Practical Applications of Using DBT Working with Clients Seeking Recovery from Eating Disorders

1. Practical Applications of Using DBT Working with Clients Seeking Recovery from Eating Disorders Shannon Hays LPC, CAADC, DBTC

2. Agenda • Overview of DBT and Theory • Basic Intro into Core DBT skills • Overview of Eating Disorders • Case Studies

3. Overview of DBT • Dialectical Behavior Therapy (DBT) is a cognitive behavioral treatment that was originally developed in 1983 to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD).    • Dr. Marsha Linehan Professor of Psychology of the University of Washington, developed this treatment  as a modification of standard CBT after her own experiences with mental illness and treatment . • The first workbook was published in 1993 and has since been modified and adapted for numerous other conditions.  • Cognitive-Behavioral Intervention designed to target maladaptive coping • Dialectic – the idea that two things can be true at the same time • Central Dialectic: Acceptance versus Change

4. Foundations of DBT • DBT is a synthesis of three paradigms: • Dialectics • Behaviorism • Mindfulness • Purpose: • Reducing dysfunctional behaviors • Increasing skillful behaviors • Building a life worth living • Client needs validating environment in which they are taught to regulate emotions, deal with interpersonal conflicts, tolerate distress, and find balance.

5. Synthesis of Opposites ChangeAcceptance Change: The client is aware that they have behaviors, emotions and desires that they want to change. Acceptance: The client must also work hard to accept those same behaviors, emotions and desires just as they currently exist.

6. DBT Assumptions An assumption is a belief that cannot be proved, but we agree to abide by it anyway. 1. People are doing the best they can. All people at any given point in time are doing the best they can. 2. People want to improve. The common characteristic of all people is that they want to improve their lives and be happy. 3. People need to do better, try harder, and be more motivated to change. *The fact that people are doing the best they can, and want to do even better, does not mean that these things are enough to solve the problem. 4. People may not have caused all of our own problems, but they have to solve them anyway.** People have to change their own behavioral responses and alter their environment for their life to change. 5. New behavior has to be learned in all relevant contexts. New behavioral skills have to be practiced in the situations where the skills are needed, not just in the situation where the skills are first learned. 6. All behaviors (actions, thoughts, emotions) are caused. There is always a cause or set of causes for our actions, thoughts, and emotions, even if we do not know what the causes are. 7. Figuring out and changing the causes of behavior work better than judging and blaming. Judging and blaming are easier, but if we want to create change in the world, we have to change the chains of events that cause unwanted behaviors and events.

7. Dialectics The term Dialectics refers to opposing forces that create a whole or synthesis. DBT focuses on finding a balance in opposing forces. Dialectics reminds us that: • The universe is filled with opposing sides/opposing forces. Two things that seem like opposites can both be true. • Everything and every person is connected in some way. • Change is the only constant. • Meaning and truth evolve over time. • Each moment is new; reality itself changes with each moment. • Change is transactional. • What we do influences our environment and other people in it. • The environment and other people influence us.

8. Biosocial Theory Emotional vulnerability is biological: It’s simply how some people are born. • They are more sensitive to emotional stimuli; they can detect subtle emotional information in the environment that others don’t even notice. • They experience emotions much more often than others. • Their emotions seem to hit for no reason, from out of the blue. • They have more intense emotions. • And their emotions are long-lasting.

9. Biosocial Theory Impulsivity also has a biological basis: Regulating action is harder for some than for others. • They find it very hard to restrain impulsive behaviors. • Often, without thinking, they do things that get them in trouble. • Sometimes their behavior seems to come out of nowhere. • They find it very hard to be effective. • Their moods get in the way of organizing to achieve their goals. • They cannot control behaviors linked to their moods.

10. Biosocial Theory An invalidating social environment can make it very hard to regulate emotions. An invalidating environment doesn’t seem to understand your emotions: • It tells you your emotions are invalid, weird, wrong, or bad. • It often ignores your emotional reactions and does nothing to help you. • People who invalidate are often doing the best they can. • They may not know how to validate or how important it is to validate. • There may be just a poor fit between you and your social environment.

