The Application of Dialectical Behavior Therapy to Eating Disorders

1. The Application of Dialectical Behavior Therapy to Eating Disorders Melissa Freizinger, Ph.D. Laurel Hill Inn, Medford, MA

2. Objectives for Today Briefly outline of Dialectical Behavior Therapy (DBT) basics. Explain how ED behaviors fit into the DBT framework. Discuss case examples for each DBT module and the applicable DBT skills. Discuss barriers to use of DBT skills. Q&A

3. What is DBT? A comprehensive treatment approach that was developed by Marsha Linehan for the treatment of people with borderline personality disorder (BPD) and parasuicidal behaviors also including self injurious behaviors. Since it�s inception, DBT has been adapted to address a variety of problems associated with emotion dysregulation. This presentation will focus on how DBT has been adapted to treat patients with primary eating disorder diagnoses. Everyone here knows according to the 4th edition of the DSM-IV, an eating disorder involves extreme forms of eating g behavior accompanied by an excessive dependence upon weight and shape as a means of self-evaluation. ED�s lead to significant impairments in health and psychosocial functioning. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002).Since it�s inception, DBT has been adapted to address a variety of problems associated with emotion dysregulation. This presentation will focus on how DBT has been adapted to treat patients with primary eating disorder diagnoses. Everyone here knows according to the 4th edition of the DSM-IV, an eating disorder involves extreme forms of eating g behavior accompanied by an excessive dependence upon weight and shape as a means of self-evaluation. ED�s lead to significant impairments in health and psychosocial functioning. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002).

4. What is DBT (continued) DBT is an empirically - supported treatment. DBT is based on biosocial theory of emotion dysregulation model of symptoms and theory of invalidating environments. DBT utilizes a complete array of cognitive and behavioral techniques. DBT incorporates acceptance-based philosophies and strategies, primarily Zen Buddhism practices, in the context of a dialectical philosophy. Biosocial theory: some individuals are more vulnerable and have a high sensitivity to emotional stimuli, they have an intense response to emotional stimuli, slow returned to basement. Their emotional response � cannot regulate their emotions when needed, informational processing is distorted, can not organize to achieve non mood dependent goals, cannot control impulsive behavior related to strong negative affect, shut down freeze�everything is mood dependent. Invalidating environment: Punishes emotional displays and intermittently reinforces emotional escalation, reject person�s internal experiences, results in self invalidation, vary between emotional inhibition and extreme emotional styles.Biosocial theory: some individuals are more vulnerable and have a high sensitivity to emotional stimuli, they have an intense response to emotional stimuli, slow returned to basement. Their emotional response � cannot regulate their emotions when needed, informational processing is distorted, can not organize to achieve non mood dependent goals, cannot control impulsive behavior related to strong negative affect, shut down freeze�everything is mood dependent. Invalidating environment: Punishes emotional displays and intermittently reinforces emotional escalation, reject person�s internal experiences, results in self invalidation, vary between emotional inhibition and extreme emotional styles.

5. The Dialectics of DBT Therapy Is the tension between promoting change (behavior therapy) and acceptance (Zen). Everything is made of opposing forces and opposing sides. Gradual changes lead to turning points, where one opposite overcomes the other. Change is evolutionary, changes moves in spirals establishing truths on both sides rather than disproving one argument. Dialectics seeks a synthesis that honors truth on both sides. Emphasizes both and rather than either.. or DBT Therapists emphasizes working with the tension between freedom and control. Linehan realized this model was necessary when she was using straight CBT behavioral theories in treatment BPD � change strategies alone were not enough to move the patient into the action phase of treatment.Everything is made of opposing forces and opposing sides. Gradual changes lead to turning points, where one opposite overcomes the other. Change is evolutionary, changes moves in spirals establishing truths on both sides rather than disproving one argument. Dialectics seeks a synthesis that honors truth on both sides. Emphasizes both and rather than either.. or DBT Therapists emphasizes working with the tension between freedom and control. Linehan realized this model was necessary when she was using straight CBT behavioral theories in treatment BPD � change strategies alone were not enough to move the patient into the action phase of treatment.

