131

The Application of Dialectical Behavior Therapy

to the Treatment of Eating Disorders
L u c e n e Wisniewski, U H H S / Laurelwood Hospital a n d Counseling Center
E l i z a b e t h Kelly, Private Practice

Dialectical behavior therapy (DBT) is a treatment that was originally designed to treat patients diagnosed with borderlinepersonality
disorder (BPD). Recent empirical evidence suggests that this treatment may also have some promise for the treatment of eating dis-
order patients. We propose that appropriately trained therapists may use the standard DBT model with some adjustments for an
eating disorder diagnosis. These adjustments are both theoretical and practical and include broadening the biosocial theory, develop-
ing eating disorder-specific dialectics, highlighting eating disorder behaviors in the treatment targets, expanding the diary card, and
adding a nutrition skills module.

IALECTICALBEHAVIORTHERAPY(DBT; Linehan, 1993a)
D is a treatment that was originally developed to treat
chronically suicidal, adult patients diagnosed with bor-
derline personality disorder (BPD). DBT blends cognitive-
behavioral approaches and acceptance-based strategies
to help patients function more effectively. Linehan (2001)
developed DBT on the premise that patients used sui-
cidal and self-harm behaviors as a way to solve their prob-
lems, and that the problem most c o m m o n l y faced by
these patients is emotional dysregulation. Several research
studies have demonstrated that DBT is effective in treat-
ing w o m e n diagnosed with BPD (Linehan, Armstrong,
Suarez, Allmon, & Heard, 1991; Linehan, Heard, & Arm-
strong, 1993). Interest in DBT has grown rapidly since
the 1993 publication of Linehan's b o o k detailing the
treatment, and researchers and clinicians alike have
begun to apply DBT to other clinical populations both
with a n d without Axis II symptoms (e.g., Dimeff, Rizvi,
Brown, & Linehan, 2000; Miller, Rathus, Linehan,
Wetzler, & Leigh, 1997).
The eating disorder community has also begun to take
notice of DBT. There are several eating disorder pro-
grams in the U.S. and Europe that have begun to use DBT
in their clinical practice (e.g., M. Marcus, personal com-
munication, April 10, 2001; R. Palmer, personal commu-
nication, April 25, 2001). In addition, research on the ap-
plication of DBT to eating disorders has begun to appear
in the literature. For example, the DBT skills training
model has been adapted and applied to the treatment of
patients diagnosed with binge-eating disorder (Telch,
1997; Telch, Agras, & Linehan, 2000) and bulimia ner-
Cognitive and Behavioral Practice 10, ! 3 1 - 1 3 8 , 2003
1077-7229/03/131-13851.00/0
Copyright © 2003 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
vosa (Safer, Telch, & Agras, 2001). The results of these in-
vestigations demonstrate that 20 sessions o f DBT skills
training is effective in decreasing eating disorder symp-
tomatology in patients who binge eat. These studies pro-
vide preliminary evidence suggesting that DBT may be an
effective model for the treatment o f binge-eating dis-
order and bulimia nervosa. There are no known data,
however, on the effectiveness o f DBT for treating patients
diagnosed with anorexia nervosa.
In this article, we present a case for applying DBT to
the treatment of patients who suffer from eating dis-
orders and outline how this might be accomplished.
S t a n d a r d DBT
DBT was designed to treat adult patients with chronic
suicidality and seff-injury--a multiproblem, difficult-to-
treat population. In DBT, four basic modes o f treatment
are provided concurrently in order to meet the treatment
goals. First, a weekly skills training group provides didac-
tic material as per the Skills Training Manual for Borderline
Personality Disord~or(Linehan, 1993b). The goal of the group
is to ensure skill acquisition, strengthening, and general-
ization in order to enhance the patient's capabilities.
There are four categories of skills, each with a specific tar-
get: emotion regulation, distress tolerance, interpersonal
effectiveness, and mindfulness. In general, the emotion
regulation and interpersonal effectiveness modules are
designed to teach the skills that address change in order
to improve one's life and current situation, while core
mindfulness and distress tolerance skills focus on the ac-
ceptance of reality. Specifically, emotion regulation skills
target m o o d - d e p e n d e n t behavior as well as impulsivity.
The goal of interpersonal effectiveness is to reduce inter-
personal chaos and increase balance in one's relation-
ships. The mindfulness skills--considered the "core skills"
 132 Wisniewski & Kelly
because familiarity with these skills is a prerequisite to
many of the skills taught in the other modules--emphasize
taking control of one's attention. The distress tolerance
skills include crisis survival strategies, designed to tolerate
difficult situations without engaging in self-destructive be-
haviors, as well as acceptance strategies to reduce suffering.
The group begins with a review of the assigned homework
from the skill taught the previous week, followed by the
introduction of a new skill for which a h o m e w o r k assign-
m e n t is given. Second, patients attend weekly individual
therapy sessions. The focus of these sessions is to address
and improve motivation and desire for change. Third,
patients receive telephone consultation as needed (the
therapist's in vivo coaching of a patient to use skills in
daily living helps with generalizing skills). Finally, a weekly
consultation team is held for all of the professionals work-
ing together within the DBT framework. The rationale
for the consultation team is to enhance the therapist's
motivation as well as her ability to provide quality care to
these often challenging patients.
These treatment components are considered the gold
standard in DBT; however, it is important to note that re-
search has yet to be conducted to determine which com-
ponents are necessary a n d / o r sufficient to produce change
in these patients.
Why Apply DBT to Patients
With Eating Disorders?
The treatments for eating disorders that have received
the greatest degree of empirical support are cognitive be-
havioral therapy (CBT) and interpersonal psychotherapy
(IPT). However, it is well known that these treatments are
not successful with all patients (Wilfley & Cohen, 1997).
