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We frequently mention that family-based treatment (FBT) is the only evidence-based eating disorder treatment for young people. But, as we all know, families vary drastically from one to the next, and no two eating disorders are the same. So do certain demographic or diagnostic factors determine whether FBT will work for a patient? According to new research, no.

Predictors of family-based treatment for adolescent eating disorders: Do family or diagnostic factors matter?

”, was co-authored by Equip’s VP of Clinical Programs, Cara Bohon, and appeared in the December 2022 issue of the 

International Journal of Eating Disorders.

Researchers analyzed data from six clinical trials in both the U.S. and Canada, which included a combined 724 patients ages 12-18 with a diagnosis of either anorexia or bulimia who were receiving some form of treatment, either FBT or other approaches. Using this data, they compared outcomes with a variety of different familial and diagnostic factors, including socioeconomic status, feelings of self-efficacy (caregivers’ belief about their ability to take care of their loved one successfully), family configuration (i.e., married vs divorced), prior treatment, illness duration, and more.

Their findings showed that the only factor that directly predicted the success of FBT was whether or not a patient had received prior eating disorder treatment (those with no prior treatment had better outcomes). No other demographic or clinical variables affected the outcome of FBT.

These results have significant implications for future treatment. While providers may hesitate to refer certain patients and families to FBT because of misconceptions around who it works for, this initial analysis suggests that factors commonly assumed to impede FBT actually have no impact. Rather, FBT can be an equally effective approach for all families and patients.

“Overall, it feels good to confirm what my clinical experience had suggested to be true,” says Bohon, who has almost 20 years of experience in clinical eating disorder research. “FBT is adaptable and can meet family and patient needs, whatever they may be.”

New Research: What Family Factors Determine Success with FBT? 

When Equip Lead Peer Mentor Makailah (Mak) Dowell reflects back on her teenage years living with 

 (BED), she vividly remembers the isolation and loneliness.

“I didn’t tell anyone and I was barely diagnosed due to the biases at play in my own healthcare,” she says. “I learned how to suffer in silence really, really well.” Dowell’s one reliable source of comfort through the struggle was her best friend, Olivia. “She would always call me to leave the house, take me to the movies with her family, and include me in any type of plans she had,” she says. “As an only child being raised by my single-parent grandparent, her family took me and my grandma in.”

Anyone who has ever witnessed a friend navigate the treacherous path of an eating disorder has likely wondered how to be a supportive and nonjudgmental ally, like Olivia was for Mak. And while all eating disorders tend to come with shame and secrecy, this can be especially true for bulimia—making it harder for the person struggling to ask for and receive support, and for loved ones to offer it. But that support is so important, and can even be life-saving. Read on for expert-approved guidance on how to help a friend with bulimia.

Why it’s so hard to know if someone is a struggling with bulimia

It can be particularly tough to know when and how to talk to a friend about their concerning behaviors if they haven’t confided in you about their disease. In some cases, they may not even be aware that they have a problem. The first step in determining whether or not someone is dealing with bulimia is knowing what, exactly, it is.

As Equip Therapy Lead, Maddie Friedman, LCSW, defines it, bulimia is a disorder characterized by episodes of binge eating followed by compensatory behaviors to “get rid of” or “make up for” the food, known as 

. These behaviors can include everything from self-induced vomiting and laxative/diuretic use to over-exercising, fasting, and taking diet pills. While those unfamiliar with the disorder may assume the signs of bulimia are easy to spot, Friedman underscores just how hidden the issue can be.

“Bulimia is often shrouded in shame and guilt, and thrives in secrecy,” she says. “Needless to say, these eating disorder behaviors can feel all-consuming and can result in people really dropping out of their lives: drifting away from close friends and family, disengaging from responsibilities and hobbies, and finding less joy in previously enjoyed activities.”

Dowell knows from her own experience and from working with others that detachment from the outside world can be a red flag. “​​One of the biggest signs of bulimia is isolation,” she says. “If your friend is gone for long periods of time or canceling plans more consistently than before, then you should check in. Most people in recovery mention that isolation allowed the eating disorder to thrive.”

