Mindful Eating and

Dialectical
Abstinence in DBT for
Eating Disorders

Dr. Kirby Reutter, DBTC, LMHC, MAC & Dr. Michael Maslar

0
Content
Introduction 2
Transcript

Applying Mindfulness to Eating Disorders 3

Transcript

Dialectical Abstinence 5
Transcript

The Addictive Component 7

Transcript

Main Points 8
Transcript

1
Introduction

Greetings and welcome to the first segment in this interview series with Dr. Michael
Maslar on the topic of DBT and bulimia.

Michael serves as the Director of the Mindfulness and Behavioral Therapies Program
as well as the Director of the Mindfulness and Skill-Based Organizational Services at
the Family Institute at Northwestern University. He’s also a prolific writer who has
published extensively on a variety of mental health topics, including The Dialectical
Behavior Therapy Skills Workbook for Bulimia.

In the first segment of this interview, Michael applies the concepts of mindfulness and
dialectics to eating disordered clients, with a special focus on mindful eating and
somatic awareness. He additionally explains the importance of helping eating
disordered clients move beyond a binary view of eating into a more nuanced,
balanced, and dialectical understanding.

In particular, Michael introduces the concept of dialectical abstinence and the

abstinence violation effect.

2
Applying Mindfulness to Eating
Disorders

Kirby How do you apply mindfulness work to eating disorders?

Michael There’s nothing special about the population with eating

disorders where there need to be radically different ways of
implementing mindfulness.

I ask my clients who seem oriented towards it to do a daily

meditative practice. Even if a person isn’t used to doing daily
meditative practices, mindfulness skills can be used. We do
mindfulness practice in our skills training groups and when it
makes sense to do so in individual work.

With the population with eating disorders, we also do a lot of

mindfulness-focused work on mindfulness of eating. Eating
slowly with full awareness, mindfulness of hunger, of satiety,
and mindfulness of one’s body in general.”

We keep working with the question, "Can you eat mindfully and
binge at the same time?" Most people can’t do that. Those are
ways that I use mindfulness practice with this population, and
the specific ones.

Kirby What’s the difference between meditative practice and

mindfulness practice?

Michael It’s a distinction between formal practice, where I might be

seated in a chair or in a cross-legged position on the floor for a
particular period of time, and practicing focusing my awareness

3
 on one hand as formal practice. In DBT, Marsha Linehan and
colleagues have analyzed what a person does when they
meditate.

We teach those skills and the person can use them in their
day-to-day life without necessarily sitting in formal practice. I’ll
help some clients to cultivate formal practice. Others don’t need
to do that as long as they’re using the skills in everyday life.

That’s the major point with DBT, taking these skills into
day-to-day life.

Kirby Are there are any particular challenges when teaching

mindfulness to this population?

Michael In general, clients with eating disorders will tend to have a

generalized difficulty being mindful. These are areas where
there’s often a lot of interference and people experience a lot of
struggle. It takes patience to build awareness.

One of the early mindfulness practices in DBT in general, and

especially with this population, is eating a raisin mindfully. This
is often, for many of my clients, their first experience with
practicing awareness in an intentional way with their eating.

This is a relatively easy way to introduce people to both the

practice of mindfulness and mindfulness of eating. To take a
single raisin and take a long time looking at it, smelling it,
feeling the texture in one’s hands, and then putting it in one’s
mouth, eating it slowly. Experiencing the taste and what
happens when you eat. That’s a good start to what can be a
difficult road for many people.

4
Dialectical Abstinence

Kirby How do you teach the concept of dialectics to clients with eating
disorders for them to implement it in a practical way?

Michael We do this by introducing the idea that we experience the world

in terms of opposites. How we develop depends on whether we
can find a way of resolving these opposites, synthesizing them.
We look at all kinds of opportunities to help a client practice this
and become aware of this.

One of the big dialectics with eating disorders is the idea that
eating is perfectly normal and natural and we need to do it to
stay alive. On the other hand, eating can be a huge problem for
some people. Both of those are true. That’s the dialectical way
of approaching that. The idea is to get past seeing things as a
dichotomy.

One of the big dialectics for this population becomes what we

call in DBT dialectical abstinence. On the one hand, helping
people come to the point where they’re willing to make a
commitment to stop bingeing and purging, and that they have to
give it their all.

