Academic journal article Journal of Counseling and Development : JCD

Description of an Intensive Dialectical Behavior Therapy Program for Multidiagnostic Clients with Eating Disorders

Academic journal article Journal of Counseling and Development : JCD

Description of an Intensive Dialectical Behavior Therapy Program for Multidiagnostic Clients with Eating Disorders

Article excerpt

Even with the availability of well established, empirically grounded eating disorder treatments (e.g., cognitive behavior therapy, interpersonal psychotherapy, traditional day treatment), a substantial number of individuals with eating disorders fail to make adequate treatment gains, require repeated hospital admissions, or terminate treatment prematurely (Wilfley & Cohen, 1997; Wilson, Fairburn, & Agras, 1997). Researchers have speculated that clients with eating disorders who do not respond to standard treatments are more likely to (a) have a comorbid Axis I or Axis II disorder (Johnson, Tobin, & Dennis, 1990); (b) enter treatment with a more severe clinical picture in terms of eating pathology and general emotional distress (Wonderlich, Fullerton, Swift, & Klein, 1994; Zeeck et al., 2007); or (c) exhibit greater emotion dysregulation, interpersonal deficits, and impulsivity (Bruce & Steiger, 2005; Fichter, Quadflieg, & Hedlund, 2006).

The lack of treatment response to traditional approaches to eating disorders is believed to be due, in part, to the failure of traditional cognitive behavioral interventions to adequately address the pervasive emotion dysregulation and skill deficits present in this unique population (Becker-Stoll & Gerlingoff, 2004; Zeeck, Herzog, & Hartmann, 2004). Furthermore, traditional treatment protocols for eating disorders were not designed to simultaneously treat chronic suicidal and self-injurious behavior, ongoing therapy-interfering behaviors (e.g., arriving late to treatment, water loading on weigh-in days, not completing homework), or pervasive personality pathology in the context of a severe eating disorder. Thus, several researchers have stated that clients with eating disorders who present with comorbid diagnoses and a history of chronic treatment failure require a more flexible, eclectic, and collaborative approach to treatment that includes individual and group psychotherapy; team consultation (Sansone, Fine, & Sansone, 1994); and a comprehensive focus on eating disorder symptoms, interpersonal skills, affect regulation, and impulse control (Zeeck et al., 2007).

Dialectical behavior therapy (DBT), a multidisciplinary treatment approach that was originally developed for clients with borderline personality disorder, is of particular interest given its effectiveness in reducing impulsive and self-destructive behaviors in a population once considered "treatment resistant" (Linehan, 1993a, 1993b). DBT is associated with significant reductions in suicidal and self-injurious behaviors, substance abuse, anger outbursts, treatment dropout, and frequency of hospital visits (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Verheul et al., 2003). Given these findings, modified DBT approaches have been the focus of several treatment studies of eating disorders. There is evidence to support the use of DBT skills training (offered either individually or in a group format) for clients with less severe bulimia nervosa and binge eating disorder (Chen & Safer, 2010; Safer, Robinson, & Jo, 2010; Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan, 2001).

Although these data are promising, our interest as clinicians and researchers has been in the development of treatments for complex, multidiagnostic, difficult-to-treat individuals with eating disorders. As we discuss later in this article, such clients are characterized by repeated treatment failures, significant therapy-interfering behaviors, high rates of psychiatric co-morbidity, and pervasive skill deficits that typically involve emotion regulation. The data for this population, however, are limited. Two case-series reports (Chen, Matthews, Allan, Kuo, & Linehan, 2008; Palmer et al., 2003) and two uncontrolled trials (Ben-Porath, Wisniewski, & Warren, 2009; Kroger et al., 2010) suggest that more intensive DBT protocols, modified to include specific content for eating disorders, may be more efficacious for clients with such a disorder and comorbid borderline personality disorder. …

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