Why friends are so important in the recovery process

 that having a strong support network can make a world of difference in eating disorder recovery, so it’s important for friends and loved ones to know how impactful their words and actions can be. In fact, many people who have overcome eating disorders 

cite these supportive relationships as one of the key factors in their recovery

. Since social isolation is such a common aspect of eating disorders like bulimia, actively supporting a friend who is struggling can help disrupt and dismantle problematic thoughts and behaviors that tend to be amplified in secrecy.

“We know that bringing your village to treatment can enhance treatment outcomes, because it challenges the secrecy that often maintains eating disorder behaviors,” Friedman says. “When supports can rally around a loved one to promote treatment and recovery, they may be more likely to reconnect with their values and life worth living outside of the eating disorder, which can be motivating despite the hardship.”

How to help a friend with bulimia who isn’t in treatment

If you’re worried that a friend is dealing with bulimia but they haven’t yet sought help, there are things you can do to help them get there. In some cases, a friend may not be aware of their concerning behaviors, or they may not believe they’re “

Here are some ways to gently guide them toward recovery:

If you’re certain a friend is struggling with bulimia but they haven’t expressed interest in treatment, Friedman says this may be an opportunity to bring in reinforcements. “Depending on the circumstances, it may be helpful to offer to contact their loved ones or help connect a friend to treatment,” she says.

 Another way to show solidarity and support a friend’s path toward recovery is to encourage or even supply food options, since simply deciding what to eat and making it can be a barrier. “You can offer to provide meal or snack support and help normalize regular eating, aka three meals and two snacks a day,” Friedman says. “Eating regularly is often one of the most helpful strategies to discourage binge eating because it disrupts the binge/restrict cycle. If folx are feeling nourished and energized, it may decrease the likelihood of engaging in binge behaviors that promote compensatory behaviors.”

Dowell says that simply being present and making yourself available can also go a long way in making a friend feel unconditionally supported. “Invite your friends out, come to them, and be there to help with distress tolerance,” she says. “My best friend would always take me out of the house and be there to enjoy food with me and watch a movie afterward. This didn’t allow the eating disorder to bully me into behaviors, and helped me to distract and enjoy a good show with my friend.” Friedman seconds this recommendation, noting that if a friend isn’t willing to seek care, “you can offer to partner with them during high vulnerability moments to resist eating disorder urges and behaviors like binging or purging.”

. While it’s commendable to want to make sacrifices to help a friend in need, Friedman also points out the importance of self-care and boundary-setting through the process. “Please also know that peer support and professional support for eating disorders exist!” she says. “You do not have to take it all on, even if your loved one isn’t willing to seek care. Boundaries are important and caregiver burnout is real.”

How to help a friend with bulimia who is already in treatment

The recovery process can be incredibly challenging, even with a team of experts guiding the way. Plus, having the support of loved ones outside of treatment can improve a person’s odds of achieving lasting recovery.

Here are a few ways to continue supporting a friend as they navigate treatment for bulimia:

 “Offering validation and support to loved ones in treatment can be critical,” Friedman says. “Treatment is really hard, and tends to be very upsetting and draining initially. Normalizing that treatment is worth it, even when it feels hard, can be super helpful. People often feel very torn between their eating disorder and their sense of self when they begin treatment, and being a consistent source of support through the storm can promote treatment compliance.”

. Though it comes from a good place, it’s never helpful to force a conversation about how recovery is going. “Someone in treatment may want to compartmentalize their life in recovery or get done with treatment and move on,” Dowell says. “Depending on your friend, you may be talking about their recovery or never talk about it explicitly. Both ways are fine! As long as you both agree that the relationship is supportive.”

 be helpful for a friend struggling with bulimia?

While there are plenty of constructive ways to approach and support a friend, it can be beneficial to understand why some tactics and strategies—even when well-intentioned—may not be helpful.

If you’re worried about a friend with bulimia, here’s what not to do:

 “If you suspect a friend is struggling with bulimia, it is always best to approach with curiosity,” Friedman says. “Refrain from confrontation or accusation, and give them space to come to you for support. Since eating disorders can be such powerful drivers of behavior, they can really disrupt relationships. It’s important to remember that your loved one is still there and is often fighting beneath the influence of the eating disorder. When we approach folx who are in the throes of an eating disorder forcefully, we’re more likely to trigger shame and guilt, and promote further isolation.”

