Academic journal article American Journal of Psychotherapy

Dialectical Behavior Therapy and Eating Disorders: The Use of Contingency Management Procedures to Manage Dialectical Dilemmas

Academic journal article American Journal of Psychotherapy

Dialectical Behavior Therapy and Eating Disorders: The Use of Contingency Management Procedures to Manage Dialectical Dilemmas

Article excerpt

Several researchers have adapted and/or applied dialectical behavior therapy (DBT) for populations with eating disorders. There is a growing body of research that indicates that DBT is an effective treatment option for this population, including those who have co-occurring Axis II disorders. The goal of the current paper is to summarize the research conducted in the area of DBT with those individuals who present with eating disorders only as well as those who present with both eating disorders and Axis II disorders. We also describe a dialectical dilemma, apparent compliance vs. active defiance, which is commonly observed in the group with comorbidities A DBT change strategy, contingency management, is discussed as an intervention to target apparent compliance and active defiance.

KEYWORDS: dialectical behavior therapy, eating disorders, contingency management

INTRODUCTION

Several randomized controlled trials have indicated that DBT is an efficacious treatment for suicidal patients diagnosed with borderline personality disorder (Koons et al., 2001; Linehan, Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Comtois, Murray, Brown, Gallop, & Heard, 2006; Linehan, Heard, & Armstrong, 1993). Indeed, Division 12 (Clinical Psychology) of the American Psychological Association listed DBT as one of four empirically supported treatments (ESTs) for borderline personality disorder (BPD) and the only EST that has "strong" research support for treating BPD (Society of Clinical Psychology, 2013).

Since the inception of DBT, several researchers have adapted and applied it to various populations that stand to benefit from this treatment. Because medical complications associated with eating disorders are common, and can become life-threatening, the treatment hierarchy in DBT provides a useful frame to address the myriad complex therapy issues. Additionally, some theorists have argued that eating disorder symptoms represent a maladaptive method to regulate negative affect (Heatherton & Baumeister, 1991; Safer, Telch, & Agras, 2001; Telch, Agras, & Linehan, 2001). Therefore, because of its efficacy in treating emotion dysregulation and the corresponding maladaptive behaviors, DBT has been suggested as a promising intervention for those with eating disorders to regulate affect, e.g., binge/purge behaviors (Federici, Wisniewski, & Ben-Porath, 2012; Wisniewski, Safer, & Chen, 2007).

DBT APPLIED TO CLIENTS DIAGNOSED WITH EATING DISORDERS: A REVIEW

To date several studies have examined the effectiveness of DBT for the treatment of individuals with eating disorders, including those diagnosed with binge eating disorder (BED), bulimia nervosa (BN) and anorexia nervosa (AN). In the first randomized study of DBT and binge eating disorder, Telch, Agras, and Linehan (2001) randomly assigned women to DBT skills training and a wait-list control condition. Results indicated that 89% of participants who received DBT skills were abstinent from binge eating as compared with only 12.5% in the wait-list control condition. Similarly, Masson, von Ranson, Wallace, and Safer (2013) randomly assigned participants to a DBT or a wait-list control condition. Dialectical behavior therapy was self-directed and consisted of an orientation, a copy of the DBT skills manual, and six 20-minute supportive phone calls over the course of 13 weeks. At the end of treatment 40% of DBT participants abstained from binge eating as compared to 3.3% in the wait-list control condition.

In order to control for the possible nonspecific effects of therapy, Safer, Robinson and Jo (2010) compared DBT with an active comparison group therapy (ACGT) modeled after Markowitz and Sacks' (2002) manual of supportive therapy for chronic depression. Participants were randomly assigned to either 20 group sessions of DBT or ACGT. Results indicated that reductions in binge frequency were greater and achieved more quickly. Abstinence rates for bingeing were higher for the DBT group than for ACGT group (e. …

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