6. A Dialectical View of Our Patients Balancing Acceptance, Validation, and Change �We know you have suffered a great deal and your life is really terrible right now, but you must work harder to recover�� This model is useful for therapists to balance pulling for change with acceptance of the difficulty of changing is useful in addressing the treatment ambivalence so characterize of eating disorder patients, especially those with AN. ED patients resent, and resist treatment interventions, so DBT therapists are trained to use emotional, behavioral and validation strategies that are designed to acknowledge that symptoms behaviors serve a meaningful function and represent a levitate effort to deal with life circumstance (acceptance). ED patients frequently elicit strong negative reactions from treaters that are often incorrectly attributed to the patient�s character. These reactions negatively influence treatment. ED patients are often perceived as dishonest, vain, and manipulative which engenders a negative response. In contrast, understanding these behaviors as being related to a lack of skill in coping with unbearable anxiety or confusion engenders a more sympathetic and helpful response from treatment providers, friends and families. Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies. This model is useful for therapists to balance pulling for change with acceptance of the difficulty of changing is useful in addressing the treatment ambivalence so characterize of eating disorder patients, especially those with AN. ED patients resent, and resist treatment interventions, so DBT therapists are trained to use emotional, behavioral and validation strategies that are designed to acknowledge that symptoms behaviors serve a meaningful function and represent a levitate effort to deal with life circumstance (acceptance). ED patients frequently elicit strong negative reactions from treaters that are often incorrectly attributed to the patient�s character. These reactions negatively influence treatment. ED patients are often perceived as dishonest, vain, and manipulative which engenders a negative response. In contrast, understanding these behaviors as being related to a lack of skill in coping with unbearable anxiety or confusion engenders a more sympathetic and helpful response from treatment providers, friends and families. Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies.

7. Why DBT for ED Patients? Comorbid BPD and parasuicidal behaviors are common among patients w/EDs. Suicide is one of the leading causes of death in patients w/AN. Many patients with EDs engage in high risk behaviors. Substantial numbers of patients w/EDs are refractory to front line treatments. DBT is a concrete and cost effective treatment. People with eating disorders often have the same type of issues with managing �overwhelming� emotions. DBT is a well characterized methodology for working with difficult patients. DBT has clear guidelines for treating multiple behaviors. DBT requires a basic respect for the meaning of the patient�s symptoms in the context of their experiences - and a matter of fact emphasis on the patient�s need for changing their behaviors (Steinhausen, 2002). Presence of BPD is a predictor of poor treatment outcomes in CBT for patients with BED and BN Grilo 2001). There�s an overlap between the BPD and the ED populations Studies of bulimic patients suggest that 15 � 40% attempt suicide (Dulit et al. 1994). 20- 58% of deaths in AN women may be related to suicide Herzog et al., 2000. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies. DBT is a well characterized methodology for working with difficult patients. DBT has clear guidelines for treating multiple behaviors. DBT requires a basic respect for the meaning of the patient�s symptoms in the context of their experiences - and a matter of fact emphasis on the patient�s need for changing their behaviors (Steinhausen, 2002). Presence of BPD is a predictor of poor treatment outcomes in CBT for patients with BED and BN Grilo 2001). There�s an overlap between the BPD and the ED populations Studies of bulimic patients suggest that 15 � 40% attempt suicide (Dulit et al. 1994). 20- 58% of deaths in AN women may be related to suicide Herzog et al., 2000. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies.

8. Traditional DBT Treatment Individual Psychotherapy Group Skills Training Team Consultation Telephone Consultation

9. Integrating DBT into Therapy Balance change with acceptance. Therapist must have strong, positive relationship with patient. Therapist responsible for helping patient replace maladaptive behaviors with skillful adaptive behaviors. Orient client to DBT and elicit commitment to therapy and collaborate on goals for treatment.

10. Possible DBT Solutions Solve the problem. Change your emotional reaction to the problem. Tolerate the problem. Stay miserable. Make things worse�.