A good analogy here is an Olympic athlete. You don’t work

really hard so that you can get a bronze medal. You have to
have your eyes on Olympic gold and you have to do everything
that you possibly can to achieve that goal. Otherwise, if you set
your sights lower, you don’t do your absolute best.

5
Dialectical abstinence also says that regardless of how hard
you might try, there’s the possibility you wouldn’t get the goal.
You may get the bronze or you may not get a medal at all.

When you have a relapse to bingeing, the stance is that this

happened because this is a difficult kind of change to make in
your life. Then you have to recommit to the opposite. I’m going
to do my absolute best and I’m going to go for the gold again.
It’s dialectical abstinence.

When you haven’t binged, it’s like, “I’ve got to do this. It’ll be the
worst thing possible for me in my life if I binge, if I relapse and
put myself all into preventing that relapse.” If it happens, of
course, it happened. That’s the dialectic of dialectical
abstinence.

6
The Addictive Component

Kirby Do you feel like there is an addictive component to eating

disordered behavior?

Michael You can look at the function of behaviors. One major way that
problem behaviors persist is that they can serve to regulate
emotions.

“I’m feeling emotional pain. When I reach for my drug, I binge, I

cut, and that changes how I feel. Sometimes, it numbs me out,
it makes me feel good. Sometimes, it helps me to feel less
bad.”

There’s that underlying function of the behavior that serves to

regulate emotion. That’s one way to look at any
addictive-seeming behavior.

Kirby How is it possible to balance both the ideal of abstinence and

the idea of harm reduction?

Michael One of the things that this addresses when you practice
dialectical abstinence is what’s called the abstinence violation
effect. If people with addictive behaviors, including eating
disorders, are working on abstinence and they have a relapse,
there is a tendency to give up and turn what is a lapse into a
relapse.

The idea with dialectical abstinence is you don’t have to do that.

You can get right back on track. That’s what you need to do to
achieve that long-term goal.

7
Main Points
1. Mindful eating and mindfulness of the body are especially relevant for clients
with eating disorders. It’s virtually impossible to mindfully eat and binge at the
same time.

2. Mindfulness practices need to focus on physical states, such as degrees of

hunger vs satiety, as well as all aspects of the eating process, including the
food itself: taste, texture, smell, color, temperature, etc.

3. Clients with eating disorders need to move beyond an artificial dichotomization

of food, in which all foods are conceptualized as either inherently good or
inherently bad, into a more nuanced, balanced, and dialectical view, in which
all food can be potentially healthy or unhealthy, depending on how we use it.

4. The purpose of dialectical abstinence is to counter the abstinence violation

effect, in which people tend to give up following a relapse, as opposed to
recommitting to abstinence.

The SLIP acronym encapsulates the essence of dialectical abstinence: skills

learning in progress. The concept of dialectical abstinence has 2 main goals:

● Prioritize and plan for complete abstinence from bingeing and purging
behaviors.
● Prioritize and plan for a return to abstinence in the event of a relapse.

8
Psychotherapy Academy, a platform by Psych Campus, LLC.
www.psychotherapyacademy.org

9
Emotional Regulation,
Interpersonal
Conflict, and DBT
Skills for Eating
Disorders

Dr. Kirby Reutter, DBTC, LMHC, MAC & Dr. Michael Maslar

0
Content
Introduction 2
Transcript

Applying Distress Tolerance Skills 3

Transcript

DBT Emotion Regulation Skills 6

Transcript

Opposite Action Behavior 7

Transcript

Interpersonal Effectiveness Skills 9

Transcript

Finding Validation 11
Transcript

Invalidation and the Etiology of Eating Disorders 13

Transcript

Main Points 15
Transcript

1
Introduction

In this segment, Dr. Michael Maslar explores the application of distress tolerance,
emotion regulation, and interpersonal effectiveness in clients with eating disorders. In
particular, he explains a wide variety of DBT skills.

Michael identifies 2 important skills for the therapist: validation and radical
genuineness. In discussing this kaleidoscope of skills, he highlights some of the
unique challenges and nuances when applying DBT, specifically to clients with eating
disorders.

2
Applying Distress Tolerance Skills

Kirby How do you apply distress tolerance skills to clients with eating
disorders? What particular skills work well?

Michael It’s impossible with any certainty to tell in advance which skills
will be helpful to which person, regardless of their specific
diagnosis or problem behaviors. It’s always a process of
learning which strategies are going to be primary and which will
be called upon when the primary ones fail.

