By Milton Spett

Dialectical Behavior Therapy (DBT) was originally developed by Marsha Linehan for treating borderline personality disorder, and has subsequently been adapted for binge eating disorder. I believe DBT will be found to be valuable for treating a wide range of overemotional disorders including narcissism, hysteria, and dissociative disorders. Linehan developed DBT in a clinic setting, but this review will discuss only those aspects of DBT that apply in private practice. Marsha Linehan’s DBT treatment manuals are available at www.guilford.com or you may call Guilford at 800-365-7006.

In DBT the primary dialectic is the dual focus on acceptance and change. The therapist must find the right balance of these two factors throughout treatment.

Acceptance Techniques

Articulating the wisdom, correctness, or value in patients’ emotions, cognitions, and behaviors.

Expressing confidence in patients’ ability to change themselves and build a happy, successful life.

Tailoring session length to the individual needs of each patient. Longer sessions are scheduled for patients who have difficulty opening up and then regaining control of their emotions.

Arranging telephone sessions when patients need extra therapeutic contact, help with a difficult situation, or as a means of repairing the therapeutic alliance after an adversarial therapy session.

Assuming that patients are doing the best they can rather than viewing patients as sabotaging the therapy.

Change Techniques

Accepting only those patients who commit to work on reaching the following behavioral targets: reducing suicidal, parasuicidal, and life-threatening behaviors, and behaviors that interfere with the process of therapy.

Patients must also commit to attend all therapy sessions, pay the established fees, and work on learning new skills for coping with life situations. These commitments may be either oral or in writing.

The initial focus of treatment is on establishing a strong therapeutic relationship. Once the relationship is established, the therapist announces that therapy will be terminated if patients do not make sufficient progress.

Skill training includes teaching patients to ask for help rather than act out, and to ask in an appropriate rather than a demanding manner.

Even in crises, hospitalization is discouraged since hospitalization takes patients out of the environment in which they must learn to function.

Guidelines for Therapists

In order to deal with these demanding, narcissistic patients, therapists are required to be in either group or individual supervision.

Supervision accepts that each therapist sets rules and limits that are appropriate for that therapist, without interpreting therapists’ limits as neurotically reflecting either a fear of intimacy or a need to be nurturant.

Therapists are expected to make mistakes and to be accepting of their own mistakes.

Therapists are vulnerable to the pattern of appeasing these demanding patients, then becoming angry and punitive, then guilty and appeasing again.

Therapists must modify the treatment to suit each patient without undermining the principles of DBT.

Therapists must maintain a balance between giving nurturance and demanding change, giving patients needed help and guidance, without doing for patients what patients can do for themselves.

Therapists must maintain and communicate optimism that the therapy will cure each patient.

DBT for Binge Eating Disorder

Wiser and Telch describe Dialectical Behavior Therapy for Binge Eating Disorders in the 1999 Journal of Clinical Psychology, 55, 6, 755-768. DBT assumes that self-destructive behaviors such as binge eating and self-mutilation are maladaptive attempts to avoid or diminish intolerable negative emotions. The focus of DBT for BED is to teach these patients to face, reduce, eliminate, and/or tolerate their painful emotions. The four components of DBT for BED are:

1. Mindfulness training (becoming aware of emotions).

2. Emotional regulation (reducing or eliminating negative emotions).

3. Distress tolerance (learning to tolerate painful emotions).

4. Interpersonal effectiveness (interpersonal skills training).

Patients use “diary cards” to record emotional experiences, behaviors, and the DBT skills they practice. Patients also complete “Behavioral chain analysis” forms where they record sequences of situations, internal reactions, and maladaptive behaviors. Each week, patients discuss this information in the first hour of their group session. In the second hour, patients learn and practice new skills. Each patient also has one individual therapy session per week.

DBT for BED Techniques

Here are some DBT techniques for BED patients described by Wiser and Telch:

1. 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.

2. Identifying the antecedents and consequences of emotions.

3. Becoming aware of the bodily responses that accompany negative emotions.

4. Understanding the relationship between cognitions and emotions, and modifying cognitions that evoke negative emotions.

5. Learning adaptive methods of coping with negative emotions: relaxing, taking walks, socializing, taking a warm bath, listening to soothing music,

6. Getting adequate sleep and reducing excessive exercise and the use of drugs and alcohol.

7. Reducing negative emotions, for example by facing rather than avoiding feared situations, and by revealing rather than hiding feelings of shame.

Alert Readers may have noticed a conflict between technique #1, experiencing emotions, and technique #7, reducing negative emotions. This conflict is the primary dialectic, from which DBT derives its name.

An Uncontrolled Trial of DBT for BED

A good deal of research has demonstrated the effectiveness of DBT for Borderline Personality Disorder, and in the Summer, 2000 issue of Behavior Therapy, Telch, Agras, and Linehan describe an uncontrolled trial of DBT for 11 women with binge eating disorder (BED). Unlike bulimia nervosa, BED includes no compensatory behaviors such as purging, fasting, or excessive exercise. DBT assumes that binges are attempts to reduce intense negative emotions. If this is true, then binges can be reduced or eliminated by teaching BED patients to identify negative emotions, reduce negative emotions, and tolerate those negative emotions that cannot be reduced.

After 20 weeks of treatment, 9 of the 11 women reported no binge eating over the previous four weeks. Of the 10 women who participated in the six month follow-up, seven remained abstinent from binge eating, and the remaining three had reduced the number of binges, and no longer met the criteria for BED. The authors compare these results favorably with CBT studies which generally find 50% abstinence from binge eating at the end of treatment.

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