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Dialectical Behavior Therapy

Dialectical Behavior Therapy (DBT) is an increasingly popular therapeutic approach among eating disorder (ED) clinicians, largely due to the expanding body of research supporting its efficacy in treating a wide range of diagnoses. In order to appreciate the value of the DBT model when navigating recovery, one must first understand the meaning behind its name. 

The term “dialectical” refers to the synthesis between two opposites. In other words, the recognition that two seemingly contradictory truths can exist simultaneously (without one truth invalidating the other). To illustrate this concept, I’ll introduce one of my favorite tools: replacing the word “but” with the word “and”. The use of the word “and” allows us to hold two conflicting truths at the same time, while also validating the intense emotions related to navigating a challenging situation. Though swapping “and” for “but” may seem simplistic, modifying language in this manner is a powerful therapeutic tool that promotes flexible thinking by shifting away from the “either/or” mindset. 

Let’s apply this concept to a realistic conflict experienced by many people seeking help for their eating disorders who face ambivalence about entering treatment. When weighing the decision of whether to enter a higher level of care program (such as a residential or partial hospitalization program), clients often express sentiments such as: “I want to get better, but I’m really uncomfortable asking for leave from work.” The use of the word “but” in this sentence communicates that the reluctance to take leave from work somehow minimizes the desire to get better, when, in reality, both truths are significant and valid. Through the use of dialectical thinking, we can rephrase this sentence in order to validate both points. When we restructure this dilemma as an “and” statement, it transforms into: “I don’t want to take leave from my job, and I’m going to need to in order to get better.” Now, let’s unpack the contents of the restructured sentence. Of course the client is worried about leaving their job—who wouldn’t be? The idea of taking time away from work is understandably anxiety-provoking and leads to many valid concerns such as: dealing with HR, potential financial impact, concerns around job security, and so forth. The fact that leaving work is a necessary means in order to get better does not make the choice less anxiety-provoking; and, at the same time, doing so remains essential.  

Here’s another example that resonates with many clients: “I know I need to eat, but I’m having a really bad body image day.” The use of the “but”, in this case, suggests that the bad body image day somehow prevents the client from eating. Rather than assigning more power to the latter part of the sentence through including the “but”, we can rephrase the sentence using “and” to transform the sentence into the following: “I’m having a bad body image day and I still need to eat.” Now, the emotional distress tied to a bad body image day is still validated, only without overshadowing the importance of the client meeting their nutritional needs. Through introducing the concept of dialectics, providers can better aid clients in navigating powerful and distressing thought processes by facilitating more flexible thinking. 

Another application of the dialectic in ED recovery is the idea of balancing behavioral extremes, which often manifest through symptom use. A common dialectical dilemma faced by clients with eating disorders is “over-controlled”, or restrictive eating patterns, versus “under-controlled”, or binge eating episodes. The two extremes in this case, are overly restrictive dieting, and perceived loss of control when emotionally eating.  For instance, clients with bulimia nervosa (BN) may find themselves engaging in the disordered pattern of excluding all sweets from their diets in attempt to cut down on stereotypically “unhealthy” foods, only to later eat several boxes of cookies during a binge-eating episode. Neither of these extremes are healthy, and yet, clients often struggle to recognize that a middle ground exists after engaging in disordered eating patterns for years. It may be difficult for clients to trust themselves with eating dessert a few times a week when their bodies experience a craving for sweets. The “all or nothing” mindset may drive clients to actively ignore such cravings, or avoid being in situations with sweets all together—lest they experience an urge to binge eat. The synthesis, or balancing of these two extremes (avoiding all sweets versus eating every dessert in the house), becomes learning to mindfully eat normalized servings of sweets more frequently than usual without losing control. 

Another common example of behavioral extremes is refraining from all physical activity, versus compulsive and excessive exercise. The synthesis of the two, in this case, being normalized, appropriate amount of movement (ideally driven by the desire to connect with one’s body, rather than the desire to compensate for caloric intake). And yes, this synthesis is possible. However, in order to experience a synthesis in dialectical dilemmas, the client must be willing to challenge their mindset around symptom use. Thus, I will explore an example of a dialectical dilemma that clients may encounter in treatment in order to further illustrate how to challenge problematic thinking patterns.
Here is an example of all-or-nothing thinking that a client may experience when struggling in a higher level of care program: “I want to discharge. I’m not sure this program is the right fit for me. I’m not getting better, and it seems like I can’t do anything right—I’m better off trying to recover on my own.” This thought process is an example of extreme thinking patterns. In this case, the “either/or” mindset leads the client to believe that the only two options are remaining in the program indefinitely, or abruptly discontinuing all treatment. One can imagine that some of the possible emotions resulting from this thought process might include: anxiety, shame, guilt, hopelessness and frustration. From a dialectical standpoint, the therapist might encourage the client to explore possible “middle ground” solutions. For instance, committing to treatment for another two weeks while continuing to problem-solve, and then re-evaluating whether or not to continue. 

Challenging black-and-white thinking allows clients to become “un-stuck”, or free from their self-imposed limitations, by identifying other perspectives that fall into the “gray” area that they may otherwise overlook. In this example, the client likely will feel less distressed once they acknowledge that discharging is not the only alternative to the current treatment arrangement—thus empowering themselves to make a choice based in logic rather than one that is driven solely by emotions. 
In sum, integrating a dialectical stance toward recovery gives clients permission to navigate a balance of acceptance and change. Rather than remaining chained to rigid and extreme patterns in behavior and thinking that fuel emotional distress, DBT allows clients to consider alternative ways of responding to intense emotions, with an emphasis on creating value-consistent, goal-directed change.

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