It’s important to work on crisis survival skills. The whole thrust

of crisis survival skills is the idea of not making it worse.

If you’re in a crisis, for example, there’s been a problem at work

and it’s after hours. You have to get yourself through that period
where you are intensely worried about what’s going on at work
without making the situation worse, like relapsing. That’s when
the patient can use the crisis survival skills.

People sometimes put this into the mindfulness module in DBT.

I tend to think of this also as a distress tolerance skill, the skill
of alternate rebellion.

For example, a teenager gets upset with his parents. He’s

upset with society. He wants to rebel. If he can identify that urge
to rebel, the idea is finding some way of doing it that doesn’t
cause him problems. For example, get a tattoo, dye your hair,
put on some loud angry music, whatever it might take for you to
address that urge to rebel in a way that isn’t going to become a

3
 problem for you. These are crisis survival skills, alternate
rebellion.

As we get into the acceptance skills in DBT, we can

conceptualize bingeing, purging, restricting, and compensatory
behaviors as willfulness, so we can work with willingness. This
means turning the mind and beginning to work on radical
acceptance, rather than rebelling against what’s going on by
bingeing or purging.

Part of radical acceptance in working with eating disorders, as

well as other behaviors like substance use, is the idea of
burning bridges. It is committing to close off excuses for using.

Again, this means closing off in one’s mind those bridges to

using and, in a radical deep way, committing to abstinence.
Burning bridges is an additional part of the acceptance skills
and distress tolerance.

Self-soothing skills are very important in helping people with

eating disorders, but they also have their difficulties. This is the
case with any specific thing you might do as part of any of the
crisis survival skills. There are certain activities as part of the
acceptance skills that wouldn’t work for some people. It’s the
same with self-soothing.

I might use the sense of smell or the sense of taste as a way of

soothing. But when I’m practicing distress tolerance, I may
need to make sure that I am careful about what smells and
tastes I choose to self-soothe. There’s that caveat, in particular,
about using those 2 senses in distress tolerance self-soothe
skills.

Kirby People with substance abuse issues experience intense urges

and cravings. I would assume that also applies to the
population with eating disorders. Are you using distress
tolerance skills also to address urges and cravings at the
moment either for bingeing, purging, or other behaviors?

Michael We do. And I’ll often address that when we’re talking about
mindfulness, for example. We practice mindfulness of urges, or

4
what we call urge surfing in DBT. This means getting used to
observing urges without acting on them.

You can start with doing a seated mindfulness practice. When

you notice urges to shift in your chair, practice not acting on
those urges. Building that awareness of urges, along with the
ability to not act on urges, is important.

5
DBT Emotion Regulation Skills

Kirby How do you apply DBT emotion regulation skills?

Michael These behaviors function to regulate emotion, and learning

emotion regulation skills can be a substitute for bingeing,
purging, restricting, compensatory behaviors, etc.

Emotion regulation skills can help in the same way, producing

the same short-term effect. The patients can feel better if they
practice these skills. They wouldn’t have the longer-term
consequences of feeling shame later.

These skills can serve the same function at the moment; they
can work better and better over time. Using skills wouldn’t give
the patient the long-term negative consequences that make
their life worse.

Also, make sure that people understand that eating disordered

behaviors are not opposite actions. They’re part of acting on the
urge that comes up with painful emotion. That opposite action is
what is required in situations like that.

6
Opposite Action Behavior

Kirby Even though bingeing and purging are opposites to each other,
do they both have the same opposite action behavior whether
the urge is to binge or purge?

Michael From the standpoint of doing behavioral therapy, the behaviors

have different forms. A binge looks and is a very different
behavior on the surface from purging. So the form is very
different, but the function is the same.

“I’m really angry with my partner and I’m having urges to binge,
so I binge and I regulate that anger. I don’t feel as angry
because I have just binged. I’ve numbed out. Very shortly
thereafter, I’m feeling full. I’m thinking about how I binged and I
start to feel shame, to feel angry with myself. Then I purge and
that helps with that feeling of shame that I had binged. It can
help with that feeling of anger at myself for having let myself
slip.”

Both of those behaviors serve to regulate emotions, even

though they look very different.

Kirby Opposite action is not necessarily acting opposite to the

behavior itself at the surface level. It means going in an
opposite direction in a way that meets the underlying need, but
much more effectively.