 “I would start by respecting your friend’s agency and checking in with them first,” Dowell says. “If you suspect something, you can ask, ‘are you facing any challenges you want to let me know about?’ or ‘I noticed you haven’t been hanging out with me as much as before, has anything changed?’ Even asking, ‘how is your mental health?’ can open up a bigger conversation.”

. If a friend doesn’t seem receptive to the conversation or chooses to avoid the subject, Dowell says this may be time to reach out to one of their loved ones for extra support. “It’s always important to respect your friend’s agency and start with curiosity,” she says. “Then once you understand that your friend needs support, reach out.”

If you’re wondering how to help a friend with bulimia, you’re already on the right track. Supportive relationships can make a significant impact on a friend’s recovery, but it’s important to help out thoughtfully. By continuing to care for yourself and understanding how to approach a delicate issue like bulimia, you’ll be empowered to show up as a prepared, empathetic, and compassionate friend.

“Olivia was a part of my recovery and still a part of my life,” Dowell says. “I’m grateful and privileged to say that I am the godmother to her first child born this year. These 15 years of friendship continue to be a place of support, love, and leaning on each other.”

“Anorexia and Friendship: Can Friends Galvanize Recovery? | Psychology Today.” n.d. Www.psychologytoday.com. Accessed April 12, 2024. 

https://www.psychologytoday.com/us/blog/hunger-artist/201910/anorexia-and-friendship-can-friends-galvanize-recovery

Wetzler, Sara, et al. 2020. “A Framework to Conceptualize Personal Recovery from Eating Disorders: A Systematic Review and Qualitative Meta‐Synthesis of Perspectives from Individuals with Lived Experience.” International Journal of Eating Disorders 53 (8): 1188–1203. 

How to Help a Friend with Bulimia: What to Do if You’re Worried

I spent several years of my life living in an energy (calorie) deficit. At the time, I never stepped back to wonder what happens if you don’t eat enough. I didn’t understand how my entire being—mind, body, and emotions—were being affected by living that way. I’m not dramatizing when I say that every part of me was drastically and negatively impacted by undereating. I suffered serious consequences, some of which I’ll share with you today. Fortunately, I committed to healing and recovery over a decade ago, which meant first moving out of an energy imbalance by eating more food, exercising less, and learning how to manage stress.

Today, as an eating disorder dietitian, I see the side effects of not eating enough in my clients and how it infiltrates every facet of their lives every day. Sadly, undereating and setting goals to undereat are normalized and supported across mainstream and social media, without much (if any) regard for the negative impact it might have.

Let’s look at the different ways that undereating can significantly impact you mentally, emotionally, and physically.

In my practice, I notice heightened anxiety is one of the main side effects of undereating, and, personally, I know now that spending years feeling on edge and suffering panic attacks was a direct result of not eating enough food.

Undereating, which often comes with malnutrition and excessive weight loss, can also 

 as well as anxiety due to changes in brain chemistry. 

, RDN, LD, explains that inadequate nutrition can lead to tissue damage in the brain, as well as a lack of nutrients—specifically vitamin B12, folate, and zinc—that 

may cause depression, cognitive decline, and irritability

, RDN, LD. She also notes that malnutrition may also lead to a decrease in production of dopamine and serotonin, two mood-regulating hormones, which can worsen symptoms of anxiety and depression.

On top of that, undereating makes it more difficult to deal with tough emotions and hard life experiences and relate to other people. “People who frequently underfuel often describe an increase in irritability, a decrease in patience, and a tendency to have diminished capacity for emotional regulation,” explains 

, MS, RD, CEDS. “They tend to experience mood swings, with less tolerance for ‘riding emotional waves’ throughout the day.”

When I was undereating, I remember feeling like I was abnormal because most of my mental space was taken up by thoughts of food. It was hard for me to stay present in conversations or to pay attention to my work and studies. Now, it’s one of the first concerns clients who are undereating share with me when we start work together: they believe they’re uniquely obsessed with food, when in fact their bodies are simply trying to survive. “Your body doesn't understand that this ‘famine’ is self-inflicted, so it's going to be on high alert to increase its ability to survive and find food,” explains Equip Nutrition Director Erin Reeves, RD. “Therefore, you might be thinking about food more or feel more out of control when you do eat because your body can't trust there won't be a famine again.”