DBT is considered an e n h a n c e d cognitive-behavioral
treatment that includes a focus on addressing and improv-
ing relationship deficits. This foundation, as well as the
treatment structure and additional emphasis on acceptance
strategies, may make DBT a viable, effective treatment ap-
proach for patients suffering from eating disorders.
Patients with eating disorders often have difficulty reg-
ulating emotions, and eating pathology (i.e., binge eat-
ing, vomiting, restricting) may be viewed as a way to cope
with that emotional vulnerability (e.g., Stice, Nemeroff, &
< Shaw, 1996; Telch et al., 2000). From a DBT perspective,
it could be said that eating disorder behaviors assist pa-
?: tients in "solving their problems," as these individuals
lack skills to solve these problems otherwise. It has been
,i
suggested that DBT's focus on emotion regulation may be
particularly helpful to eating disorder patients in that nei-
ther CBT nor IPT have specific components that address
emotion regulation (Telch, 1997). We propose that DBT's
focus on helping patients more effectively regulate emo-
:i tions makes it particularly useful to eating disorder patients.
:')I
A n o t h e r reason that DBT may be a useful intervention
for eating disorder patients is that DBT was designed for
patients with multiple problems. Patients who suffer from
eating disorders often present with high rates of both
Axis I and Axis II comorbidiv/(Braun, Sunday, & Halmi,
1994; Herzog, Keller, Sacks, Yeh, & Lavori, 1992), and the
eating disorders themselves usually have a significant ef-
fect on interpersonal and vocational functioning. This is
especially true for patients who have suffered with the dis-
order over many years. Furthermore, personality disorder
symptoms have been shown to predict poor treatment out-
come for some eating disorder patients (Rossiter, Agras,
Telch, & Schneider, 1993).
DBT's inherent structure also provides a g o o d model
for treating patients diagnosed with an eating disorder.
For example, skills coaching via telephone helps patients
avoid engaging in problematic behaviors such as binge
eating, purging, or restricting. In addition, weekly consul-
ration team meetings help to keep therapists motivated
and provide valuable input and feedback a r o u n d treat-
m e n t approach. Because therapists of eating disorder pa-
tients can experience isolation, frustration, a n d / o r burn-
out as a result of the difficulty and tenacity of the eating
disorder, the weekly team m e e t i n g - - a s well as the multi-
disciplinary treatment team a p p r o a c h - - r e c o m m e n d e d
in DBT is considered to be the treatment of choice for
eating disorder patients. DBT also provides a clear behav-
ioral hierarchy that may guide clinicians in targeting in-
terventions. Finally, the emphasis on balancing change
procedures with acceptance of the patient and her behav-
iors in the m o m e n t may be effective in maintaining ther-
apeutic alliance and progress in treatment with this chal-
lenging population.
Theoretical/Conceptual Adaptations
of DBT for Eating Disorders
We propose some theoretical adaptations to the stan-
dard DBT model in order for the treatment of eating dis-
order patients to occur smoothly. Specifically, it may be
useful to b r o a d e n the standard bio-social theory to in-
elude eating disorders and to develop dialectic tensions
that are faced by eating disorder patients.
The Biosocial T h e o r y
Linehan developed the biosocial theory to help ex-
plain why a particular individual might develop BPD.
This theory states that the primary deficit evidenced in
patients diagnosed with BPD is emotion dysregutation.
According to the theory, the borderline client has a bio-
logical temperament that results in an increased sensitiv-
iv/to emotional stimuli, an intensity in the emotional re-
sponse itself, as well as a slow return to emotional
baseline (Linehan, 1993a). It is believed that this vulner-
 DBT and Eating Disorders
ability interacts with an invalidating e n v i r o n m e n t to re-
sult in the d e v e l o p m e n t o f BPD. T h e invalidating envi-
r o n m e n t is generally characterized by a chronic a n d
pervasive c o m m u n i c a t i o n to the individual t h a t h e r re-
sponses a n d reactions are n o t a p p r o p r i a t e a n d do n o t
m a k e sense (i.e., are invalid).
We suggest that the biosocial theory can aid o u r un-
d e r s t a n d i n g of how s o m e individuals develop an eating
disorder. If we e x p a n d the biosocial theory to include eat-
ing d i s o r d e r patients, t h e n it c o u l d be stated that an eat-
ing d i s o r d e r develops because o f the transaction between
a person's biological vulnerability (emotional, nutritional,
o r both) a n d the invalidating e n v i r o n m e n t . However, in
o r d e r to fully e n c o m p a s s issues u n i q u e to eating d i s o r d e r
patients, we p r o p o s e that the c u r r e n t biosocial theory
would n e e d to include a nutrition vulnerability a n d a
b r o a d e n e d view o f the invalidating e n v i r o n m e n t .
Emotion and nutrition vulnerability. Consistent with the
biosocial theory o f BPD, m a n y patients with eating dis-
orders also r e p o r t suffering f r o m an inability to regulate
e m o t i o n s effectively. These deficits in e m o t i o n m o d u l a -
tion are wide in scope a n d may vary significantly by diag-
nosis. F o r a n o r e x i a nervosa patients, the p r o b l e m with
e m o t i o n s may manifest itself as difficulty with identifica-
tion a n d awareness o f e m o t i o n , e x t r e m e avoidance o f
e m o t i o n s , a n d i n h i b i t e d e m o t i o n a l e x p r e s s i o n (i.e.,
over c o n t r o l o f e m o t i o n ; e.g., Casper, H e d e c k e r , & Mc-
Clough, 1992). O n the o t h e r h a n d , patients d i a g n o s e d
with b u l i m i a nervosa a n d b i n g e - e a t i n g d i s o r d e r may
struggle with e m o t i o n intensity a n d dyscontrol (e.g.,
Telch & Agras, 1996).