Michael Yes. This is where there is a lot of confusion with the opposite
action. It’s not opposite the behavior. It’s not opposite the
emotion because, fundamentally, emotions are just different

7
experiences that we have, and they’re not opposites, per se,
although we can think of them that way.

Each emotion is just simply different from other emotions. It’s

understanding the urge that is connected with the emotion.
When you can understand the urge that’s connected with the
emotion, then you can act opposite the urge.

For example, I might have an urge to binge and I act opposite.

Or I have an urge to lash out and so I act opposite that urge.

8
Interpersonal Effectiveness Skills

Kirby What interpersonal effectiveness skills do you find particularly

helpful for clients with eating disorders?

Michael For many people with eating disorder problems, one of the
prompting events can be an interpersonal conflict. The idea is
to use interpersonal skills to address the conflict, to do
problem-solving with the problem in the relationship, rather than
resorting to an eating disorder behavior. The latter will just
regulate the emotion, but doesn’t address the problem in the
relationship. That doesn’t work well in the long run.

Addressing problems in relationships is helpful for anyone. It

makes it less likely that they’re going to experience negative or
painful emotions that then lead to urges to binge.

With this population, in particular, I help them to use the DEAR

MAN skill to effectively say no to people who might be
intentionally or unintentionally prompting binge behaviors. This
means learning how to say no like you would with any
addictive-looking behavior.

We also work on the skill of asking for healthy portions of food.

Many people will find it difficult to assert themselves in these
kinds of ways. It is important to be able to ask more effectively
for what one wants so that one can get it.

It can be important with this population as well as others to find

ways of expressing emotions accurately to people around them.
When they can do that, they can express themselves
emotionally in an effective way.

9
 An important thing to do is the practice of DEAR MAN to ask
someone to just listen and understand you. That can be
important to regulate emotion as well.

Kirby Do you find that it’s useful to teach clients interpersonal

effectiveness skills to do damage control within the
relationship?

Michael Certainly. It’s relevant to be able to deal with other people in the
aftermath of bingeing or purging behaviors. Quite often, these
kinds of behaviors are done in private. They end up having
effects on people’s relationships. Being able to identify those
problems and using interpersonal skills to help address them is
important.

10
Finding Validation

Kirby How do you apply validation when you’re working with this
population?

Michael Looking for opportunities as often as possible to validate a

person’s experiences is useful. The idea within DBT is finding
the kernel of truth in a person’s thinking, their emotions, and
their behaviors. For example, you had a fight with your partner,
you got angry, and you had urges to binge. Having those urges
to binge makes perfect sense given everything that’s happened
to you.

This is, in DBT, what’s called finding validation in terms of past

experiences or biological dysfunction. It is noticing with the
person that it makes perfect sense that they had urges. On the
other hand, be careful not to validate what is invalid. For
example, “It wasn’t so great that you ended up acting on that
urge to binge and you binged.”

Be willing over and over again to find the kernel of truth in a

person’s behavior. For example, “It makes sense you felt angry.
It makes sense given your history that you had urges. It’s not so
great that you binged.” Also, have the willingness not to validate
the invalid.

That’s always a difficult path for the therapist to take to be able

to identify that kernel of truth without inadvertently validating the
invalid. Of course, you wouldn’t say, “It makes perfect sense
that you end up acting on that impulse,” stating that this is true.
But that is also not valid in terms of what the client’s goals are.

11
It ends up being a dialectic by working with what’s valid and
what isn’t valid in a person’s behavior.

12
Invalidation and the Etiology of Eating
Disorders

Kirby Do you see invalidation as part of the etiology of eating

disorders?

Michael What we focus on, in standard DBT for borderline personality

disorder, is the invalidation of one’s emotional experience: “No,
you’re not feeling this. You’re feeling that.” Also, invalidation of
the person’s thoughts and behaviors over and over again.

With eating disorders, there might be an invalidation of a

person’s internal experience of being hungry or of being full.
For example, “Oh, you didn’t. That’s all you ate. No! You should
eat some more,” or, “You’re not hungry. You just want sweets.
You’re not really hungry.” These are communications that can
complicate things for people and that can be part of that
pathway to developing eating disordered behaviors.