12. Biosocial Model continued • High Sensitivity • High Reactivity • Slow Return to Baseline • Often “Transactional” with the Environment

13. Slow Return to Baseline

14. Standard v. Modified Standard/Adherent DBT • BPD Clients/Complex Dx • Weekly skills group to teach full range of DBT skills • Minimum of weekly therapy session • Phone contact after hours to assist client with using skills • Validating clients use of skills in stressful situations • Therapists consultation team. • Modified DBT • Variety of clients with somewhat less complex diagnoses • Clients struggling with impulse control, parasuicidal behaviors and/or addiction • Issue specific skills are taught in weekly group therapy • Weekly to bi-weekly individual therapy session • Validating clients use of skills in stressful situations

15. DBT Modules • Mindfulness: the practice of being fully aware and present in this one moment • Distress Tolerance: how to tolerate pain in difficult situations, not change it • Interpersonal Effectiveness: how to ask for what you want and say no while maintaining self-respect and relationships with others • Emotion Regulation: how to change emotions that you want to change

16. Mindfulness • When we practice mindfulness, our thoughts tune into what we’re sensing in the present moment rather than rehashing the past or imagining the future. • Mindfulness is a clear and careful observation of experiences or emotions in the present moment. • Mindfulness encourages an awareness of thought or emotion without judging them as good or bad • Mindfulness is effective in reducing stress and promoting peace and emotional well being

17. Mindfulness

18. Core Mindfulness Skills WHAT Skills: • Observe – observe the moment you are in. Turn your mind to WHATEVER is in this present moment. External and internal mindfulness… • Describe – describe what you are observing. Attach words to what you are experiencing… • Participate – participate in the moment. Be involved in whatever you are doing…

19. Core Mindfulness Skills HOW skills: • Non-Judgmentally – Assume non-judgmental stance and accept the moment just as it is. Notice what is helpful and harmful but try not to judge. • One-Mindfully – Be mindful of each activity, doing one thing at a time. Let go of distractions – use “Teflon mind” – letting unhelpful thoughts slide off your mental frying pan and then return to the present moment. • Effectively – Focus on what works effectivelyfor the moment. Use the principles, morals and values you know and trust. Use effective tools: journaling, prayer and social support. Consider your options – what is most effective (not perfect) for the situation.

20. Goals of Distress Tolerance • Survive Crisis Situations Without Making Them Worse • Accept Reality - Replace Suffering and Being “Stuck” with Ordinary Pain and the Possibility of Moving Forward. • Become free of having to satisfy the demands of Desires, Urges, and Intense Emotions.

21. Distress Tolerance

22. Crisis Skills • STOP • TIP • PROS & CONS • Pair Muscle Relaxation • Sensory Awareness • Other Grounding Techniques

23. STOP STOP • Stop: Freeze! Don't react. Emotions can cause us to to act without thinking.. • Take a step back: Breathe. Take a break. • Observe: what is going on, both around you and inside you. • Proceed mindfully. Think of your goals. Ask wise mind, what will make it better or worse?

24. Pros and Cons • Use to decide between two actions • Use before it becomes a crisis • Write out your plan for an expected scenario • Practice the plan and carry it with you

25. TIP Quickly changes emotional state • Temperature • Intense Exercise • Paced Breathing • Paired Muscle Relaxation

26. Distracting - ACCEPTS The first skill, distracting, helps clients change their focus from upsetting thoughts and emotions to more enjoyable or neutral activities. A – is for activities and distracting oneself with healthy, enjoyable pursuits such as hobbies, exercise, and visiting with friends. C – is for contributing and doing things to help others, through volunteering or just a thoughtful gesture. C – is for comparing oneself to those less fortunate, finding reasons to be grateful. E – is for emotion; identifying the current negative emotion and acting in an opposite manner, such as dancing or singing when one is feeling sad. P – is for pushing away, by mentally leaving the current situation and focusing on something pleasant and unconnected to the present circumstances. T – is for thoughts; diverting one’s attention from the negative feelings with unrelated and neural thoughts, such as counting items or doing a puzzle. S – is for sensations, and distracting oneself with physical sensations using multiple senses, like holding an ice cube, drinking a hot beverage, or enjoying a warm foot soak.

27. Self-Soothing Self-soothing using the five senses to nurture themselves in a variety of ways: • Vision: Look at beautiful things such as flowers, art, a landscape, or an artistic performance. • Hearing: Listen to music, lively or soft, or enjoy the sounds of nature such as birds chirping and waves crashing. Savor the voice of a relative or friend. • Smell: Use a favorite lotion or perfume, light a scented candle, notice the scents of nature, or bake an aromatic recipe. • Taste: Enjoy a hearty meal or indulge in decadent dessert. Experiment with a new flavor or texture, and focus on the food’s flavors. • Touch: Pet an animal or give someone a hug. Have a massage, rub on lotion, or snuggle up in a soft blanket.

