DBT versus CBT: Effective Therapy for Eating Disorders

Dialectical Behavior Therapy (DBT) and Cognitive Behavioral Therapy (CBT) may seem to present opposing factions when searching for one to surpass the other in terms of eating disorder treatment effectiveness. Yet, once the core premise of both modalities is evaluated, they tend to be more complementary than not. Based on its origin, DBT is an enhanced form of CBT that incorporates a systemic spectrum of therapeutic concepts and interventions. When addressing eating disorders, using both CBT and DBT in unison, clients can discover the importance for addressing one’s destructive thought processes, which often result in poor behavior, and the need for emotional stability. 

CBT is generally a short-term therapeutic approach that currently has research supporting its efficacy for treatment.

A basic premise of CBT is that a person’s thoughts affect their feelings and thus perpetuate particular behavior (1). This premise would hold true for patterns resulting in life-enhancing or life-depreciating outcomes. In a clinical setting, the initial treatment step is to use a Functional Analysis of a patient’s selected destructive thought, corresponding feeling, and resulting behavior (2). This form of therapeutic intervention has its best results when used with a patient who has the ability for introspection, insight, and subsequent innate goal-directed motivation. 

Once a person identifies the origins of a destructive thought leading to poor behavior, they begin to institute corrective measures with which to change that thought over time. The goal is to achieve more favorable behavior. In its simplest form, CBT seeks to affect change in one’s thoughts, which then ends destructive behavior and facilitates constructive behavior as the new normal.  

DBT adds to this clinical equation by improving how a patient self-regulates their internal states of emotion.

DBT maintains an initial perspective that patients are not aware of the causes of their states of dysregulated emotion (3). They also fail to understand how these states of dysregulated emotion might correlate with their destructive thoughts and poor behavior. DBT begins developing the process of self-regulation by including the concepts for “Awareness” of fluctuating emotion states and personal “Acceptance” that there is a need for change. The dialectic in play can be found in the need for the patient to “Accept” themselves for where they are or what their behavior is and subsequently recognize they have a need to change.  

In regard to eating disorders, for the sake of this article, let’s reduce the multiple causal features often inherent for such disordered behavior to a single lineage. For example: A patient with Bulimia purges at 10:00 p.m. By facilitating a DBT intervention called the Behavioral Chain Analysis (BCA) (4) in written form, which identifies a reverse sequence of events leading to the purge action while identifying the corresponding thoughts and feelings.

In eating disorder treatment, a therapist might discover the following sequential dynamic using this DBT intervention:

10:00 p.m.: behavior – purge; thought – I deserve punishment; feeling – calmness

9:00 p.m.: behavior – binge; thought – I am so full my stomach hurts; feeling – shame

7:00 p.m.: behavior – isolation; thought – I am of no value; feeling – despair

5:30 p.m.: behavior – family gathering; thought – I disappoint everyone; feeling – anger

10:00 a.m.: behavior – employment; thought – All project deadlines must be met; feeling – fear

6:00 a.m.: behavior – waking up; thought – How can I get through this day?; feeling – anxiety

12:00 a.m.: behavior – sleep; thought – I’m not able to get to sleep at a reasonable time; feeling – irritable and distractible

Using the above scenario, a CBT-based approach may initially focus on the thought regarding the action of purging by seeking to alter the corresponding 10:00 p.m. thought of “I deserve punishment.” Interventions seeking a gradual change to an improved thought of “I deserve love” may be the end goal. Examples of activities to improve self-care – such as getting a pedicure, “paying it forward” at a local coffee house or providing volunteer services for the elderly – could be utilized to enhance a core sense of self-worth. The end goal for seeing oneself as having meaning is of significant value, yet this may or may not be enough to achieve a long-term favorable shift in the patient’s core emotion regulation functions. 

In the same simplified scenario, a DBT approach could view this episode of purge as the result of emotion dysregulation stemming from an earlier experience that the patient is not aware has direct correlation.

By implementing a BCA, the patient can be guided to consider the incremental development through previous behavior with correlating thoughts and feelings leading to an event of origin, such as experiencing poor sleep patterns similar to 12:00 a.m. illustration above. Having less than adequate sleep affects one’s mood state and memory as well as their ability to behave in top form. The experience of habitual poor sleep patterns combined with stressful events, such as a sense of failure at 10:00 a.m., may contribute to an increase in temperamental sensitivity to an uncomfortable feeling like fear, leaving one vulnerable to impulsive behavior such as the 9:00 p.m. binge episode. Consequently, following a significantly large volume binge episode, the subsequent 10:00 p.m. purge episode would reasonably follow suit for a patient who experiences a calming effect from such an action. 

Through the use of a BCA, an eating disorder patient learns that their state of self-awareness, self-care habits, and life experiences contribute to various states of emotion regulation or dysregulation. They may choose to practice intentional improvements with how they enhance favorable self-care such as their sleep habits as a starting point. To gain a more robust foundation from which to improve one’s life, a patient would be taught Mindfulness and Distress Tolerance skills. With practice, these skills-based interventions will permit the patient to begin implementing a moment-to-moment routine of self-care. The intentional use of self-care habits can permit the patient to see each life encounter as an opportunity to increase their self-awareness, so they identify their current state of emotion. Plus, they can choose to implement a DBT skill for maintaining a state of self-regulation even when they encounter some form of discomfort.

Both CBT and DBT seek to stop destructive behaviors and enhance productive behaviors.

Together, CBT and DBT promote mental health education and use a plethora of interventions focused on improving one’s circumstances. They both propose that one’s life experiences affect thought patterns and behavioral actions. DBT takes this idea a step further by considering that one’s progressive state of emotion is a core element facilitating unhealthy or healthy life patterns. DBT uses a more systematic series of education modules with defined skills. In considering the features of both treatment modalities, the outcome is less of a DBT versus CBT mindset, as it is more of a CBT and DBT integration that may best serve a patient afflicted with an eating disorder. 

At Hidden River, we utilize both DBT and CBT as well as other treatment modalities to successfully treat patients with eating disorders at our residential level of care. For additional information about the treatment of eating disorders, please call us today at 833.30.RIVER.

References

1. Wright, J.H. (2006). Cognitive Behavior Therapy: Basic Principles and Recent Advances. Focus, 4(2), 173-178.
2. Drossel, C., Rummel, C. Fischer, J.E. (2009). Assessment and Cognitive Behavioral Therapy: Functional Analysis as Key Process. (pp. 15-41). In W. O’Donohoe & J.E. Fischer’s  (Eds.) General Principles and Empirically Supported Techniques of Cognitive Behavioral Therapy. John Wiley & Sons.
3. Lynch, T.R, Chapman, A.L., Rosenthal, M.Z, Kuo, J.R., & Linehan, M.M. (2006). Mechanisms of change in dialectical behavior therapy: Theoretical and empirical observations. Journal of Clinical Psychology, 62(4), 459-480.
4. Rizvi, S.L. & Ritschel, L.A. (2014). Mastering the Art of Chain Analysis in Dialectical Behavior Therapy. Cognitive and Behavioral Practice, 21(3), 335-349.