In a d d i t i o n to e m o t i o n vulnerability, eating d i s o r d e r
patients may also suffer from nutrition-related vulnerabil-
ity. For example, there is some evidence o f a biological
d i s r u p t i o n in the body's ability to a p p r o p r i a t e l y signal
h u n g e r a n d satiety (e.g., Wisniewski, Epstein, Marcus, &
Kaye, 1997). In addition, overeating as well as u n d e r e a t -
ing can exacerbate a patient's vulnerability to e m o t i o n
dysregulation. Moreover, if a p a t i e n t does n o t experi-
e n c e p r o b l e m s with satiety r e g u l a t i o n b e f o r e the o n s e t
o f h e r disorder, the effects o f severe restriction, b i n g e
eating, o r p u r g i n g often m a k e d e t e c t i o n o f h u n g e r or
fullness problematic.
Taken together, o u r a d a p t a t i o n of the biosocial theory
for eating disorders t h e r e f o r e poses that persons who de-
velop eating disorders may have some biological vulnera-
bility in regulating e m o t i o n s or in the h u n g e r / s a t i e t y sys-
tem (i.e., n u t r i t i o n vulnerability) or both. We p r o p o s e
that if this biological vulnerability interacts with a certain
type of e n v i r o n m e n t (i.e., invalidating), the patient may
develop an eating disorder.
Invalidating environment. S t a n d a r d DBT hypothesizes
that an invalidating e n v i r o n m e n t is o n e that fails to com-
m u n i c a t e to the individual that h e r responses a n d reac-
133
tions make sense o r have validity. This invalidation can
occur across a s p e c t r u m from severe physical o r sexual
abuse to a p o o r fit between the t e m p e r a m e n t o f the indi-
vidual a n d h e r environment (e.g., extreme t e m p e r a m e n t a l
differences between the patient a n d h e r environments).
F u r t h e r m o r e , this theory assumes that the e n v i r o n m e n t
does n o t teach the individual the necessary skills to regu-
late h e r emotions. T h e result is an individual who is unable
to pay attention to a n d trust h e r own responses a n d reac-
tions b u t instead learns to rely on the e n v i r o n m e n t for
cues b o t h a b o u t what to feel a n d what is accurate or true.
With respect to patients who suffer f r o m eating disor-
ders, attempts to c o n t r o l weight in response to stress, dif-
ficult emotions, o r invalidation from the e n v i r o n m e n t
may seem to be a "valid" solution in this culture that typi-
cally rewards weight loss a n d ( a p p a r e n t ) self-control. T h e
emotionally vulnerable individual may t u r n to dieting to
initially feel b e t t e r a n d to feel "in control." T h o u g h diet-
ing generally leads to low m o o d - - a n d , if excessive, lack
o f c o n t r o l - - d i e t i n g behaviors have the potential to pro-
vide short-term relief a n d r e i n f o r c e m e n t from others.
Nutritional deficits can t h e n f u r t h e r complicate the pic-
ture. T h e eating d i s o r d e r is the p r o b l e m b u t also be-
comes the solution for the p a t i e n t who t h e n engages in
eating d i s o r d e r e d behaviors to cope with biological deft-
tits a n d to m a n a g e the invalidating environment.
Patients who suffer from eating disorders may experi-
ence o t h e r levels o f invalidation in a d d i t i o n to the ones
described above. First, we live in a culture that invalidates
a healthy, accepting stance toward o n e ' s b o d y a n d ap-
pearance. Research has shown that very few A m e r i c a n
w o m e n are as thin as the average fashion m o d e l a n d that
as the A m e r i c a n p o p u l a t i o n gets fatter, Playboy center-
folds a n d Miss A m e r i c a contestants b e c o m e t h i n n e r (Gar-
ner, Garfinkel, Schwartz, & T h o m p s o n , 1980). O u r cul-
ture is t h e r e f o r e clearly invalidating as its standards o f
beauty are n o t obtainable for the majority o f women. We
also live in a culture that tends to equate physical appear-
ance with self-worth, especially for w o m e n a n d increas-
ingly for men. A t t e m p t s to control eating a n d weight may
function to provide some patients with an identity o r
sense o f a c c o m p l i s h m e n t . Second, patients are often in-
validated with respect to their eating disorder s y m p t o m s - -
challenged, for example, with statements such as, "What
d o you m e a n you c a n ' t eat it, it's only a piece o f bread?"
o r "Why c a n ' t you j u s t stop eating" or "Don't you see how
you are h u r t i n g yourself by purging?" Finally, for some
eating d i s o r d e r patients, the invalidation may also occur
when the e n v i r o n m e n t makes excessive attempts to re-
move stress (i.e., overprotection). T h e i n a d v e r t e n t mes-
sage b e c o m e s that the individual c a n n o t adequately han-
dle life's problems. These o t h e r examples o f invalidation
m a y be m o r e subtle, b u t can l e n d s u b s t a n t i a l l y to a
patient's sense of alienation.
134 Wisniewski & Kelly
Dialectics
Dialectics inform b o t h the theory as well as many treat-
m e n t strategies used in DBT (Linehan, 1993a, 1993b).
Dialectics stress the i n t e r c o n n e c t e d n e s s o f reality, the
truth as constantly evolving, a n d the tension a n d resolu-
tion o f opposites to p r o d u c e change. T h e p r i m a r y dialec-
tic, or tension, in DBT is between acceptance a n d change.