28. Improve the Moment IMPROVE the moment using positive mental imagery to improve one’s current situation. I – is for imagery, such as visualizing a relaxing scene or a successful interaction. Imagine negative feelings melting away. M – is for creating meaning or purpose from a difficult situation or from pain, i.e., finding the silver lining. P – is for prayer—to God or a higher power—for strength and to be open in the moment. R – is for relaxation, by breathing deeply and progressively relaxing the large muscle groups. Listen to music, watch a funny television show, drink warm milk, or enjoy a neck or foot massage. O– is for one thing in the moment, meaning the individual strives to remain mindful and focus on a neutral activity in the present moment. V – is for vacation, as in taking a mental break from a challenging situation by imagining or doing something pleasant. This could also be taking a day trip, or ignoring calls and emails for a few hours. E – is for encouragement, by talking to oneself in a positive and supportive manner to help cope with a stressful situation.

29. Radical Acceptance • Acceptance of Reality as it is • Acceptance is complete and comes from deep within • Emotional/Physical Pain + Non-acceptance = SUFFERING • Let Go and Start Accepting Reality • Letting go transforms unbearable suffering into more ordinary pain, which is part of life • Turning the Mind implies that acceptance is an active choice and requires and inner commitment

30. Emotional Regulation Understand and Name your Own Emotions: Identify (observe and describe) your emotions .Know what emotions do for you. • Decrease the Frequency of Unwanted Emotions • Stop unwanted emotions from starting in the first place. • Change unwanted emotions once they start. Decrease Emotional Vulnerability • Decrease vulnerability to emotion mind. • Increase resilience, your ability to cope with difficult things and positive emotions. Decrease Emotional Suffering • Reduce suffering when painful emotions overcome you. • Manage extreme emotions so that you don’t make things worse.

32. Emotional Regulation • Observe Your Emotion – just name it. • Experience Your Emotion – as a wave coming and going. • Remember You Are Not Your Emotion – emotions only last 8-15 seconds. The more we accept what we feel and distract our thoughts to neutral or positive experiences, the less we feed the distress and suffering of our emotions. • Practice Loving Your Emotion – don’t judge it… practice accepting it.

33. Check The Facts • Purpose • Helps the client to problem solve an emotional situation • Helps to identify the problem • Defuse emotions • Technique: • Name the emotion and intensity • Identify the prompting event • Create a narrative of the situation • Identify interpretations; beliefs, thoughts etc • Is there a true threat? What is it? • What is the catastrophe if the threat is real? • Describe ways to cope if it is true • Rate the emotion: Does it fit the facts?

34. Opposite Action

35. Problem Solving • Step 1. Figure out and describe the problem situation. • Step 2. Check the facts (all the facts) to be sure you have the right problem situation! • Step 3. Identify your goal in solving the problem. • Step 4. Brainstorm lots of solutions. • Step 5. Choose a solution that fits the goal and is likely to work. • Step 6. Put the solution into action. • Step 7. Evaluate the results of using the solution. It worked? Yea!!! It didn’t work? Go back to Step 5 and choose a new solution to try.

36. Interpersonal Effectiveness • Clarifying Priorities; What is important • Objectives Effectiveness; effectively asserting your rights and wishes • Relationship Effectiveness; maintain positive relationships • Self-Respect Effectiveness; act in ways that allow you to keep your self respect

37. Interpersonal Effectiveness • Often the greatest feelings of joy, sadness, anger and excitement happen within the context of interpersonal relationships. • People with extreme anxiety often worry about their interactions • As a result they may avoid people or situations which increase their anxiety. • Preparing for these encounters is a tremendous boost in being successful in communicating effectively.

38. DEAR MAN DEAR (WHAT to say) • Describe the situation. • Express what you are feeling/experiencing. • Assert what you want or don’t want. • Reinforce how getting what you want will help you and the relationship. MAN (HOW to say it) • Mindful: Remain focused and mindful of the objective or subject at hand. Repeat your objective if the other person is going down another track. • Appear Confident: You don’t need to feel confident, but maintain good eye contact, remain calm and speak confidently. • Negotiate: Respect their “no,” but also explore if you can negotiate a third option to satisfy you both. Also consider his/her perspective. If necessary, take time to think of other options and come back together at a later date.

39. GIVE Guidelines for Relationship Effectiveness: Keeping the Relationship (GIVE ) • (Be) Gentle – Be Nice and respectful, no attacks, threats or manipulative statements, tolerate no, mind your body language • (Act) Interested – Active Listening - Listen and appear interested in the other person, Listen to the other person’s point of view. • Validate - With words and actions, show that you understand the other person’s feelings and thoughts about the situation. • (Use an) Easy manner - Use a little humor. Smile . Ease the person along. Leave your attitude at the door.

