Dialectical Behavioral Therapy for Eating Disorders: Managing Painful Emotions in Recovery
Written by ‘Ai Pono Hawaii Staff Writer
Eating disorder recovery is no easy feat — it is a challenge, and it brings up challenging emotions. After relying on an eating disorder as a coping mechanism for so long, letting it go feels like there’s no way to cope with underlying issues. The process of eating regularly and changing habits can be difficult, but there are several ways to cope — they just have to be learned.
Dialectical Behavioral Therapy (DBT) is all about teaching you the skills you need to cope with high levels of stress, anxiety, and emotional pain.
In this article, you’ll learn:
Why eating disorders act as a coping mechanism
How DBT can help replace the eating disorder as a coping mechanism
The four key areas of DBT
Some DBT skills
At ‘Ai Pono, we practice DBT skills, along with other modes of therapy in our program, to guide you towards a lasting recovery.
Eating Disorders are, in part, a coping mechanism.
It seems counterintuitive to those who have never experienced an eating disorder, but eating disordered behaviors, at first and possibly for a long time, act as coping mechanisms for other problems.
While some of the motivation of some eating disorders are motivated by wanting to change the body, a lot of it is also the desire to change the emotions. Many studies have found that those with eating disorders have difficulty regulating their emotions, and hold the belief that using behaviors will change emotions.
Restricting is associated with reducing anxiety, as the feeling of hunger numbs you. Binging also works along this line, and is sometimes used to improve mood. Purging, in all forms, is seen as a way to release emotions such as guilt and shame. Behaviors are used to manage acute emotions, as well as to block out emotions from co-occurring conditions, especially trauma. These are just some examples, but eating disorders serve many different functions for many different people.
Related: What’s the link between trauma and eating disorders? Find out here.
DBT is meant to help replace the eating disorder as a coping mechanism.
While an eating disorder may serve the purpose of managing emotions at first, it's not sustainable. Once the eating disorder takes over, it causes more problems than solutions. Eventually, once you accept that an eating disorder is really no longer serving you, you may begin your recovery journey.
Without the eating disorder as a coping tool, how are you supposed to manage extreme emotions? DBT is one way.
DBT is an evidence based psychotherapy proven to treat conditions like borderline personality disorders, anxiety disorders, and yes — eating disorders. It's a behavioral based therapy, meaning that behaviors are assessed and clients and clinicians work to replace maladaptive behaviors with more helpful ones.
It stems from the philosophical idea of balancing opposite forces. In this context, it means balancing extreme emotions and perspectives. This kind of therapy focuses heavily on regulating emotions and interpersonal relationships. It also works to help clients accept what will not change, and work to change what will.
The four key skills of DBT are:
Distress Tolerance for Intense Situations
This DBT skill is used to survive intense situations, such as anxiety attacks, crisis situations, without using eating disorder behaviors. Distress tolerance skills should be used when you're in extreme physical or emotional pain that won't go away soon, in a situation that is distressing but can't be avoided, or when you want to solve a problem that can't be immediately solved.
Distress tolerance skills help you:
Distract yourself until you’re calm enough to think without overwhelming yourself with emotion
Self-soothe by doing relaxing activities
Find ways to improve the moment you’re in, even when it’s a hard one to be in
Use a pros/cons list to compare options and come to a decision in a rational way
There are several distraction techniques, including relaxing your physical body to calm down, imagining yourself in a peaceful place, and distracting yourself with soothing activities such as coloring or watching TV.
Another common term you’ll likely hear in the eating disorder recovery process is “Radical Acceptance,” which is a DBT skill. It is essentially the practice of recognizing that a decision or reality is not necessarily something you want to do, or are comfortable with, and doing it anyway. It’s an incredibly helpful skill in recovery — you’re set on minimizing and stopping behaviors, and you know it’s uncomfortable, and you do it anyway.
For an in-depth distress tolerance skills list, click here.
Core Mindfulness
The DBT philosophy recognizes that acting without awareness leads to emotional reactions. Core mindfulness is meant to increase your awareness of your thoughts, feelings, behaviors, and behavioral urges. Increased awareness will empower you to take charge of your mind and emotions in a different way.
The goal of core mindfulness is also something you’re likely to hear in eating disorder treatment: Wise Mind. Core mindfulness posits that there are three states of mind: logical mind, emotional mind, and wise mind. Wise mind is the ideal combination of your logical, non-emotional mind, and the part of your mind filled with heated emotions. You need both in order to live a balanced life, to honor your feelings and your goals. You get to Wise Mind by using the “what” and the “how” skills.
The “what” skills are: observe, describe, participate. Observing means to actively notice your thoughts, feelings, events, and behaviors without trying to change them. This helps you understand how you perceive certain events and what you do about them. When using the describe skill, you are thoroughly describing an experience, in order to distinguish feelings from facts. This is important to do, as our perception of reality is often warped when it comes to intensely emotional events. The participate skill is used to mindfully engage in our lives, to be fully present in the moment.
The “how” skills are: non-judgmentally, one-mindfully, and effectively. The non-judgmentally skill helps you observe events as not good or bad, but rather, to look at things as behaviors and their consequences. To think one-mindedly means to focus on the task at hand, so as not to be overwhelmed by worry. The effectively skill is understanding and acting according to your goals, instead of what is “right”. This helps you honor your goals and let go of judgment.
Emotion Regulation
Emotion regulation is a skill to understand the function of emotions, the urges that come with each emotion, and whether or not to act upon that emotion. It helps mitigate strong emotions and increase the capability to handle these emotions if they do come up. Emotion regulation differs from distress tolerance in that it is a preventative skill, not a responsive one.
Related: Want to delve into the interaction between emotions, emotional identification, and eating disorders? Read here.
There are several emotion regulation skills to learn, but one of the most widely taught is opposite action. Opposite action is done when your feelings don’t fit the facts. If you feel overwhelmed by something in treatment, such as facing a fear food, then you would use opposite action and act against your emotions to do what you logically know is good. It also moves you to act in situations where you might have done nothing more than deliberate.
Interpersonal Effectiveness
Interpersonal effectiveness skills help you to have thoughtful, intentional interactions, instead of ones fueled by emotion. They are important to cultivating and maintaining healthy relationships. Two of the most important components of interpersonal effectiveness include advocating for yourself and your needs, and saying “no” to requests, when appropriate.
Three types of effectiveness that should be addressed in interpersonal interactions are:
Objective effectiveness: the measure of how effective an interaction was in meeting an objective goal that you have defined
Relationship effectiveness: refers to how effective a relationship is in minimizing conflict and benefiting you
Self-respect effectiveness: how intact your self worth is during and after interactions
You will probably find yourself prioritizing these differently for different interactions, and for different people. For example, a partner may want to go out tonight but you want to stay in. You might go out if you value relationship effectiveness first. But if they rudely insisted on going without regarding your feelings, you may prioritize self-respect effectiveness and stay at home.
Find specific interpersonal effectiveness skills here.
Recovery is hard, and it is entirely possible.
DBT skills can help you with all of the challenges that come with recovery. They help to mitigate your reactions to distressing situations, and proactively work on coping and relationship building. DBT, in addition to other types of therapy, will help you find and stay on the path towards recovery.
If you or a loved one is suffering from an eating disorder, take the first step today and talk to someone about recovery or simply learn more about the holistic eating disorder recovery programs we offer.