Part of the function in the therapy of using validation with a

client is ultimately helping them learn to validate themselves.
Clients with eating disorders often engage in a lot of
self-invalidation, making things much more difficult for
themselves. We need to help them to learn how to self-validate,
and validating what is valid rather than validating what is
invalid.

Kirby Over time all of this external invalidation probably becomes

internalized and it probably becomes self-invalidation. That’s
how they can ignore basic cues from their bodies regarding
hunger or satiation. Self-validation is extremely important in

13
DBT because we’re never going to get all of the external
validation that we need to heal. So we have to learn to become
our self-validators.

14
Main Points
1. Since both food and substances can be used as maladaptive forms of emotion
regulation, DBT skills typically used for substance abuse (such as alternate
rebellion, urge surfing, and burning bridges) can also be applied to eating
disordered behaviors.

2. When applying self-soothing skills to clients with eating disorders, be careful

with taste and smell since these 2 senses are so closely related to eating.
Both senses can still be effective forms of distress tolerance, but they can also
be triggering, so clinical judgment is required.

3. When applying opposite action to clients with eating disorders, it would be

easy to assume that bingeing and purging are already opposites. However,
both extremes are unhealthy, non-dialectical behaviors. Even though bingeing
and purging seem like opposites on the surface, they both serve the same
underlying function of attempting to regulate emotions.

4. Regardless of which extreme your client is experiencing, opposite action must

focus more on addressing the underlying maladaptive attempt at emotion
regulation than on the actual surface behavior.

5. There is a vicious cycle between interpersonal conflict and eating disordered

behavior. As with substance abuse addicts, it can be difficult for eating
disordered clients to say no, be assertive, or set inappropriate boundaries.
Therefore, even though interpersonal effectiveness doesn’t seem
diagnostically related to eating disorders, it’s an important part of treatment.

15
6. There is also a vicious cycle between invalidation and eating disordered
behavior. Therefore, it’s especially important for DBT therapists to provide
appropriate validation, which also includes radical genuineness.

16
Psychotherapy Academy, a platform by Psych Campus, LLC.
www.psychotherapyacademy.org

17
Traditional and
Radically Open DBT
for Eating Disorders:
TIBs and the
Treatment Hierarchy

Dr. Kirby Reutter, DBTC, LMHC, MAC & Dr. Michael Maslar

0
Content
Introduction 2
Transcript

Between-Sessions Support 3
Transcript

Underregulation and Overregulation in Eating 6

Disorders
Transcript

Radically Open DBT 7

Transcript

Eating Disorders and Treatment-Interfering 9

Behaviors
Transcript

Teaching DBT Skills 11

Transcript

Minor Adaptations That Can Be Made to DBT to 12

Treat Bulimia Nervosa
Transcript

Integrating Other Models to DBT 14

Transcript

Main Points 16
Transcript

1
Introduction

In the final segment of this interview series on DBT and bulimia, Dr. Michael Maslar
discusses the importance of between sessions support as a form of
context-dependent learning.

He also distinguishes between traditional standard DBT (which was designed to treat
disorders of underregulation) vs radically open DBT (which was designed to treat
disorders of overregulation). Since eating disordered behaviors can potentially
involve both underregulation and overregulation, both approaches can be effective.

Finally, Michael discusses the treatment hierarchy for treating symptoms of bulimia.
In addition to distinguishing between therapy-interfering behaviors vs relationship
ruptures, he outlines a specific sequence of treatment priorities.

2
Between-Sessions Support

Kirby Do you find the DBT concept of between-sessions support to

be helpful with clients with eating disorders? Do you encounter
the same sort of crises that you would have with the population
with borderline personality disorder?

Michael Certainly. In DBT, there’s a target hierarchy for each one of the
modalities of treatment. For phone coaching, you have a target
hierarchy of addressing suicidal and life-threatening behaviors
first and foremost, and then helping people to use skills that
they are learning in therapy. Finally, we address a sense of
distance or alienation from the therapist.

Those categories of behaviors can be addressed with eating

disorders. Some people with eating disorders self-injure and
may be suicidal. So certainly, it is useful for the therapist to be
available for that.

In particular, with eating disorders, the second level of the

hierarchy, addressing skills use, is helping coach people in
using emotion regulation skills. This helps manage emotion
dysregulation so that the person doesn’t take that step of
bingeing and then purging.

In any therapy, one big obstacle that people face when they’re
trying to make changes in their lives is taking what they’re
learning in the therapy session and applying it in everyday life.