11. Treatment Hierarchy Target One: Life Threatening Behaviors Target Two: Therapy Interfering Behaviors (anything that threatens the continuation of therapy) non-compliance Target Three: Quality of Life Interfering Behaviors (inconsistent with a meaningful life) Substance abuse or housing problems Employment issues Target Four: Increasing Behavioral Skills to facilitate a life worth living DBT Treatment Hierarchy provides an effective framework for prioritizing and organizing the many problematic behaviors with which ED patients present. Target One: Suicidal and other imminent life threatening behaviors non suicidal self injurious behaviors are addressed first in treatment for ed patients abuse of ipecac/insulin perhaps consult with medical professionals Target Two: May occur within the context of treatment - attention is given to TIB to emphasize the necessity of a strong positive interpersonal relationship between patient and therapist. DBT uses the relationship to achieve therapeutic goals. The relationship is conceptualized in two ways, as being the therapy itself and the mechanism for effecting change. TIB�s include: missing sessions, lying, losing weight, restricting meals, if patients do not inform treaters of medical complications etc. showing up late to treatment, anything that interferes with the relationship and therefore the treatment. Behaviors that burn out the therapist. Therapy interfering behaviors on the part of the therapist: 2 categories: those that create therapeutic imbalance (too much emphasis on change and not enough on validation, and those that demonstrate a lack of respect for the patient i.e. arriving late for group. Target 3: QOL: Housing issues, employment issues, laxative use, the bulk of treatment for ED patients who are not suicidal or at imminent risk of death will fall within Targets 2 and 3. Attend to Immediacy of problem Solvability of problem Functional relationship of behaviors to higher priority targets The Clients GoalsDBT Treatment Hierarchy provides an effective framework for prioritizing and organizing the many problematic behaviors with which ED patients present. Target One: Suicidal and other imminent life threatening behaviors non suicidal self injurious behaviors are addressed first in treatment for ed patients abuse of ipecac/insulin perhaps consult with medical professionals Target Two: May occur within the context of treatment - attention is given to TIB to emphasize the necessity of a strong positive interpersonal relationship between patient and therapist. DBT uses the relationship to achieve therapeutic goals. The relationship is conceptualized in two ways, as being the therapy itself and the mechanism for effecting change. TIB�s include: missing sessions, lying, losing weight, restricting meals, if patients do not inform treaters of medical complications etc. showing up late to treatment, anything that interferes with the relationship and therefore the treatment. Behaviors that burn out the therapist. Therapy interfering behaviors on the part of the therapist: 2 categories: those that create therapeutic imbalance (too much emphasis on change and not enough on validation, and those that demonstrate a lack of respect for the patient i.e. arriving late for group. Target 3: QOL: Housing issues, employment issues, laxative use, the bulk of treatment for ED patients who are not suicidal or at imminent risk of death will fall within Targets 2 and 3. Attend to Immediacy of problem Solvability of problem Functional relationship of behaviors to higher priority targets The Clients Goals

12. DBT: Four Modules Acceptance Skills 1. Mindfulness 2. Distress Tolerance Change Skills 3. Emotional Regulation 4. Interpersonal Effectiveness

13. Behaviors treated by DBT Skills 1. Mindfulness � inability to identify cues of hunger and satiety, mindless eating 2. Distress Tolerance � impulsivity, anxiety, tolerating re-feeding, using ED to manage emotions 3. Emotional Regulation � labile or no affect, inability to identify emotions 4. Interpersonal Effectiveness � interpersonal chaos, saying no, asking for help, passivity

14. DBT can be helpful to: Increase: Structured eating Awareness of hunger/fullness Non-judgmental approach toward food and body Skill use when emotionally dysregulated Decrease: Unstructured eating Food avoidance Food/body obsessions Judgments about weight, shape, appearance Compensatory behaviors Use of ED to cope with difficult emotions

15. Mindfulness  �Mindfulness means paying attention in a particular way; on purpose,in the present moment, andnonjudgmentally.� Jon Kabat-Zinn There are three types of mindfulness: observe, describe, and participate. We are going to start with a breath focused mindfulness where we are going to observe our breath.There are three types of mindfulness: observe, describe, and participate. We are going to start with a breath focused mindfulness where we are going to observe our breath.

16. Mindfulness Works in Tandem with the Other DBT Skills Mindfulness is incompatible with ED behaviors because one cannot be mindful and engage in behaviors that decrease affect. Patients become mindful of their avoided emotions and self-judgments. Mindfulness provides a framework for teaching the difference between thoughts, emotions, and the values of each � and prepares patients to use other DBT skills.

17. Three Primary States of Mind The states of mind conceptualization is useful for targeting ambivalence in ED patients because it promotes active and awareness of decision making. The model provides a framework for evaluating decisions and is useful for teaching the difference between thoughts and emotions and the inherent value of each.The states of mind conceptualization is useful for targeting ambivalence in ED patients because it promotes active and awareness of decision making. The model provides a framework for evaluating decisions and is useful for teaching the difference between thoughts and emotions and the inherent value of each.

