increase far more quickly than the average person’s • attain a higher level of emotional stimulation • take a significant amount of time to return to baseline arousal levels

Five Components of a Full DBT Program DBT Skills Training • There are four modules in skills training: • Mindfulness: the practice of being fully aware and present in this one moment • Distress Tolerance: how to tolerate pain in difficult situations, not change it • Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others • Emotion Regulation: how to change emotions that you want to change

Five Components of a Full DBT Program DBT Skills Training (continued) • DBT skills training focuses on enhancing clients’ capabilities by teaching them behavioral skills • Skills training is frequently taught in groups; the group is run like a class where the group leaders teach the skills and assign homework • The homework helps clients practice using the skills in their everyday lives. • Groups meet on a weekly basis for approximately 2. 5 hours, and it takes 24 weeks to get through the full skills curriculum, which is often repeated to create a 1 -year program

Five Components of a Full DBT Program Individual Therapy • DBT individual therapy is focused on enhancing client motivation and helping clients to apply the skills to specific challenges and events in their lives • In the standard DBT model, individual therapy takes place once a week for as long as the client is in therapy, and it runs concurrently with DBT skills training Coaching • Telephone coaching and other in vivo coaching to provide in-the-moment support • Clients can call their individual therapist between sessions to receive coaching at the times when they need help the most • Goal is generalization of skills

Five Components of a Full DBT Program Case Management • Case management strategies help the client manage his or her own life, such as their physical and social environments • The therapist applies the same dialectical, validation, and problem-solving strategies in order to teach the client to be his or her own case manager DBT Consultation Team • The DBT consultation team is focused on the people who provide DBT, including individual therapists, skills training group leaders, case managers, and others who help treat the client or patient • The consultation team is designed to help therapists stay motivated and competent so they can provide the best treatment possible • This is especially important when they are treating people with severe, complex, difficult-to-treat disorders so the team can help one another manage burnout and share their knowledge

Applying DBT Skills to ED Treatment • DBT Programs with all 5 -components are hard to find • Only a few DBT certified programs in Florida-closest one to Orlando is in Tampa • Not all programs offer all modes, either! • When applied to the eating disorder population: • Four main skills are taught with emphasis on examples pertaining to ED

Applying DBT Skills to ED Treatment • Mindfulness • What does this food taste like right now? Texture? Flavor? Enjoyment of Taste? • What can I do to intentionally live with awareness in this present moment? • Distress tolerance • What can I do right now, while I’m eating, to improve this moment? Conversation, games, art, etc. ? • STOP Skill- Stop, Take a step back, Observe, Proceed Mindfully

Applying DBT Skills to ED Treatment • Emotion regulation covers strategies to manage and change intense emotions that are causing problems in a person’s life. • When I’m feeling frustrated at the table with my parents/spouse, how can I communicate my emotions? • What is my emotional range? What emotions do I frequently experience? How do my emotions serve me? • Interpersonal effectiveness consists of techniques that allow a person to communicate with others in a way that is assertive, maintains self-respect, and strengthens relationships. • How can I get others to meet my needs without utilizing eating disorder behaviors? • How do I build healthy relationships and end destructive relationships?

Why use DBT for ED? • People with eating disorders often start off with dieting and then realize that their weight-control behaviors also help to regulate distressing emotions • Obsessing about food, weight, and calories is a distraction from other upsetting thoughts or worries • Bingeing can be self-soothing and creates a numb feeling, and purging relieves anxiety or other intense emotions • Eating disorder behaviors may be individuals’ best efforts to care for themselves

Why use DBT for ED? • We teach DBT skills to equip clients with new strategies to cope with distressing thoughts and emotions • We also target behaviors to reduce and use ‘behavior chains’ to analyze what prompts and reinforces these behaviors • This helps patients increase their awareness about how to change these behaviors

DBT for Eating Disorders-Logistics • The ideal model will include both individual therapy and a weekly skills training group • Easy to implement in Residential, PHP, and IOP levels of care • May be able to implement in private practice • Overarching goal of DBT for eating disorders: reduce and eventually extinguish life-threatening behaviors and keep patients out of the hospital • Any behavior that interferes with therapy is targeted early on so that the patient may engage fully and safely on an outpatient basis • Shorter lengths of stay mandates preparation for discharge from Day 1

DBT for Eating Disorders-Logistics • Teach skills (preferably in groups) every day • Have staff do skills coaching with patients as needed • Utilize individual therapy to reinforce motivation and practice applying skills to personal and challenging scenarios • Patients fill in daily diary cards and homework cards to track the target behaviors they are working to reduce (e. g. , bingeing, purging, overexercising, laxatives use, etc. ) • The diary cards also track their use of the skills they’re striving to develop.