DBT and therapies like DBT that offer this component are
essential for helping people learn how to take what they’re

3
 learning in therapy and practicing it, using emotion regulation
rather than bingeing. This is because our learning is highly
context-dependent.

There’s research that shows that if you study in the room where
you’re going to be taking an exam, you tend to do better than if
you studied somewhere else. Even just the physical
surroundings cue up behaviors. Sitting with your therapist in the
therapy environment is very different than day-to-day life.

Phone coaching helps bridge the gap between what’s

happening in the therapy room or in the skills training group
with day-to-day life.

Kirby In your work with clients with eating disorders, are you utilizing
mostly standard DBT, radically open DBT, or a combination of
both?

Michael It depends on the eating disordered behavior. In binge-purge

types of behaviors, like bulimia nervosa, standard DBT is what
is indicated.

Radically open DBT, on the other hand, is the first treatment

that we have that shows efficacy with adult anorexia nervosa.
The therapist can make those distinctions based on the type of
problem that a person has or their diagnosis.

Kirby What are some of the key distinctions between standard DBT
vs radically open DBT?

Michael There are minor modifications to standard DBT that have been
developed for eating disorders, like bulimia nervosa, antisocial
personality disorder, dissociative disorders, or
substance-related disorders.

Radically open DBT is a major adaptation of DBT that is

dissimilar in lots of ways. It’s still a behavioral treatment and
integrates mindfulness skills into its work. The difference is that
it addresses the whole collection of behaviors that are on the
opposite end of a spectrum or dialectic from all the other

4
behaviors that are addressed with standard DBT, which can be
thought of as undercontrolled behaviors.

This is where we make the assumption that emotion

dysregulation drives a lot of the problem behaviors because a
person has difficulty acting in regulated ways. That’s
undercontrol and standard DBT.

Radically open DBT addresses people who have too much of a

good thing. They exert too much control over themselves. They
can’t connect with other people. They have difficulty being
flexible and being able to address problems effectively in the
world because they operate by rules which don’t always fit.

It’s not about emotion dysregulation. It’s about problems with

being open to new learning, being flexible, and being isolated.
This is opposed to problems with standard DBT that are about
being out of control in some ways.

That’s the core issue with eating disorders, the sense of when
bingeing that one’s behavior is out of one’s control. So radically
open DBT is very different. It has almost completely different
skills than the ones we teach in standard DBT. The treatment
hierarchy in individual therapy is almost completely different
than in standard DBT.

There are major differences also in the way that the therapist
tends to interact in radically open DBT vs standard DBT. Those
2 treatments have diverged quite a bit, but they still share the
same basic behavioral and mindfulness principles.

5
Underregulation and Overregulation in
Eating Disorders

Kirby Would it be fair to say that eating disorders can be a matter of

underregulation as well as overregulation?

Michael Depending on the specific function of the behaviors, yes. The

form is different. The problems of people who mainly restrict are
associated with overcontrol.

That’s the nature of restricting and compensatory behaviors. I’m

exerting control over my body. People who are on the opposite
end may experience emotion dysregulation and they may go
back and forth between losing control and then getting control
again, whereas the person who is overcontrolled tends to be
overcontrolled and in control too much of the time, and in ways
that interfere with their goals.

6
Radically Open DBT

Kirby Can standard DBT and radically open DBT be useful for this
population at different times?

Michael Depending on whether the basic underlying problem is one of

emotion regulation, I will primarily be doing standard DBT. I may
bring in some of the skills from radically open DBT, but I’m
fundamentally doing standard DBT.

It’s the same if I go in the other direction. If I’m working with

somebody with anorexia nervosa, we’re primarily doing
radically open DBT, but I may pull in skills from standard DBT
because they can help anybody.

I have a basic therapeutic approach. I try to be as adherent as

possible and then maybe bring in skills from the other treatment
when needed.

Kirby What is the second priority in radically open DBT?

Michael In standard DBT, we deal with a lot of therapy-interfering

behaviors, we address them as such because that’s important.
We work with therapy-interfering behaviors because that makes
the whole therapy work more effectively.

In radically open DBT, we tend to view behaviors that might

interfere with the therapy as signs of relationship rupture. In that
second tier of the hierarchy, we’re looking for relationship
ruptures. Then we bring in a rupture repair protocol and begin
to work on the relationship.