18. Mindfulness Skills The What Skills: Observe Describe Participate  The How Skills: Non-judgmentally One-mindfully Effectively  States of Mind

19. Mindfulness Applied Mindfulness skills needed when:Patients lack limited awareness of emotions and hunger and have a poor ability to distinguish between the two To served as non reinforced exposure to sensations To promote a non judgmental approach to body image To have a nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What might your rational mind say??? .Mindfulness skills needed when:Patients lack limited awareness of emotions and hunger and have a poor ability to distinguish between the two To served as non reinforced exposure to sensations To promote a non judgmental approach to body image To have a nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What might your rational mind say??? .

20. MINDFULNESS HANDOUT #2 According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies.

21. Distress Tolerance Goal of DT: to help patients tolerate pain and accept life as it is in the moment rather than using impulsive behaviors. Four sets of crisis survival skills are taught: Distracting Self-soothing Improving the moment Pros and cons Acceptance skills are taught: radical acceptance, turning the mind willingness vs. willfulness. Needed to assist clients in accepting body shape, metabolism and genetics To assist clients in accepting events such as past trauma, etc. without engaging in ED behaviorsNeeded to assist clients in accepting body shape, metabolism and genetics To assist clients in accepting events such as past trauma, etc. without engaging in ED behaviors

22. Distress Tolerance Applied According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies.

23. Distress Tolerance Handout 1 According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies.

24. Emotion Regulation Goal: Emotion regulation skills focus on improving control over emotions and learning techniques for modulating emotions. Skills: Understand emotions Reduce emotional vulnerability Decrease emotional suffering Act opposite to painful emotions Identify and label emotions vs. hunger/fullness Increase pleasant activities Emotion regulation skills focus on improving control over emotions and learning techniques for modulating emotions. The goals of this skill module are to understand emotions, reduce emotional vulnerability, and decrease emotional suffering. These skills are useful for educating ED patients about the effects of ED behaviors on mood. Hunger, malnution and other physical syumptoms are viewed as vulnerability factors for emotional dysregulation that can impede effective use of new skills. Emotion regulation skills increase exposure to emotions by encouraging patients to experience their emotions without judging or attempting to inhibit or block them. Needed when clients confuse or unable to differentiate between negative emotions vs. hunger and fullness When clients are in high emotional states due in part to an imbalance in eating and or exercise To teach clients how to engage in pleasant activities Teach patients to deal with shame guilt sadness depression, anger, anxiety Emotion regulation skills focus on improving control over emotions and learning techniques for modulating emotions. The goals of this skill module are to understand emotions, reduce emotional vulnerability, and decrease emotional suffering. These skills are useful for educating ED patients about the effects of ED behaviors on mood. Hunger, malnution and other physical syumptoms are viewed as vulnerability factors for emotional dysregulation that can impede effective use of new skills. Emotion regulation skills increase exposure to emotions by encouraging patients to experience their emotions without judging or attempting to inhibit or block them. Needed when clients confuse or unable to differentiate between negative emotions vs. hunger and fullness When clients are in high emotional states due in part to an imbalance in eating and or exercise To teach clients how to engage in pleasant activities Teach patients to deal with shame guilt sadness depression, anger, anxiety

25. Emotional Regulation Applied According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies.

26. Emotional Regulation Handout 10 According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies.

27.  Interpersonal Effectiveness Goal: To help patients learn to use their voice rather than using their ED behaviors to become socially effective. Skills: Obtaining changes one wants while maintaining the relationship and self-respect Negotiating conflict Asking for what one needs Assertiveness and saying no Dealing with interpersonal conflict Staying emotionally regulated while in conflict For example, an eating disorder patient may be able to successfully negotiate the demands and tasks associated with an academic curriculum, but are often inept when negotiating interpersonal relationships in a social context. Developing assertiveness skills is a primary objective of the IE skills. The skills focus on teaching patient show to achieve objectives such as making requests and saying no to requests, while maintaining important interpersonal relationships and one�s self respect. ED patients commonly have an inability to assertively communicate feelings and requests � many of our patients are very competent in one area of their lives i.e.work, (Called apparent competence) but have difficulty negotiating personal relationships. The IE skills challenge ED patient�s tendency to want to avoid conflict and the skills teach patients effective means to express thoughts and feelings and get their needs met, while decreasing reliance on a people pleasing demeanor and the use of ED behaviors to modulate negative moods. For example, an eating disorder patient may be able to successfully negotiate the demands and tasks associated with an academic curriculum, but are often inept when negotiating interpersonal relationships in a social context. Developing assertiveness skills is a primary objective of the IE skills. The skills focus on teaching patient show to achieve objectives such as making requests and saying no to requests, while maintaining important interpersonal relationships and one�s self respect. ED patients commonly have an inability to assertively communicate feelings and requests � many of our patients are very competent in one area of their lives i.e.work, (Called apparent competence) but have difficulty negotiating personal relationships. The IE skills challenge ED patient�s tendency to want to avoid conflict and the skills teach patients effective means to express thoughts and feelings and get their needs met, while decreasing reliance on a people pleasing demeanor and the use of ED behaviors to modulate negative moods.