DBT for Eating Disorders-Logistics • Weekly therapy sessions are highly structured • Include a mindfulness exercise and a review of homework and skills learned in prior sessions as well as the teaching of a new skill for the week • Not process-oriented therapy • Processing of emotional material is contained to best use time developing strategies to cope with whatever is coming up • There is little focus on historical origins of the problem within that session • Rather, the interest is in managing one’s struggles right now • Outpatient therapy or treatment program friendly

DBT for Eating Disorders-Logistics • Relative to the different therapies for eating disorders: • DBT is most focused on developing a catalog of concrete skills and strategies to use • Purpose is to cope more effectively in day-to-day life AND reduce ED symptoms, cycles, and behaviors • Patients are given daily homework assignments to work on between sessions/days/meals • At times, patients may even be encouraged to reach out to therapist between sessions for coaching or support in accessing skills • Depends on LOC and treatment infrastructure

When and How to apply DBT for Eating Disorders • DBT is most effective when combined with otherapies to achieve successful behavior change • (for patients with eating disorders) • Still need a combined, multidisciplinary approach, possibly including: • Medication, CBT, nutrition therapy, process work, interpersonal group therapy, experiential therapy, etc. • Estimated 50% of patients with bulimia and BED fail to improve with standard treatment methods • When CBT alone does not resolve bingeing or binge/purge behaviors, DBT’s focus on emotion regulation may be more promising.

DBT for Bulimia and BED • Most research to-date pertains to DBT for Bulimia and BED • Success in helping clients improve emotional regulation and affect • Decreases in binge and/or binge-purge cycle behaviors • DBT was developed to treat borderline personality disorder, where individuals struggle with chaotic emotions and impulsive behaviors • DBT translates more easily to people with eating disorders who are struggling with impulsive behaviors like bingeing and purging, • Relative to those with anorexia are struggling with being rigid and controlling their food and their emotions

DBT for Bulimia and BED • Individuals with more impulsive behaviors such as bingeing and/or purging may embrace DBT skills more readily • Patients usually experience behaviors like bingeing and purging as more distressing than restriction • Patients tend to be more motivated to learn skills that will help them decrease binge and/or purge behaviors • All eating disorder behaviors function as ways of coping; learning alternative strategies to cope is key to extinguishing these behaviors.

DBT for Anorexia? • Traditional DBT was not specifically designed for the full spectrum of thoughts and behaviors that make Anorexia difficult to treat • Adaptation is necessary • Still, DBT offers much patients can connect with and utilize • Aspects of DBT that have proven useful in recent research include mindfulness skills, interpersonal effectiveness, and understanding the model of emotions as DBT explains it • Facets of DBT can be used with patients with all types of eating disorders, • However, DBT should not be primary mode of therapy for an outpatient client with anorexia

DBT for Anorexia! • Modified form of DBT developed by Thomas Lynch, Ph. D, called “Radically Open Dialectical Behavioral Therapy (RO-DBT) that may be of use to therapists treating anorexia • New, evidence based treatment targeting a spectrum of disorders characterized by excessive self control, often referred to as overcontrol (OC)

DBT for Anorexia! • RO-DBT treatment involves both individual treatment sessions and skills training classes, • Centers around five OC themes: • • • Inhibited and disingenuous emotional expression; Hyper-detailed focused and overly cautious behavior; Rigid and rule-governed behavior; Aloof and distant style of relating; High social comparison and envy/bitterness. • Lynch continues to research the efficacy of this new model with patients with anorexia • 2 RCTs already completed; 2013 and 2014

How can I Implement DBT for ED? • DBT Skills Corner • (or basket, or box, or treasure chest, or whatever works for your space!) • Diary Cards • Worksheets • Get out of the “Processing” frame of mind • At least while using DBT!

DBT Skills Corner • DBT skills corner in the milieu-based program can promote “in the moment skill development” to supplement DBT skills base learned in psycho-educational groups • This enables clients to develop self-efficacy and autonomy in applying skills to in real-time • Staff checks in at the beginning and at the end of this time • Only exception is if client is at a 10; • Staff may remain present for duration of time • DBT Scale: 1 -10 • Assist in linking to appropriate skill set on 10 -point scale • 7 -10= Distract/ Distress Tolerance • 4 -6= Self-soothe • 1 -3= IMPROVE

DBT Skills Corner • Levels 7 -10: Distress Tolerance • Highly Stressful situations, triggering events • (e. g. , Exposure Meal/Restaurant Night or Family Therapy/Family Meal • Utilize “Wise Mind ACCEPTS” activity • Some activities include: “find it, ” stress ball, rip a phone book, frozen fruit