In one famous landmark study (called the 

 on Human Starvation by researcher Ancel Keys), a group of men were intentionally underfed over an extended period. 

 the earliest and most present symptom of their starvation experience was a fixation on and thoughts about food. All the men said they experienced “intellectual inefficiency,” including decreased concentration and rate of learning, or poor judgment. Additionally, some men responded by gathering recipes and cookbooks, eating faster than normal, and dreaming of food, and some said they wanted to watch others eat often while others said they couldn’t bear doing so.

When you aren’t eating enough food, Burkholder says, “much of the ‘airtime’ in your mind is consumed by thoughts of food, leaving little room for other things. This is one of the non-physical effects of not eating enough that I find scariest: without room or energy for life outside food and body, it’s impossible to live in alignment with your true core values. In other words, it’s impossible to be yourself.

In the landmark study I mentioned, the men reported 

 alongside emotional issues like increased irritability. These personality changes included social introversion, loss of sexual interest, decrease in self-initiated activity, and lethargy. Underfueling can also lead someone to become a 

 than they are when they’re eating enough.

In my work with clients who aren’t eating enough, the changes that I observe over our time together can be mind-blowing. As they work toward fueling their body adequately, it’s as if they’re re-emerging from a dark haze that was keeping them disconnected from themselves, their lives, and the people around them. Their sense of humor and mental flexibility returns, their voices become more authentic, hobbies are more interesting, their ability to access life’s pleasures come back, boundaries become easier to set and relationships richer, and their genuine paths in life often become clearer.

Another common side effect of undereating is a decreased basal metabolic rate (BMR), or the amount of energy your body needs to perform basic functioning. The simplest way to think about this is that your body is focused on survival, so if you’re not adequately fueling your body, it will slow down all of its processes in order to conserve energy and survive with less energy. “There are no tricks around this by eating a certain spicy food or doing a certain workout,” explains Reeves. “Your metabolism will slow down if you aren't giving it enough."

This is one of the reasons that so many people who spend years yo-yo dieting to lose weight often end up at higher weights than when they started: their bodies get thrown off by undereating and try to recalibrate by adjusting metabolic speed, only to get confused again, and the cycle continues.

 (or loss of period for more than three months) was my body’s main indicator of not yet being fully recovered from my own eating disorder. It’s a common side effect of undereating and can lead to a myriad of issues, including infertility and osteoporosis. Food restriction, anxiety, depression, emotional stress, excessive exercise, energy imbalance, and malnutrition are associated with development of amenorrhea, according to 

The Journal of Clinical Endocrinology & Metabolism

 concluded that low energy availability from undereating can suppress all reproductive hormones. “In females, levels of estradiol and progesterone—two important reproductive hormones—decrease. Estradiol is responsible for bone growth and remodeling, so low estradiol levels can quickly diminish bone density,” Burkholder explains. “In males, low energy availability disturbs testosterone levels and leads to fatigue, low sex drive, sexual dysfunction, and low bone mineral density.” Essentially, when you don’t eat enough, your body prioritizes vital functions, like heartbeat and lung expansion, and shuts down processes it deems non-essential. “Your body downregulates to conserve as many calories as possible, and that means forfeiting reproductive function,” Burkholder adds.

6. Nutrient deficiencies & muscle breakdown

Another serious side effect of undereating is the development of nutrient deficiencies, which can lead to health conditions like anemia (often a result of iron deficiency), cold intolerance, hair loss, skin problems, insomnia, bone issues, and a weakened immune system. “Your immune system will be depressed, causing an increase in infection, cold and flu or other illnesses,” says Reeves. “Your heart rate slows, there’s less oxygen flow, dizziness and fatigue.”