DBT emphasizes finding a balance a n d searching for
what is missing when l o o k i n g for a solution. It challenges
the therapist a n d p a t i e n t to entertain m a n y possible ver-
sions o f reality a n d to assume a n d search for some truth
in all o f them. T h e therapist n o t only uses a dialectical ap-
p r o a c h in h e r stance toward the p a t i e n t in o r d e r to main-
tain a collaborative relationship, b u t also attempts to
teach a n d m o d e l dialectical t h i n k i n g a n d behavior in
every interaction with the patient.
L i n e h a n (1993a) has described the following behav-
ioral p a t t e r n s as b e i n g in f r e q u e n t tension for patients
with BPD: e m o t i o n dysregulation vs. self-invalidation, in-
hibited grieving vs. u n r e l e n t i n g crisis, a n d a p p a r e n t com-
petence vs. active passivity. The resolution o f these tensions
is consistently addressed b o t h in t r e a t m e n t in general a n d
in the m o m e n t - t o - m o m e n t interactions with the patient.
We p r o p o s e that for eating d i s o r d e r patients, the pri-
m a r y dialectical d i l e m m a may be c o n c e p t u a l i z e d as over-
c o n t r o l l e d e a t i n g vs. absence o f an eating plan. Patients
with eating disorders may swing from o n e e x t r e m e o f the
d i a l e c t i c - - o b s e s s i n g over every detail o f f o o d a n d eating
(e.g., when, what, how m u c h ) , to the o t h e r extreme: a
mindless a p p r o a c h toward eating. Patients often s p e n d
an e n o r m o u s a m o u n t o f time a n d energy deciding, plan-
ning, a n d m o n i t o r i n g what they will a n d will n o t eat. This
overcontrol may be reflected in such behaviors as ex-
t r e m e food avoidance, calorie counting, excessive weigh-
ing, a n d obsessive thinking a b o u t food a n d weight. O n
the o t h e r hand, a n d n o t u n r e l a t e d , when patients are un-
able to m a i n t a i n this rigid, o v e r c o n t r o l l e d pattern, they
often move to the o t h e r side o f the dialectic. T h e m i n d -
less a p p r o a c h may manifest as binge eating o r as e x t r e m e
efforts to avoid the body's e x p e r i e n c e o f hunger.
Dialectics a n d a dialectical a p p r o a c h have m u c h to
c o n t r i b u t e to the t r e a t m e n t o f eating disorders. F i n d i n g
"the m i d d l e path" is critical to this p o p u l a t i o n , whose ex-
t r e m e a p p r o a c h to food, a n d frequently themselves, is
central to their p r o b l e m behaviors. A dialectical a p p r o a c h
to the "wisdom" o f the patient's c u r r e n t situation is also
helpful in e n c o u r a g i n g flexibility a n d r e d u c i n g frustra-
tion for the therapists treating these patients.
Dialectics can foster a m o m e n t - t o - m o m e n t explora-
tion a n d u n d e r s t a n d i n g of the complexity of the patient's
situation (e.g., wanting to give u p their eating d i s o r d e r
b u t n o t wanting "to get fat"). For m a n y patients, eating o r
n o t eating b e c o m e s a way o f e x e r t i n g control, a n d a dia-
lectical a p p r o a c h highlights the many sides o f the patient's
d i l e m m a while providing a potentially less frustrating
framework u n d e r which the therapist can work. Dialecti-
cal strategies (e.g., irreverence a n d extending) have the
potential to move t r e a t m e n t forward when c h a n g e strate-
gies have n o t b e e n effective. A d d i t i o n a l dialectical dilem-
mas will likely e m e r g e as DBT is e x p a n d e d to treat the
eating d i s o r d e r p o p u l a t i o n . Specific d i l e m m a s for the dif-
ferent subgroups o f eating disorders (i.e., a n o r e x i a ner-
vosa vs. b u l i m i a nervosa vs. binge-eating disorder) may
also be indicated.
In summary, we p r o p o s e that some theoretical a n d
c o n c e p t u a l a d a p t a t i o n s to s t a n d a r d DBT may be n e e d e d
in the process o f applying this t r e a t m e n t to patients with
eating disorders. These changes include e x t e n d i n g the
biosocial theory to include nutritional vulnerabilities as
well as a b r o a d e r view o f the invalidating e n v i r o n m e n t
a n d the d e v e l o p m e n t o f dialectic tensions specifically for
eating disorders.
Practical Adaptations to Standard
DBT to Treat Eating Disorders
We p r o p o s e that in actual practice, DBT as a p p l i e d t o
an eating d i s o r d e r p o p u l a t i o n would n o t l o o k very differ-
e n t f r o m traditional DBT. However, we outline below the
changes that would n e e d to be c o n s i d e r e d when using
DBT with a p a t i e n t who has an eating disorder.
Treatment Targets
It is i m p o r t a n t to reiterate that the p r i m a r y t r e a t m e n t
goal for a p a t i e n t with an eating d i s o r d e r who is receiving
DBT t r e a t m e n t would be to resolve the dialectical di-
l e m m a between rigid, o v e r c o n t r o l l e d eating a n d the ab-
sence o f eating structure o r plan. This would i n c l u d e
h e l p i n g the p a t i e n t to achieve a b a l a n c e d a p p r o a c h to-
ward eating a n d f o o d a n d h e l p i n g h e r to e m b r a c e a life
worth living without an eating disorder. In o r d e r to
achieve the resolution o f the dialectical dilemma, patients
will l e a r n skills that will increase behaviors consistent with
their goals a n d decrease those behaviors in o p p o s i t i o n to
their goals. In general, the behaviors that patients will at-
t e m p t to increase include following a structured meal
plan, eating a wide r a n g e o f foods, increased self-identifi-
cation of h u n g e r a n d fullness, a n d increased awareness
o f eating. Moreover, patients will a t t e m p t to develop a
b a l a n c e d a n d n o n j u d g m e n t a l a p p r o a c h toward food, eat-
ing, a n d b o d y image. Patients wilt a t t e m p t to decrease re-
strictive eating, avoidance o f specific food(s), compensa-
tory behaviors, unstructured eating, obsessing a b o u t food,
as well as j u d g m e n t s a b o u t weight, shape, o r a p p e a r a n c e .