40. FAST Guidelines for Self-­Respect Effectiveness: Keeping Respect for Yourself (FAST) (Be) Fair - Be fair to yourself and to the other person. Remember to validate your own feelings and wishes, as well as the other person’s. (No) Apologies - Don’t over apologize. No apologizing for being alive or for making a request at all. No apologies for having an opinion, for disagreeing. No invalidating the valid. Stick to values Stick to values - Don’t sell out your values or integrity for reasons that aren’t very important. Be clear on what you believe is the moral or valued way of thinking and Acting. (Be) Truthful - Don’t lie. Don’t act helpless when you are not. Don’t exaggerate or make up excuses.

41. Eating Disorders Overview • Anorexia Nervosa (AN) • Bulimia Nervosa (BN) • Binge Eating Disorder (BED) • Avoidant/Restrictive Food Intake Disorder (ARFID) • Co-Occurring Disorders and Comorbidities

42. Anorexia Overview A- Persistent restriction of energy intake leading to significantly low body weight (in context of what is minimally expected for age, sex, developmental trajectory and physical health). B. An intense fear of gaining weight or becoming fat, or persistent behavior that interferes with weight gain (even though individual is atasignificantly low weight). C. Disturbance in the way one’s body weight or shape is experienced, undue influence of body shape and weight on self-evaluation, or persistent lack of recognition of the seriousness of the current low body weight.

43. Anorexia –Types Restrictive Type - During the last three months, the individual HAS NOT engaged in recurrent episodes of binge eating or purging behavior (i.e., self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Weight loss is accomplished primarily through dieting, fasting and/or excessive exercise. Binge-Eating/Purging Type: During the last three months, the individual HAS engaged in recurrent episodes of binge eating or purging behavior (i.e. self-induced vomiting or the misuse of laxatives, diuretics, or enemas). Purging type: Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise

44. Anorexia Possible Symptoms • Avoidance of food (groups) • skipping of meals • Food rituals • Calorie counting • Excessive or compulsive exercise • Mood alterations • Sleep disturbance • Social withdrawal • Body dissatisfaction • Body distortions • Body checking • Obsessive weighing • Excessive concern with body, weight or shape • Avoidance of eating in front of others • Loss of menstrual cycle (may or may not be present)

45. Anorexia Health Risks • Slow heart rate & low blood pressure • Associated risk of heart failure • Reduction of bone density (Osteoporosis) • Muscle loss and weakness • Severe dehydration • Potential kidney failure • Fainting, fatigue and overall weakness • Dry hair and skin • Hair loss • Lanugo (fine, soft hair covering body) • Constipation • Amenorrhea

46. Bulimia Overview A - Recurrent episodes of binge eating• Eating in a discrete period of time (e. g. within any two hour period), an amount of food that is substantially larger than most people would eat in a similar period of time under similar circumstances. A sense of lack of control over eating during the episode. B. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as: self-induced vomiting; misuse of laxatives, diuretics or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months. D. Self-evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of Anorexia Nervosa

47. Bulimia Possible Symptoms • Range of intensity and frequency of binge/purge episodes • Variety of binge/purge combinations within same Individual • Multiple cognitive distortions and irrational beliefs around food, weight and appearance • Body distortion • Body loathing • Hiding and sneaking of food • Discomfort and/or avoidance of eating in public • Obsessive weighing • Body checking • Frequent, compulsive exercise • Dieting and/or calorie counting • Food rituals • Rituals associated with binge eating

48. Bulimia Health Risks • Electrolyte imbalances potentially leading to arrhythmias and heart failure, even death • Inflammation and possible rupture of the esophagus from • Vomiting (Mallory-Weiss Syndrome) • Tooth decay and erosion after vomiting • Constipation from excessive use of laxatives • Overuse injuries related to excessive exercise

49. Binge Eating Overview A - Recurrent episodes of binge eating • Eating in a discrete period of time (e. g. within any two- hour period), an amount of food that is substantially larger than most people would eat in a similar period of time under similar circumstances • A sense of lack of control over eating during the episode B - The binge eating episodes are associated with three (or more) of the following: • Eating much more rapidly than normal • Eating until feeling uncomfortably full • Eating large amounts of food when not feeling physically hungry • Eating alone because embarrassed by the amount one is eating • Feeling disgusted with oneself, depressed, or guilty afterward C. Marked distress regarding binge eating is present. D. The binge eating occurs, on average, at least once a week for three months. E. The binge eating is not associated with the recurrent use of inappropriate compensatory behavior as in Bulimia Nervosa and does not occur exclusively during the course of Bulimia Nervosa or Anorexia Nervosa.

50. Binge Eating Symptoms • Symptoms very similar to Bulimia Nervosa • No compensatory behaviors • Typically occurs later in life than Anorexia Nervosa and Bulimia Nervosa • Individuals may be underweight, normal weight or overweight • No overvaluation of shape and weight