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 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).


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.g., 64% vs. 36%, respectively). Despite these earlier gains, reported differences between groups were not maintained upon the three-, six-, and 12-month follow up suggesting that DBT may be responsible for the initial rapid treatment gains but not long-term therapy gains in those with BED.

Given that symptoms of bulimia have been theorized to play a role in regulating affect, several researchers have used DBT to treat individuals with bulimia nervosa. For example, Safer, Telch, and Agras (2001), in a randomized treatment study, assigned individuals diagnosed with binge/ purge behaviors to once-weekly individual DBT treatment or a wait-list control group. At the end of 20 weeks, 28.6% of participants in the DBT-treatment group were abstinent from binge eating/purging behaviors as compared with no participants in the wait-list control condition. …

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