In DBT, the establishment o f t r e a t m e n t targets assists
the therapist in designating what behaviors to prioritize
in each interaction with the patient. Targeted behaviors
outline the goals for t r e a t m e n t a n d the o r d e r in which
 DBT and Eating Disorders
behaviors will b e a d d r e s s e d w h e n they occur. T h e behav-
iors to b e targeted, their priority, a n d their rationale are
m a d e clear to the p a t i e n t at the start o f treatment. More-
over, the p a t i e n t is asked to m a k e a c o m m i t m e n t to work
o n these specific goals in a p a r t i c u l a r o r d e r (e.g., life-
t h r e a t e n i n g behavior will be a d d r e s s e d p r i o r to quality-of-
life issues). This is n o t to say that a higher-level target will
b e addressed to the exclusion o f lower target behaviors,
b u t simply that the highest priority target will n o t go un-
noticed. F o r instance, if a p a t i e n t has an increase in sui-
cidal i d e a t i o n a n d severe p u r g i n g b e h a v i o r o n h e r diary
card, b o t h would likely b e addressed. This w o u l d be espe-
cially true if t h e quality-of-life i n t e r f e r i n g b e h a v i o r
( p u r g i n g ) was l i n k e d in any way to i n c r e a s e d t h o u g h t s
o f self-harm.
Before actual t r e a t m e n t can begin, however, patients
m u s t agree to c o m m i t to the t r e a t m e n t a n d its targets. It
is assumed that patients e n t e r DBT t r e a t m e n t voluntarily,
agreeing to work o n certain goals in a specific o r d e r with
their therapist (e.g., r e d u c i n g b i n g e i n g a n d p u r g i n g be-
haviors p r i o r to resolving vocational goals). It is t h e r e f o r e
i m p o r t a n t to distinguish patients who are in active treat-
m e n t f r o m those who are in a p r e t r e a t m e n t stage o f DBT
for eating disorders.
D u r i n g the p r e t r e a t m e n t stage, patients are o r i e n t e d
a n d m a k e a c o m m i t m e n t to t h e i r individual targets (e.g.,
weight gain, d e c r e a s e d p u r g i n g ) . This p r e t r e a t m e n t
phase is crucial, as a p a t i e n t may be asked for a commit-
m e n t to c h a n g i n g ego-syntonic behaviors (e.g., maintain-
ing a low weight). This is especially true for patients suf-
fering from a n o r e x i a nervosa, for w h o m c o m m i t m e n t
(which in m a n y ways is the treatment) is often difficult. It
is n o t u n c o m m o n to r e t u r n to the c o m m i t m e n t stage
m a n y times over the course o f active treatment.
O n c e a c o m m i t m e n t - t o - t r e a t m e n t goal is o b t a i n e d , ac-
tive t r e a t m e n t can begin. As in s t a n d a r d DBT, t h e r e are
t h r e e groups o f behaviors, o r targets, a d d r e s s e d in active
treatment. T h e following describes the s t a n d a r d DBT tar-
get hierarchy a n d the a p p l i c a t i o n o f behaviors o f dis-
o r d e r e d eating to these targets.
Target 1."Life-threatening behaviors (suicide, parasuicide).
Target I focuses o n those behaviors that are likely to e n d
in death. DBT is based o n the n o t i o n that (a) failure to
address these behaviors is inconsistent with the goals o f
psychotherapy a n d (b) a p e r s o n who is d e a d c a n n o t re-
ceive t r e a t m e n t (Linehan, 1993a). As in s t a n d a r d DBT,
suicidal i d e a t i o n (with p l a n a n d / o r i n t e n t ) a n d self-
injury are the first targets to address. Active eating dis-
o r d e r behaviors in this t r e a t m e n t are the p r i m a r y targets
addressed in quality-of-life i n t e r f e r i n g behaviors (Target
III). Eating d i s o r d e r behaviors may be m o v e d to Target I
w h e n they p r e s e n t an i m m i n e n t t h r e a t to the patient's
life. Moving eating d i s o r d e r behaviors to Target I ahnost
always reflects a m e d i c a l e m e r g e n c y a n d it is t h e r e f o r e
135
i m p o r t a n t to have an a g r e e d u p o n p l a n for b o t h how
medical information will b e c o m m u n i c a t e d a n d how, what,
a n d who will d e c i d e w h e n medical i n t e r v e n t i o n n e e d s to
occur. Examples o f situations that would move eating dis-
o r d e r behaviors to Target I status include, b u t are n o t lim-
ited to, evidence o f bradychardia, orthostatic b l o o d pres-
sure, electrolyte imbalances, EKG abnormalities, a n d syrup
o f ipecac use.