28. Interpersonal Effectiveness Applied Attending to relationships particularly when effective communication around ED issues and food are involved. Balancing priorities vs. demands Balancing wants vs. shoulds especially as it pertains to food wants and shoulds Build mastery and self-respect. Attending to relationships particularly when effective communication around ED issues and food are involved. Balancing priorities vs. demands Balancing wants vs. shoulds especially as it pertains to food wants and shoulds Build mastery and self-respect.

29. Interpersonal Effectiveness Handout 8 According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies. According to research, (Fairburn, Marcus, & Wilson, 1993) empirically derived treatments such as CBT and IPT are ineffective for about 50% of patients with BN and BED. Treatment effects for AN are thought to be even more modest (Fairburn & Harrison, 2003). (IPT Garner and Garfinkle 1997), (CBT Brownell and Fairburn 2002). nonjudgmental acceptance of all moods and encourages observation and labeling of emotions. Mindfulness resembles exposure in that it involves increasing awareness of the mood states eating disorder patients typically seek to avoid . The �states of mind� conceptualization (i.e., emotion mind, reasonable mind and wise mind) is also useful for targeting ambivalence in eating disorder patients because it promotes active and aware decision making. �What night your rational mind say??? Why does this good treatment fail in many cases? EDs differ from other behavioral disorders such as depression and anxiety in the significant degree of ambivalence ED patients have and maintain about changing their behaviors. Treatment of ED problem behaviors therefore requires a sophisticated use of commitment strategies and must focus not only on helping patients change their specific ED behaviors but also focus on the relationship of these behaviors to their long term treatment goals. DBT is based on both change and acceptance based strategies.

30. Structuring the Session First address Target One issues Burning issues? (yours and mine) Homework Review Summarize Goal Setting Homework Homework example: DBT worksheet, notice thoughts after eating breakfast on Monday Most important work occurs outside of session, homework is integral to this, must review the homework.Homework example: DBT worksheet, notice thoughts after eating breakfast on Monday Most important work occurs outside of session, homework is integral to this, must review the homework.

31. Barriers to Treatment What do you do if your client rejects the skill? 

32. Q & A Thank you for your time!

33. Resource list Cognitive-Behavioral Treatment of Borderline Personality Disorder. Marsha Linehan. The Guilford Press. (May 14, 1993). http://behavioraltech.org Skills Training Manual for Treating Borderline Personality Disorder. Marsha M. Linehan. The Guilford Press. (May 14, 1993). Dialectical Behavior Therapy in Clinical Practice: Applications across Disorders and Settings. Linda A. Dimeff, Kelly Koerner. Marsha M. Linehan (Foreword). The Guilford Press. (August 14, 2007). Dialectical Behavior Therapy with Suicidal Adolescents. Alec L. Miller, Jill H. Rathus, Marsha M. Linehan. The Guilford Press; (November 16, 2006). Helping Teens Who Cut: Understanding and Ending Self-Injury. Michael Hollander. The Guilford Press. (June 10, 2008). The High Conflict Couple: A Dialectical Behavior Therapy Guide to Finding Peace, Intimacy, & Validation. Alan Fruzzetti, Ph.D. (Foreword- Marsha M. Linehan). New Harbinger Publications. (December 3, 2006). Dialectical Behavior Therapy Workbook: Practical DBT Exercises for Learning Mindfulness, Interpersonal Effectiveness, Emotion Regulation, & Distress Tolerance. Matthew McKay, Jeffrey C. Wood, Jeffrey Brantley. New Harbinger Publications. (July 2007). Depressed and Anxious: The Dialectical Behavior Therapy Workbook for Overcoming Depression & Anxiety. Thomas Marra. New Harbinger Publications. (May 2004).