7
This is because one of the fundamental difficulties with
overcontrol is that the person has difficulty connecting with
another person.

That is part of the therapy relationship. You’ll get people who

have problems with overcontrol and they’ll look very engaged in
the therapy and they are. They are very compliant because
that’s what they’re supposed to do, but not because they have
a connection with a therapist.

It usually takes several alliance ruptures to happen so that that

person has the visceral experience of having a relationship
rupture with another person that gets addressed effectively and
the relationship is repaired.

People with overcontrol often are isolated. One of the reasons

is because they’ve been unable to effectively address problems
connecting with other people in their lives. They don’t
necessarily have the connectedness experience.

Ultimately, in radically open DBT, it’s having that deep

connection with the therapist that’s important. It gives the
person the experience of being able to connect with other
people. There’s that difference in the hierarchy. We certainly
have behaviors in radically open DBT that interfere with the
therapy but we tend to assess them as connected to alliance
ruptures.

8
Eating Disorders and
Treatment-Interfering Behaviors

Kirby When you’re working with eating disorders, what do you find to
be more problematic, treatment-interfering behaviors or
ruptures in the therapeutic alliance?

Michael It depends on whether the person is undercontrolled or

overcontrolled.

Many people who are undercontrolled also have a very basic

kind of relationship hunger. They want to connect and to be
able to depend on you as the therapist. They want to connect
with other people in their lives. We’ll work on therapy-interfering
behaviors as such.

People with overcontrol are very threatened by connection

because they haven’t learned how to do it well. Rather than
addressing the behavior that interferes with therapy simply for
what it is, patients with eating disorders will try to be compliant.
But this doesn’t address what might be connected functionally
to those problem behaviors as the therapy relationship.

“Are you really connecting? Are you letting me know that I

understand you? Are you helping me to correct that when I
don’t understand you?” Those are really basic fundamental
skills related to connecting with another person that will make
the therapy more effective.

9
That second tier of the hierarchy, in both standard DBT and
radically open DBT, addresses making the therapy more
effective, coming at it from different directions.

10
Teaching DBT Skills

Kirby What are some of the most difficult DBT skills to teach clients
with eating disorders?

Michael Mindfulness, mindfulness of behaviors related to eating, and

behaviors related to one’s body. When I say behaviors in DBT,
we have a radical behavior space that we work from. In that
space, everything that a person does is a behavior.

What I do outwardly, my overt behavior, is also what I do

inwardly. My thoughts are behaviors. My emotions are
behaviors. Even my basic physiological activity, like respiratory
rate or heart rate, are behaviors as well.

Practicing any of the skills that we learn in DBT and

mindfulness, in particular, of eating disorder-related behaviors
can be difficult. When practicing self-soothe skills, be careful
about which senses are being used and how they’re being used
for self-soothing.

With emotion regulation, it is difficult to be able to help to get

the idea and the practice of using emotional regulation rather
than the problem behavior. These are mindfulness skills,
distress tolerance skills, and emotion regulation skills.

There are challenges in each of those areas and others

depending on the person.

11
Minor Adaptations That Can Be Made
to DBT to Treat Bulimia Nervosa

Kirby What are the minor adaptations that it’s possible to make to
standard DBT, specifically with bulimia nervosa in mind?

Michael As part of the hierarchy of treating behaviors in individual work

with eating disorders, the most important level if someone has
suicidal behavior or self-injury, is addressing that first and
foremost. The second tier is stopping therapy-interfering
behavior. That’s the way it is for any adaptation of DBT.

Once we get into the third level of the hierarchy with eating
disorders, the following sets of behaviors are important in this
order, and this helps to organize and focus the therapy. The
next behavior to address is stopping bingeing. Then, eliminating
mindless eating or practicing mindful eating. We aim to
decrease cravings, urges, and preoccupations with food using
skills to do that.

Decrease giving in to urges. Help people understand that it’s a

choice that they make to give in. Decrease apparently irrelevant
behaviors. “I just brought these leftovers from the office
because I think my son would like them but then I binge on it.”
Buying large quantities of binge foods for guests if people show
up. “Now, I have this binge food that’s around.” We aim to
decrease apparently irrelevant behaviors that just make it
harder for a person to be able to stop bingeing and then
purging.