Target II: Therapy-interfering behaviors. T h e active atten-
tion to behaviors that interfere with t r e a t m e n t compli-
ance a n d progress is o n e o f several features o f DBT that
has the potential to c o n t r i b u t e to the t r e a t m e n t o f e a t i n g
disorders, given the longevity o f the n e e d for t r e a t m e n t
d o c u m e n t e d for this p o p u l a t i o n . Target II is b a s e d on the
assumption that a p a t i e n t has to be in t r e a t m e n t in o r d e r
to b u i l d a life worth living without an eating disorder. Ac-
tive attention is given b o t h to p a t i e n t a n d / o r therapist
behaviors, in o r o u t o f session, that interfere with the pa-
tient receiving treatment. T h e attention to Target II be-
haviors works to p r e v e n t p a t i e n t d r o p o u t as well as thera-
pist b u r n o u t . DBT emphasizes the i m p o r t a n c e o f e a c h
therapist observing his o r h e r own limits r a t h e r t h a n set-
ting arbitrary limits or b o u n d a r i e s in interactions with pa-
tients. These limits may b e different f r o m therapist to
therapist a n d may vary within an individual over time. F o r
example, therapists may differ in their limits a r o u n d rate
o f weight gain o r decision to hospitalize a p a t i e n t with sig-
nificant p u r g i n g behaviors. T h e rationale for this individ-
ualized limit setting is for the therapist to m o d e l self-care
a n d to preserve the t h e r a p e u t i c relationship. This active
attention to preserving the t h e r a p e u t i c relationship is es-
pecially critical with eating disorder patients who may n e e d
p r o l o n g e d treatment in o r d e r to recover a n d for therapists
who often feel frustrated a n d are at risk for b u r n o u t .
Therapy-interfering behaviors that can occur in the
t r e a t m e n t o f eating d i s o r d e r patients include the follow-
ing: n o t c o m p l e t i n g f o o d diary cards; an inability to focus
in session as a result of m a l n o u r i s h e d state; refusing to be
weighed; e n g a g i n g in behaviors to surreptitiously alter
weight; an absence f r o m t r e a t m e n t because o f the n e e d
for medical intervention; e n g a g i n g in p u r g i n g that inter-
feres with m e d i c a t i o n efficacy; substance abuse.
Target III: Quality-of-life interfering behaviors. Behaviors
t h a t severely interfere with the patient's c h a n c e o f having
a life worth living are a d d r e s s e d in Target III. These in-
clude most Axis I disorders. F o r eating d i s o r d e r patients
who are n o t suicidal a n d whose eating d i s o r d e r does n o t
pose an i m m i n e n t risk, the majority of the t r e a t m e n t will
occur within Targets II a n d III. In addition, behaviors
that increase the l i k e l i h o o d o f t a r g e t e d behaviors occur-
ring are addressed. For instance, if restricting increases
every t i m e a p a t i e n t b e g i n s a r e l a t i o n s h i p , this w o u l d
b e a n a l y z e d a n d a d d r e s s e d in t r e a t m e n t . T a r g e t III
t r e a t m e n t also addresses behaviors that are "apparently
136 Wisniewski & Kelly
Table !
Quality-of-Life Interfering Behaviors for Patients With Eating Disorders
Eating Disorder Behaviors Other Quality-of-Life Behaviors
Restrictive or unstructured eating Financial problem
Binge eating/purging Interpersonal isolation/difficulties
Diet pill~diuretic~laxative abuse Other Axis I, especially substance
Excessive exercising abuse
Calorie counting
Body checking
Water loading
Avoiding food-related events
Buying clothes that are too small
Planning to diet
u n i m p o r t a n t " (i.e., behaviors that seem u n i m p o r t a n t b u t
inevitably lead to eating d i s o r d e r behaviors). Examples o f
these include driving past a particular fast f o o d restau-
r a n t in which b i n g e f o o d is typically b o u g h t o r trying on
clothes that are a smaller size. Table 1 lists examples o f
Target III behaviors.
Expanded Diary Card
In s t a n d a r d DBT, diary cards are the b a c k b o n e of the
treatment. We suggest that the s t a n d a r d diary card, a
daily self-monitoring form k e p t by the patients, needs to
be a d a p t e d in o r d e r to m e e t the needs o f the eating dis-
o r d e r patient. Between each therapy session, eating dis-
o r d e r patients c o m p l e t e a diary card on which they mon-
itor intake, targeted behaviors (e.g., binge eating, purging,
laxative use, exercise), emotions, a n d the use o f skills. Pa-
tients are asked to c o m p l e t e the self-monitoring form
daily. Similar to a s t a n d a r d food diary typically used in
most CBT treatments, patients d o c u m e n t f o o d intake or
the failure to c o m p l y with their f o o d p l a n as well as track
their urges a n d active eating d i s o r d e r behaviors. Patients
are also asked to track their use o f DBT skills a n d the ef-
fectiveness o f the skills in h e l p i n g to control d i s o r d e r e d
eating behaviors. T h e diary card includes a section for
m o n i t o r i n g a range o f emotions; this section emphasizes
the core c o n n e c t i o n o f e m o t i o n s to eating behaviors a n d
targets increased mindfulness o f the e m o t i o n a l experi-
ence. T h e diary card t h e n provides the focus for the next
therapy session. Patient a n d therapist discuss the prob-
lematic behaviors that have o c c u r r e d since the last ses-
sion a c c o r d i n g to the designated targets.
We wish to u n d e r s c o r e the i m p o r t a n c e of the e x p a n d e d
diary card. Although the card can be quite lengthy, its use
is i m p o r t a n t for several reasons. First, it provides the ther-
apist a n d p a t i e n t with i m p o r t a n t information. Use o f the
diary card assists in accurate assessment a n d reinforce-
m e n t o f progress. Second, use o f the diary card p r o m o t e s
m i n d f u l eating. Cognitive avoidance o f what is eaten can
be a significant p r o b l e m for many patients with an eating
disorder. F u r t h e r m o r e , r e c o r d i n g intake can be consid-
e r e d a form o f exposure. Finally, the i n f o r m a t i o n ob-
tained via the diary card can assist the therapist in effi-
ciently setting session a n d t r e a t m e n t goals.