Undereating can also cause catabolism, or when the body breaks down lean tissue like muscle for fuel, which can lead to loss of muscle mass and muscle wasting. “Your muscles will get broken down faster because there are neither the energy nor the building blocks—amino acids and protein—available to maintain itself,” Reeves explains. Since the heart is largely made of muscular tissue, it will also start to weaken with chronic underfueling, and vital signs like blood pressure and heart rate can fall dangerously low. “This weakening of the heart reduces the ability to pump blood throughout the body, which can lead to fatigue and shortness of breath,” Grimes explains. “Malnutrition also disrupts the electrical activity of the heart, the power behind the heart’s contractions, which can be fatal.” And without enough blood sugar circulating in your blood, which can occur when you’re regularly undereating and have depleted all the glucose stores in your liver and muscles, you can experience hypoglycemia, which can also be deadly. 

Plus, if you’re engaging in physical activity while undereating, your muscles will have a harder time recovering and you’re likely to experience decreased athletic performance, according to Burkholder.

Grimes explains that in addition to affecting heart tissue, malnutrition can result in the breakdown of tissue in the digestive tract, which can, over time, lead to a weakening of muscles in the stomach and intestines. In fact, 

 shows malnutrition and weight loss from undereating can slow down the gastrointestinal (GI) tract, which can cause general 

 (or slowed movement or motility of stomach muscles), constipation, reflux, heartburn, bloating, and diarrhea. Reeves explains that undereating will also decrease the amount of enzymes your body makes that help break down food, leading to further GI symptoms. In my practice, I’ve observed GI disturbances from undereating that cause significant disruptions in clients’ day-to-day functioning and overall quality of life.

 I mentioned, the men reported that once the restriction period ended, they felt an initial loss of control around food during the refeeding period. Some of them reported wanting to eat continuously, while others said they binge ate (and never had before the experiment). More than half of them reported overeating.

In my work, I’ve noticed that most of my clients are surprised when they realize their bingeing or overeating is often rooted in undereating. The thing is, when we’re underfed, our bodies will do everything possible to get us to reclaim a state of equilibrium, and that can sometimes manifest in out-of-control eating, binge eating, or an inability to listen to and honor your hunger and fullness cues. Additionally, undereating and 

“Some people find themselves in chronic deficits unintentionally—their lives are busy, schedules are packed, perhaps their physical activity is high, or they’re struggling with a low appetite,” Burkholder says. “Others may find their chronic deficit has deeper roots: body image concerns, pressure from family members or coaches to maintain a low weight, or an internalized list of rigid food rules.” Also, several of my clients presented with undereating that stems from trauma, and they’re using restriction to cope, numb, disassociate, and indirectly express hard feelings.

The effects of not eating enough are widespread and serious. But there’s good news: most can be reversed with adequate nourishment. Since I stopped undereating and now live within energy balance, my anxiety is manageable, I feel generally more at ease, my focus and ability to stay present with others is good, I have ample brain space for life outside of food, and my reproductive system is fully functioning.

However, it’s tough to get there on your own. Establishing or re-establishing energy balance and reversing the effects of undereating usually takes professional guidance from a team of providers (usually at least a therapist and a dietitian). “Learn from a non-diet dietitian how much your body really needs. It's difficult to use online calculators or providers that endorse weight loss, because you will likely get a calorie goal that is far too low,” Reeves says. “Stay in your lane: don't compare yourself to others or ask your friends how many calories they eat. Your body is its own unique machine, and looking at a snapshot from a peer or someone's 'what I eat in a day' is not going to give you the personal guidance you need to thrive.”

If you’re concerned that you’re not eating enough, we’re here to help. 

Reach out to our team for a free consultation

Issue 59 I The Starved Brain – Can What We Eat Determine How We Think?

https://nedc.com.au/eating-disorder-resources/find-resources/show/issue-59-i-the-starved-brain-can-what-we-eat-determine-how-we-think#:~:text=Restricted%20eating%2C%20malnourishment%2C%20and%20excessive

Lachance, L., & Ramsey, D. (2015). Food, mood, and brain health: implications for the modern clinician. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6170050/#:~:text=Several%20nutritional%20deficiencies%2C%20such%20as

Eckert E.D. et al. (2018). A 57-Year Follow-Up Investigation and Review of the Minnesota Study on Human Starvation and its Relevance to Eating Disorders. 