Then increase the use of skills. We talk about all of these sets
of behaviors and working on them in that order as the pathway

12
in DBT that’s adapted for eating disorders. We call that the
pathway to mindful eating overall.

After suicide behaviors and treatment-interfering behaviors,

Marsha Linehan addresses anything that interferes with the
quality of life. What you’ve done is expanded that and made
that much more concrete.

13
Integrating Other Models to DBT

Kirby Have you found it useful to integrate other models outside of

DBT world altogether when you’re working with clients with
eating disorders?

Michael Virtually any behavioral treatment that’s in existence, and I

include cognitive-behavioral treatments because they share the
same base as DBT and can be integrated into DBT. There’s a
way that DBT is the shell that you can insert all kinds of other
protocols, like CBT for OCD, CBT for phobias, exposure
treatment for trauma, and cognitive processing therapy for
trauma.

These are all therapies that can be used within standard DBT. I
often do bring them in, depending on what the person needs, of
course.

Kirby What are your favorite DBT skills that you use in your own life?

Michael The way that most training in DBT proceeds is that the clinician
who’s learning DBT has to learn the skills and has to learn their
use through practicing in their own lives. This makes it easier to
teach the skills but it’s also crucial to have an effective therapy
practice, especially if you’re working with a lot of clients who
have emotion dysregulation problems.

It can be stressful. It’s important that the therapists are skillful

themselves for the therapy process, not to mention that it can
make your life a whole lot better outside of the therapy room.
That’s often the report that I get from people that I train, and
what we hope for is you’re using skills in everyday life. People

14
almost always say, “This has made my personal life better
because I learned these skills.”

Mindfulness skills are very fundamental to me. I practice the

skills and do formal practice as often as I can. Certainly,
emotion regulation is important. A big one from distress
tolerance is practicing radical acceptance. That probably is the
skill that I use and work on the most and the one that has
helped me live a happy and fulfilling life.

15
Main Points
1. Learning tends to be context-dependent. Even though the counseling office is
a safe environment for learning new skills, it’s often difficult for clients to apply
those skills in real-life situations outside of the counseling office.

2. DBT therapists need to provide between-session support so that clients can

generalize skills learned in session to their own real-world settings.

3. Standard, traditional DBT was developed to treat disorders characterized by

symptoms of underregulation, such as borderline personality disorder.
Radically open DBT was designed to treat disorders characterized by
symptoms of overregulation, such as obsessive-compulsive disorder.

4. Overall, standard DBT is more effective for treating symptoms of bulimia,

whereas radically open DBT is more effective for treating symptoms of
anorexia. However, since eating disorders can involve forms of both
underregulation and overregulation, both approaches can be effective.

5. For clients who tend to be underregulated, it’s important to address

treatment-interfering behaviors; otherwise, treatment will be undermined. For
clients who tend to be overregulated, treatment compliance will not be an
issue, but that does not mean they feel connected to the therapist—in which
case, treatment will still be undermined. Therefore, for clients who tend to be
overregulated, it’s important to address relationship ruptures instead.

16
6. When specifically treating symptoms of bulimia, treatment should also focus
on the following priorities, in order:

● - Eliminate any life-threatening behaviors.

● - Decrease treatment interfering behaviors.
● - Stop bingeing.
● - Eliminate mindless eating and replace it with mindful eating.
● - Decrease cravings/preoccupation with food.
● - Decrease capitulating to urges.
● - Decrease apparently irrelevant decisions.
● - Learn other skills to foster an overall healthier life.

17
References
Linehan, M. M. (1991). Cognitive-behavioral treatment of chronically parasuicidal
borderline patients. Archives of General Psychiatry, 48(12), 1060.

Linehan, M. M., Armstrong, H. E., Suarez, A., Wisniewski, L., Safer, D., & Chen, E.
(2007). DBT and eating disorders. In L. A. Dimeff & K. Koerner (Eds.), Dialectical
behavior therapy in clinical practice: Applications across disorders and settings (pp.
174-221). Guilford Press.

Linehan, M. M., & Chen, E. Y. (2005). Dialectical behavior therapy for eating
disorders. In A. Freeman, S. H. Felgoise, C. M. Nezu, & M. A. Reinecke (Eds.),
Encyclopedia of cognitive behavior therapy. Springer.

18
Psychotherapy Academy, a platform by Psych Campus, LLC.
www.psychotherapyacademy.org

19