Additional Skills Modules
Skills training is o n e o f five c h a n g e p r o c e d u r e s used in
s t a n d a r d DBT. DBT assumes that skill deficits are a m a j o r
i n t e r f e r e n c e in the patient's ability to g e n e r a t e m o r e
adaptive solutions in their lives. We believe that these
m o d u l e s can be helpful to patients suffering from eating
disorders. We propose, however, that it may be necessary
to use an additional nutrition skills as well as an ex-
p a n d e d mindfulness m o d u l e in o r d e r to achieve the mid-
dle p a t h of b a l a n c e d eating with awareness. To adminis-
ter this information, we suggest the use o f a skills-based
g r o u p where weight o r weight loss in n u m b e r s is n o t dis-
cussed. This g r o u p should have skill acquisition as its pri-
m a r y target a n d emphasize a n o n j u d g m e n t a l a p p r o a c h in
o r d e r to increase s u p p o r t a n d skills r a t h e r than competi-
tion a m o n g patients. Empirical evidence is clearly n e e d e d
to evaluate the effectiveness o f this model. If a DBT skills
g r o u p specifically for eating d i s o r d e r patients is n o t avail-
able to a patient, a s t a n d a r d skills g r o u p (i.e., with a
varied p a t i e n t p o p u l a t i o n ) with the individual therapist
or a DBT-informed nutritionist teaching the nutrition
m o d u l e could be a reasonable s e c o n d choice.
Nutrition module. T h e nutrition m o d u l e that we pro-
pose is one that can provide basic e d u c a t i o n r e g a r d i n g
nutrition a n d can address specific myths a b o u t dieting
a n d weight control. We believe that this m o d u l e is neces-
sary even for patients for w h o m e m o t i o n regulation is a
p r i m a r y deficit. In o u r experience, patients' eating disor-
d e r behaviors c a n n o t be d i s r u p t e d without the structure
a n d skills to specifically teach b a l a n c e d eating. It is also
i m p o r t a n t to p o i n t out that many eating d i s o r d e r patients
have a p p a r e n t c o m p e t e n c e with respect to p r o p e r nutri-
tion. In o t h e r words, patients often a p p e a r as if they have
accurate i n f o r m a t i o n r e g a r d i n g the "healthiness" o f a
f o o d o r facts a r o u n d dieting, a l t h o u g h they do n o t (e.g.,
knowledge o f fat c o n t e n t in a variety o f f o o d b u t lack o f
kiaowledge about the necessity o f fat in one own's diet). It
may therefore be erroneously assumed by the therapist that
a patient has the prerequisite skills a n d is not using them.
In reality, patients may e i t h e r lack accurate i n f o r m a t i o n
o r the i n f o r m a t i o n they d o have (e.g., accurate knowl-
edge o f a food's caloric content) actually reinforces the eat-
ing disorder rather than guides effective eating behaviors.
We believe that a nutrition m o d u l e is essential to edu-
cate o r r e e d u c a t e eating d i s o r d e r patients a b o u t topics
such as p o r t i o n size, meal planning, metabolism, the
function o f a varied diet, as well as the effects o f f o o d re-
striction a n d c o m p e n s a t o r y behaviors on weight c o n t r o l
a n d m o o d . As p a r t o f the nutrition m o d u l e , a p p r o p r i a t e
 DBT and Eating Disorders
meal plans can be established. Patients are expected to
follow their meal plans daily. It can b e helpful to use be-
havior chain analyses, a step-by-step analysis of the tar-
geted behavior a n d its antecedents a n d consequences, in
o r d e r to identify the barriers to following a meal plan a n d
to be able to p i n p o i n t skills that can be used in the future
to ensure successful c o m p l e t i o n of the meal plan. The
n u t r i t i o n m o d u l e can also address myths a b o u t dieting,
advertising, a n d cultural reinforcers for dieting behaviors.
T h e skills group can be used to identify the behaviors that
lead to p r o b l e m eating as well as those that lead to bal-
a n c e d eating. T h e goal would be to increase behaviors
that lead to balanced eating a n d to avoid the "apparently
u n i m p o r t a n t behaviors" o n the path toward mindful eating.
As stated above, a nutritionist can be brought in to teach
this module b u t it is also essential that the therapist have a
solid u n d e r s t a n d i n g of basic n u t r i t i o n in o r d e r to assist
the p a t i e n t in m a k i n g behavioral changes in their eating.
Mindfulness module. T h e core mindfulness skills in
DBT are the behavioral a n d psychological adaptation of
Eastern m e d i t a t i o n techniques, specifically Zen. T h e goal
of mindfulness is to be able to have control of one's m i n d
rather t h a n have your m i n d control you. The reader is re-
ferred to tile skills training m a n u a l for detailed informa-
tion a b o u t these particular skills (Linehan, 1993b).
T h e use of core mindfulness skills a n d principles may
be a valuable c o n t r i b u t i o n to the t r e a t m e n t of this popu-
lation. Eating disorder patients generally report that they
have great difficulty a t t e n d i n g to eating a n d their own
body without j u d g m e n t . Eating disorder patients may
often mistakenly identify h u n g e r signals with e m o t i o n
cues. Increased attention to one's experience in a n o n -
j u d g m e n t a l way can give patients m o r e accurate informa-
tion so that they are t h e n able to access other DBT strate-
gies as a way of s o M n g their problems. Practicing b e i n g
in the m o m e n t with one's experience promotes a stance
toward eating that competes with using eating to solve
problems, Mindfulness practices that encourage an ac-
cepting stance toward one's body a n d a n appreciation of all
of the functions of the body are also a potentially effective
intervention in the treatment of this population. Mindful~
ness can be used in an individual or skills training session to
increase awareness, increase control of attention, a n d re-
duce the extreme j u d g m e n t a l stance so c o m m o n in our pa-
tients. Mindful attention to the task of eating and to the
body also acts as exposure for eating disorder patients, who
ordinarily take great lengths to avoid these experiences.