DBT Skills Corner

DBT Skills Corner Distress Tolerance Example Activities • “Find it” Activity- There is hidden objects in the plastic capsule that is filled with small beads, and the goal of the ct. is to find the objects hidden in the capsule. This activity takes their mind off of their stress in order to focus on the current task • Frozen Limes- Clients are to squeeze or scratch the limes. The texture, scent, color, and temperature of the fruit collectively helps the client to focus on the “here and now”, a state of awareness that is encouraged in Dialectical Behavioral Therapy • Holding Ice- Clients can squeeze ice in their hands or throw it at an outside wall. The squeezing and throwing of ice stimulates a physiological effect that takes the client’s focus away from their ruminating thoughts and emotions and directs it towards the sensation of the coldness in their hands • Scream into a pillow- This activity helps to expend a client’s stored up physical energy that result from their intense emotions • Stress Balls/bean bags- By expending physical energy, the activity of squeezing soft balls relieves intense emotions that are stored up within a client’s body • Silly Putty- Silly putty is a great exercise in mindfulness. It offers endless possibilities for sculpting and manipulating its shape, while also providing the client the opportunity to sooth him or herself through feeling its unique texture. Similarly to stress balls, it expends physical energy to relieve a client’s intense emotions • Ripping up Phone Books- Ripping up phone books is a particularly helpful outlet in relieving anxious or angry emotions because it expends the adrenaline produced by anxiety or anger • Etch a sketch- This activity draws attention away from intense emotions and to a detailed task of creating a picture

DBT Skills Corner • Levels 4 -6: Self-Soothe • Become aware of and sooth 5 senses • Grounding • Some activities include: aromatherapy, sand-tray, art books, make a playlist

DBT Skills Corner

DBT Skills Corner Self-Sooth Skills • Aromatherapy/Scents- Engaging the sense of smell allows a client to distract themselves from self perceived crises situations that are causing them distress or emotional dysregulation. Gives a client the opportunity to shift their attention away from their current distressing or dysregulated emotion to a new memory or emotion. • Walk Barefoot- This activity allows clients to be mindful of their feet—which literally and figuratively grounds the client’s physical and emotional state. • Dry Lentils/container of rice- Clients can play with dry lentils or rice. The firm rounded texture of the lentils or smooth surface of rice can soothe client’s current jagged emotional state. • Feet in pool- A client can put their feet into the pool for sensual stimulation. Being in water increases dopamine and norepinephrine levels, which reduces a client’s state of stress and anxiety. • Relaxation CDs- Here is a description if you do: A client can calm their visual and audio senses in watching a video and consequently quiet their current dysregulated emotional state. • Create a Playlist- We often tie music to memories. This distracting task of putting together inspirational songs can help clients to recall happy times, or when they went through difficult times and how they got through them. • Pool Waterfall/Being Around a Fountain- The sound of water can sooth a client’s current emotionally dysregulated state. • Art Books- Looking through different photos or pieces of art allows clients to focus on beauty rather than their distressed emotional state. It can also trigger different nostalgic memories, bringing clients to a more positive state of mind. • Deep Breathing- This exercise helps clients by taking a deep breath and stepping away from their current emotional state. It slows their heart rate and decreases physiological arousal associated with intense emotions.

DBT Skills Corner • Levels 1 -3: Improve the Moment • In the moment mood-regulation • Some activities include: Buddha Book, Magnetic Poetry, Cardmaking/writing, Positive affirmations

DBT Skills Corner

DBT Skills Corner Improve the Moment • Playing Cards- This is a distracting activity and provides a goal for clients to be working towards (for example, the goal may be winning a game of solitaire). It can also encourage social connection by requiring the client to invite others to play card games with them. • The Buddha Board- This is a mindfulness activity in which one starts by drawing a picture on the Buddha board. The picture will slowly erase and during that time one can practice other mindfulness activities. • Magnetic Poetry- Clients can create poetry sentences with cut out magnetic words. This creates an opportunity for clients to express their emotions through a constructive and calming activity. • Reading Entry Letter- When clients first come into treatment they will write a letter to themselves explaining their current attitude towards treatment and their goals. Reviewing their original thoughts and goals helps clients to recognize how far they have come since their admission. • Sandbox- Clients can use the sandbox to sift sand between their hands or to draw pictures. This technique is utilized to distract clients from their current state of emotion, or to express their distress through sculpting. • Quote Books- Clients can read through quotes from different inspirational figures and authors to encourage them through difficult times when they are experiencing intense emotional dysregulation. These quotes can provide clients inspiration and guidance. • Write a letter/card- This activity provides clients the opportunity to reach outside of themselves and encourage another individual in their life. Shifting the attention from oneself onto another can alleviate distress and emotional dysregulation while also encouraging another who may be experiencing similar feelings. • You. Tube Videos- Watching movie clips can provide inspiration and guidance for clients during distressing or emotionally disturbing times, while also giving clients insight about their current state or how to constructively handle their emotions. • Affirmation Cards- Clients can encourage others by providing affirmation or words of advice. This takes away a client’s distress or emotional dysregulation by shifting the client’s focus away from oneself and focusing on another. • Word Searches- Clients can exercise their brain through engaging in word games or searches. Such stimulation benefits clients by strengthening their cognitive functioning and helping them to focus on problems solving rather than ruminating on negative or distressing emotions.

Diary Card Example

Homework Skills Card Example