https://www.researchgate.net/publication/324507398_A_57-YEAR_FOLLOW-UP_INVESTIGATION_AND_REVIEW_OF_THE_MINNESOTA_STUDY_ON_HUMAN_STARVATION_AND_ITS_RELEVANCE_TO_EATING_DISORDERS

. (2023, May 9). Duke Department of Psychiatry & Behavioral Sciences. 

https://psychiatry.duke.edu/blog/starvation-experiment

. (n.d.). Mayo Clinic. Retrieved April 1, 2024, from 

https://www.mayoclinic.org/diseases-conditions/eating-disorders/symptoms-causes/syc-20353603#:~:text=Dieting%20and%20starvation.&text=Starvation%20affects%20the%20brain%20and

Gordon, C. M., Ackerman, K. E., Berga, S. L., Kaplan, J. R., Mastorakos, G., Misra, M., Murad, M. H., Santoro, N. F., & Warren, M. P. (2017). Functional Hypothalamic Amenorrhea: An Endocrine Society Clinical Practice Guideline. 

Montani, J. (2021). Ancel Keys: The legacy of a giant in physiology, nutrition, and public health. 

Wasserfurth, P., Palmowski, J., Hahn, A., & Krüger, K. (2020). Reasons for and Consequences of Low Energy Availability in Female and Male Athletes: Social Environment, Adaptations, and Prevention. 

https://doi.org/10.1186/s40798-020-00275-6

Iwasa, T., Minato, S., Imaizumi, J., Yoshida, A., Kawakita, T., Yoshida, K., & Yamamoto, Y. (2021). Effects of low energy availability on female reproductive function. 

National Centre for Eating Disorders. (2011). 

The Effects Of Under-Eating | National Centre for Eating Disorders

https://eating-disorders.org.uk/information/the-effects-of-under-eating/

Cost, J., Krantz, M. J., & Mehler, P. S. (2020). Medical complications of anorexia nervosa. 

Mathisen, T. F., Heia, J., Raustøl, M., Sandeggen, M., Fjellestad, I., & Sundgot‐Borgen, J. (2019). Physical health and symptoms of relative energy deficiency in female fitness athletes. 

Scandinavian Journal of Medicine & Science in Sports

https://www.mayoclinic.org/diseases-conditions/gastroparesis/symptoms-causes/syc-20355787

‌Eckert E.D. et al. (2018). A 57-Year Follow-Up Investigation and Review of the Minnesota Study on Human Starvation and its Relevance to Eating Disorders. 

What Happens If You Don’t Eat Enough? 8 Ways Undereating Affects Your Body and Mind

 for my eating disorder, I was surprised to learn just how many forms of therapy my program included. There were, of course, solo sessions with my assigned therapist, where we mostly used cognitive behavioral therapy (CBT), as well as group therapy with other program participants and facilitators. But my particular program also mandated regular meetings with a dietitian, weekly art projects, thrice-weekly group meals, and a form of therapy I’d never heard of before: DBT. As I’d later learn, DBT for eating disorders is a widely used and well-studied approach, but at the time, it was completely new to me.

DBT, which stands for dialectical behavior therapy, is a therapeutic modality that helps people shift harmful behaviors and build a skill set that enables them to thrive in recovery. It was first developed in the 1970s to treat personality disorders and address interpersonal conflict, but 

 shows that it’s also an effective approach to treating eating disorders.

Read on to learn more about DBT for eating disorders, how it works, its benefits and drawbacks, and more.

At its core, DBT is a form of talk therapy designed for people coping with very intense emotions. While the approach is based on the structured, goal-oriented form of talk therapy known as CBT, DBT is distinct in that it focuses not only on helping people accept the reality of their specific situations and behaviors, but also on learning strategies to change unhelpful patterns. “DBT is a specific therapeutic approach aimed at helping people find balance with managing their emotions and relationships,” explains Jessie Menzel, PhD, clinical psychologist and VP of Program Development at Equip.

, a psychologist and researcher who has lived experience with borderline personality disorder (BPD). Due to Linehan’s own experience and research, DBT is often referenced as 

, a mental disorder characterized by patterns of impulsiveness and unstable, intense relationships, among other things. “While DBT is considered the gold-standard treatment for BPD, it has been used in applications far beyond it,” Menzel says. “DBT is now used in the treatment of substance use, 

 and self-harm, PTSD, and eating disorders.”