Summary and C o n c l u s i o n s
DBT is a t r e a t m e n t that was originally designed to help
chronically suicidal adult patients diagnosed with BPD.
Recently, researchers a n d clinicians alike have b e g u n to
consider whether DBT will be helpful in the t r e a t m e n t of
137
eating disorders. Preliminary empirical evidence suggests
that DBT is a n effective t r e a t m e n t for patients diagnosed
with binge-eating disorder or b u l i m i a nervosa. Additional
research is n e e d e d to replicate these studies a n d to evalu-
ate whether DBT is helpful to patients diagnosed with
anorexia nervosa as well.
We have o u t l i n e d how a therapist with the requisite
t r a i n i n g can apply DBT to eating disorder patients with
only some small adaptations to the standard DBT model.
However, as Robins (2000) has also noted, we are mind-
ful there is limited empirical support of the use of stan-
dard DBT with borderline patients, a n d the move to adapt
the t r e a t m e n t may be premature. We therefore h o p e that
this article will move others to consider using DBT with
eating disorder patients a n d to empirically evaluate its
effectiveness with this population.
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Address correspondence to Lucene Wisniewski, Ph.D., UHHS/
Laurelwood Hospital, 35900 Euclid Avenue, Suite 1700; Willoughby,
OH 44094; e-mail: Lucene.Wisniewski@uhhs.com.
Received:January 2002
Accepted: August 1, 2002

• • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Food Refusal by Infants and Young Children:

Diagnosis and Treatment
I r e n e C h a t o o r , Children's National Medical Center, Washington, DC, a n d The George Washington University
J o d y G a n i b a n , The George Washington University

Parents report that 25 % of toddlers exhibit food refusal. A subgroup of these children demonstrate such severefood refusal that their
nutritional status is compromised, leading to the diagnosis of a feeding disorder. Although food refusal is common, and can pose a
significant health risk for some children, few researchers and clinicians have described the different farms food refusal may take, or
have relatedfood refusal subtype to feeding disorders subtypes. Such critical issues must be addressed and discussed because different
types offood refusal and feeding disorders may necessitate different treatment approaches. This review proposes that food refusal can
be expressed in qualitatively different ways, including (a) unpredictable food refusal; (b) selectivefood refusal; and (c) fear-based
food refusal. Furthermore, it is proposed that each farm offood refusal gives rise to a qualitatively different feeding disorder: Unpre-
dictable food refusal is associated with infantile anorexia; selectivefood refusal is related to sensory food aversions; and fear-based
food refusal is central to a posttraumatic feeding disorder. Implications for the treatment of each type offeeding disorder are discussed.

T IS ESTIMATED THAT 25% o f otherwise n o r m a l l y devel- children c o n t i n u e d to exhibit serious eating p r o b l e m s at

I o p i n g infants a n d u p to 80% o f those with develop-
mental handicaps have feeding problems (Chatoor, Ham-
burger, Fullard, & Rivera, 1994; Lindberg, Bohlin, &
Hagekull, 1991; Reilly, Skuse, Wolke, & Stevenson, 1999).
Additional studies indicate that early feeding problems are
associated with behavioral problems, anxiety disorders, a n d
eating disorders during later c h i l d h o o d a n d adolescence
(Marchi & Cohen, 1990; Timimi, Douglas, & Tsiftsopoulou,
1997). Accordingly, f e e d i n g p r o b l e m s are c o m m o n a n d
m a y f o r e s h a d o w l o n g - t e r m e a t i n g a n d behavioral p r o b -
lems. Food refusal is a key symptom o f several feeding dis-
orders. Dahl a n d S u n d e l i n (1986) r e p o r t e d that 1% to
2% o f infants u n d e r 1 year o f age d e m o n s t r a t e d severe
food refusal a n d p o o r growth. Seventy p e r c e n t o f these
Cognitive and Behavioral Practice 10, 138-146,
1077-7229/03/138-14651.00/0
Copyright © 2003 by Association for Advancement of Behavior
Therapy. All rights of reproduction in any form reserved.
4 a n d 6 years o f age (Dahl, Rydell, & Sundelin, 1994;
Dahl & Sundelin, 1992).
In spite o f the serious implications o f early f e e d i n g dif-
ficulties, research a n d clinical practice have b e e n ham-
p e r e d by an inconsistent n o m e n c l a t u r e a n d by diagnostic
criteria that do n o t adequately describe the range o f feed-
ing p r o b l e m s that exist. F o r example, in 1994, the Amer-
ican Psychiatric Association (APA) a d d e d "Feeding Disor-
d e r o f Infancy a n d Early C h i l d h o o d " to the Diagnostic and
Statistical Manual of Mental Disorders (DSM-IK,', APA, 1994).
F e e d i n g disorders were d e l i n e a t e d by the following crite-
ria: (a) persistent failure to eat adequately with signifi-
cant failure to gain weight o r significant loss o f weight
over at least 1 m o n t h ; (b) the disturbance is n o t due to an
associated gastrointestinal o r o t h e r medical condition;
(c) the disturbance is n o t a c c o u n t e d for by a n o t h e r men-
tal d i s o r d e r o r by lack o f available food; a n d (d) the onset
2003
is b e f o r e the age of 6 years. However, these diagnostic
criteria exclude whole groups o f c h i l d r e n who p r e s e n t
with p r o b l e m a t i c f e e d i n g behaviors a n d show a d e q u a t e