When I entered outpatient treatment 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 a growing body of research 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.

What is DBT?

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.

DBT was developed by Marsha Linehan, 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 treatment for BPD, 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, major depression, bipolar disorder, suicidal ideation and self-harm, PTSD, and eating disorders.”

The word “dialectical” refers to the integration of opposing ideas. By helping people both accept and 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 DBT for eating disorders 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. One early study looking at the effect of DBT on binge eating disorder (BED) 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 subsequent study 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 the treatment of BED. 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 data indicating that people diagnosed with binge/purge behaviors (like people with bulimia or anorexia binge-purge subtype) 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 a study 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:

1. Weekly individual therapy
2. Weekly skills group therapy
3. Out-of-session phone coaching
4. A consultation team for DBT therapists

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)
• Limiting unhelpful behaviors
• Addressing specific blocks to progress
• 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.”

What does DBT look like at Equip?

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.”

Research has shown 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, DBT skills training covers four main topics:

1. Mindfulness
2. Interpersonal effectiveness
3. Emotion regulation
4. Distress tolerance skills

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 our mentors 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 on our YouTube page. 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, reach out to our team. We’re here to answer any questions you have and to talk through next steps.