The word “dialectical” refers to the integration of opposing ideas. By helping people both accept 

 change their unhelpful behaviors, DBT offers space for two opposite truths to exist simultaneously—and introduces the possibility that there is more than one way to perceive a specific situation.

Why is DBT used in eating disorder treatment?

The goal of all DBT practices is to help people learn to regulate their responses to challenging emotions in an adaptive way. Because problems with emotion regulation and awareness can be common in eating disorders, using 

 was a natural expansion of its original purpose.

“DBT has been used in eating disorder treatment largely because of the prominent role that emotions play in maintaining eating disorder behaviors,” Menzel explains. “Many eating disorder behaviors are triggered by difficult emotions and may even be used as a way to help people cope with difficult emotions.”

Indeed, people struggling with eating disorders often use disordered behaviors to regulate emotions in the short-term—for instance, restricting to numb difficult feelings, or bingeing to quiet distressing thoughts—but doing so actually increases emotional dysregulation in the long-term. Because of this, the emotion-regulation skills of DBT not only serve as healthy replacements for disordered coping strategies, but also help people better navigate the ups and downs of life and connect with those around them.

“By teaching patients how to manage their emotions effectively and in a way that isn’t harmful, we can help them reduce their vulnerability to difficult emotions and their need to rely on eating disorder behaviors as a way to cope,” Menzel says.

What does the research say about DBT for eating disorder treatment?

There are several studies examining the effectiveness of DBT for eating disorder treatment, and the results indicate largely positive effects. 

 found that 89% of participants who were taught DBT skills didn’t binge eat as compared with only 12.5% in the waitlist control condition. A 

 on BED found that 40% of DBT participants abstained from binge eating as compared to 3.3% in the waitlist control condition.

“DBT can be very effective as a treatment for eating disorders,” Menzel says. “There have been studies that support the success of DBT particularly in 

 Clinically, DBT is also a great treatment choice for individuals with more complex eating disorders or eating disorders with multiple co-occurring problems, such as self-harm or suicidal ideation and substance use.”

But research on DBT and eating disorders isn’t limited to BED. There is also 

 that people diagnosed with binge/purge behaviors (like people with 

) who were assigned to once-weekly individual DBT treatment had higher rates of abstinence from binge/purge behaviors as compared to a waitlist control group after 20 weeks (28.6% versus 0%). And 

 on women with anorexia found that after an average of 21.7 weeks of DBT, 35% of patients were in full remission, an additional 55% were in partial remission, and there was also a significant increase in post-treatment BMI.

Potential drawbacks to using DBT in eating disorder treatment

While research suggests that DBT can have a significant impact on treatment success, Menzel does caution that the protocol requires serious commitment. “Traditional DBT is a very time-intensive treatment,” she says. “It requires weekly individual therapy and weekly skills groups. Patients are also asked to commit to treatment for a minimum of 6 months or up to a year. While these aspects of DBT may seem overwhelming, they’re part of what makes DBT so effective.”

Another potential obstacle to be aware of when considering DBT for eating disorder treatment is accessibility. Firstly, there’s a limited number of trained and experienced clinicians who specialize in using DBT to treat eating disorders. And secondly, DBT treatment isn’t always covered by insurance. “Treatment that is truly adherent to DBT may be very difficult to find and harder to access if a provider or clinic doesn’t accept insurance,” Menzel says. “Because DBT is so intensive and a big commitment, it isn’t typically recommended as a frontline treatment for most eating disorders.”

At Equip, DBT is incorporated into our treatment approach (more on that below), and Equip is in-network with most insurance plans.

What does DBT look like and what can you expect?

While the specifics of DBT will vary depending on the provider, the program, and the patient, there are some elements that remain consistent. Menzel explains that DBT treatment has four components:

Weekly individual therapy sessions typically last about 40-60 minutes. During these sessions, patients and their therapist will work toward creating goals around:

Minimizing self-harm behaviors (if applicable)

Learning skills to replace maladaptive behaviors

“For patients, treatment also relies heavily on doing work out of sessions,” Menzel explains. “Patients are expected to complete a daily log of their emotions, behaviors, urges, and skills use, as well as completing weekly practice of skills learned during group therapy.”

