USING DIALECTICAL BEHAVIOR THERAPY TO TREAT A VARIETY OF DISORDERS DeLinda Spain, LCSW, CGP, CEDS Austin, Texas LEARNING OBJECTIVES Diagnostic criteria for Eating Disorders Diagnosis History of Dialectical Behavior Therapy Marsha Linehan s Bio-Social Model Understanding the term Process Addiction. How to use DBT to treat Eating Disorders and other types of Process Addictions 1
ANOREXIA NERVOSA DSM IV Criteria: Refusal to maintain body weight at or above minimally normal weight for age and height (weight being 85% of what would normally be expected Intense fear of gaining weight or becoming fat, even though underweight Disturbance in the way in which one s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, denial of the seriousness of the current low body weight. In post-menarcheal females, amenorrhea. Subtypes: Restricting Type and Binge-Eating/Purging Type DSM V: CHANGES TO DIAGNOSIS Removal of refuses to maintain body weight at or above a minimally normal weight for age and height Removal of intense fear of gaining weight or becoming, adding in or persistent behaviors that prevent weight gain, even though at a significantly low weight. Change from or denial of recognition of the seriousness of the current low body weight to..or persistent lack of recognition of the seriousness of the current low body weight. 2
SUB-CLINICAL Restrictive Meal Plans Vegetarian Vegan Ortho-rexia Diet Fads: paleo, blood type, juicing and fasting BULIMIA NERVOSA DSM IV Criteria: Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a discrete period of time (e.g., within any 2- hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. 3
BULIMIA NERVOSA DSM IV Criteria: The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months. Self-evaluation is unduly influenced by body shape and weight. The disturbance does not occur exclusively during episodes of Anorexia Nervosa. Specify type: Purging Type: during the current episode of Bulimia Nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas Non-purging Type: during the current episode of Bulimia Nervosa, the person has used other inappropriate compensatory behaviors, such as fasting or excessive exercise, but has not regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas DSM V: CHANGES TO DIAGNOSIS The word purge has been removed and replaced with inappropriate compensatory behaviors Reduction of frequency of binge/compensate behaviors to once a week for a duration of three months This is important for people who were not receiving this diagnosis because they not using behaviors enough, BN is one of the nine parity diagnosis Removal of the criterion for purging and nonpurging 4
SUB-CLINICAL Cyclic Behaviors Episodes of dieting & healthy lifestyle Chronic Dieting Jumping from one restrictive meal plan to another Focus on fad dieting, use of diet aids (over the counter medications) Exercise Episodes of intense exercise that can not be maintained SUB-CLINICAL Purging Vomiting Laxatives & diuretics Exercise 5
BINGE EATING DISORDER DSM V Criteria: The Eater Must experience at least three of the listed states Eating much more rapidly than normal Eating until feeling uncomfortably full Eating large amounts of food when not feeling physically hungry Eating alone because of being embarrassed by how much one is eating Feeling disgusted with oneself, depressed, or very guilty after overeating. The Eater must be very distressed about his or her binge eating, binges must take place at least twice a week for at least six months, and there must be no inappropriate compensatory behaviors following a binge BINGE EATING DISORDER DSM V Criteria: Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: Eating, in a discrete period of time (e.g., within any 2- hour period), an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating) 6
DIALECTICAL BEHAVIOR THERAPY Developed by Marsha Linehan in 1980. Originally designed to treat folks with: chronic suicidal behaviors Difficulties regulating emotions Impulsive behavior CBT didn t seem to be working as well with these particular clients. Primary difference between CBT and DBT is the addition of mindfulness and acceptance techniques. Introduction of the Bio-social Theory BIO-SOCIAL THEORY The Bio part Higher sensativity to emotions, both in themselves and with others Have higher re-activity Stay activated longer Return to their baseline much more slowly Have difficulty regulating themselves and calming themselves down Para-sympathetic system gets activated (body feelers) 7
BIO-SOCIAL THEORY The Social Part Invalidating environment Not necessarily abusive or neglectful Little social support Wears friends out Trauma Medical School Society PROCESS ADDICTIONS These are usually behaviors that occur in a ritualistic form that helps soothe The rewards centers of the brain are not necessarily activated There is positive and negative reward (validation) 8
DBT Three parts to DBT Treatment Weekly 2 hour skills group Weekly individual sessions Consultation meetings Four sets of skills to be learned 2 or acceptance focused and 2 are change focused An Individual can not fail at DBT but DBT can fail an individual All skills are based in how and what framework SKILLS Mindfulness Interpersonal Effectiveness Skills Emotion Regulation Skills Distress Tolerance Skills 9
MINDFULLNESS INTERPERSONAL EFFECTIVENESS Objectives Effectiveness: Getting your Objectives or Goals in a situation Obtaining your legitimate rights. Getting another to do something. Refusing an unwanted or unreasonable request. Resolving an interpersonal conflict. Getting your opinion or point of view taken seriously. Relationship Effectiveness: Getting or keeping a good relationship Acting in such a way that the other person keeps liking and respecting you. Balancing immediate goals with the good of the longterm relationship. 10
INTERPERSONAL EFFECTIVENESS Self-Respect Effectiveness: Keeping or Improving Self-Respect and Liking for yourself Respecting your own values and beliefs; acting in a way that makes you feel moral. Acting in a way that makes you feel capable and effective. EMOTION REGULATION Understand Emotions You Experience Identify (observe and describe) emotion. Understand what emotions do for you. Reduce Emotional Vulnerability Decrease negative vulnerability (vulnerability to emotion mind) Increase positive emotions. Decrease Emotional Suffering Let go of painful emotions through mindfulness. Change painful emotional through opposite action 11
DISTRESS TOLERANCE SKILLS 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 your own desires,urges and intense emotions ASSUMPTIONS OF DBT People are doing the best they can. All people at any given point in time are doing the best they can. People want to improve. The common characteristic of all people is that they want to improve their lives and be happy. 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. 12
ASSUMPTIONS OF DBT CONTINUED 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. 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. ASSUMPTIONS OF DBT CONTINUED 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. 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. 13
BRINGING IT ALL TOGETHER This is the part where I talk a lot Process addiction and self soothing Navigating complex internal emotional worlds Relating to oneself and to others Using DBT skills to increase efficacy in life. DELINDA SPAIN 512-771-9313 delindaspain@gmail.com 14