Equip treatment incorporates DBT in a specific and thoughtful way. “At Equip, we focus on one component of DBT: skills group therapy,” Menzel says. “While skills are just one component of DBT, we believe that they are a very important component.”

 that just the skills group therapy piece of DBT alone—especially when combined with other types of care—can be an effective way of supporting those struggling with eating disorders. In general, 

Each of these four skills categories includes a number of different specific skills, all of which can be employed in different moments to help people manage distressing emotions or situations without turning to disordered behaviors. According to Menzel, learning skills seems to be essential for getting the most out of treatment.

“We’ve woven skills into our treatment in a few ways,” Menzel says. “First, we offer weekly skills group sessions for our teens and adults. We also provide weekly skills videos to our patients and their supports because we believe that our patients have the best chance for recovery if their loved ones are learning skills, too. Finally, all of 

 are trained in how to teach DBT skills so that they can support our patients in using these skills in their everyday lives as they recover.”

You can find all of our weekly DBT skills videos 

. If you’re struggling with an eating disorder or supporting someone who is, try watching a few different videos until you find a skill that resonates. DBT skills can be truly game-changing for stopping disordered eating as well as other patterns and behaviors that aren’t serving you. Below is an example of one of our videos that talks about distress tolerance skills for eating disorder recovery.

And if you want to learn more about DBT for eating disorders at Equip, 

. We’re here to answer any questions you have and to talk through next steps.

Blackford, Jennifer Urbano, and Rene Love. 2011. “Dialectical Behavior Therapy Group Skills Training in a Community Mental Health Setting: A Pilot Study.” International Journal of Group Psychotherapy 61 (4): 645–57. 

https://doi.org/10.1521/ijgp.2011.61.4.645

Chapman, Alexander L. 2006. “Dialectical Behavior Therapy: Current Indications and Unique Elements.” Psychiatry (Edgmont) 3 (9): 62–68. 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963469/

Cleveland clinic. 2022. “Cognitive Behavioral Therapy (CBT).” Cleveland Clinic. Cleveland Clinic. August 4, 2022. 

https://my.clevelandclinic.org/health/treatments/21208-cognitive-behavioral-therapy-cbt

Lynch, Thomas R, Katie LH Gray, Roelie J Hempel, Marian Titley, Eunice Y Chen, and Heather A O’Mahen. 2013. “Radically Open-Dialectical Behavior Therapy for Adult Anorexia Nervosa: Feasibility and Outcomes from an Inpatient Program.” BMC Psychiatry 13 (1). 

Masson, Philip C., Kristin M. von Ranson, Laurel M. Wallace, and Debra L. Safer. 2013. “A Randomized Wait-List Controlled Pilot Study of Dialectical Behaviour Therapy Guided Self-Help for Binge Eating Disorder.” Behaviour Research and Therapy 51 (11): 723–28. 

https://doi.org/10.1016/j.brat.2013.08.001

Mayo Clinic. 2019. “Borderline Personality Disorder - Symptoms and Causes.” Mayo Clinic. July 17, 2019. 

https://www.mayoclinic.org/diseases-conditions/borderline-personality-disorder/symptoms-causes/syc-20370237

Pisetsky, Emily M., Lauren M. Schaefer, Stephen A. Wonderlich, and Carol B. Peterson. 2019. “Emerging Psychological Treatments in Eating Disorders.” Psychiatric Clinics of North America 42 (2): 219–29. 

https://doi.org/10.1016/j.psc.2019.01.005

Rahmani, Maliheh, Abdollah Omidi, Zatollah Asemi, and Hossein Akbari. 2018. “The Effect of Dialectical Behaviour Therapy on Binge Eating, Difficulties in Emotion Regulation and BMI in Overweight Patients with Binge-Eating Disorder: A Randomized Controlled Trial.” Mental Health & Prevention 9 (March): 13–18. 

https://doi.org/10.1016/j.mhp.2017.11.002

Telch, C. F., W. S. Agras, and M. M. Linehan. 2001. “Dialectical Behavior Therapy for Binge Eating Disorder.” Journal of Consulting and Clinical Psychology 69 (6): 1061–65. 