Dr. Leslie Karowski Anderson blasted in with a case review that I suspect every practitioner in the audience recognized:
“Isabel” is a 16 year-old high school junior born in the US to South American born parents. She plops down in the chair to let you know that she’s only here because her parents have made her come. She’s had two suicide attempts, self harms, has bulimia, and abuses marijuana. She self-harms with razors several times a week for the past 3 years, binge-drinks 2-3 times a week, eats-purges twice a week.
The question Dr. Karowski Anderson then posed to the audience is “Where do you even start?” Exactly.
She then placed that case review within the context of population-wide multi-impulsivity trends as follows:
- 40% of adolescents with eating disorders report self-harming. In particular it co-occurred with eating/purging sessions. 1
- In two population-based samples of primarily adolescents, 53% of those with BN reported suicide ideation. 26% reported a plan, 35% reported an attempt, and 17% reported multiple attempts. 2
- Among adolescents seeking treatment for BN, 66% reported alcohol use and 30% reported illegal drug use. 3
And finally Dr. Karowski Anderson outlined the treatment challenges in these cases:
- “Nothing works as well as ________________,” will be a common refrain from the patient.
- Both peer groups and the media glorify the behaviors.
- The behaviors are inadvertently reinforced (more on that later).
- The behaviors actually become a communication tool (a maladaptive one).
- All the oppositionality and rebellion that would be expected during adolescence get entrenched and funneled through the behaviors.
Historically, treatment approaches target only one type of behavior (what we call here on this site the “whack-a-mole” approach to recovery).
Family-based treatment (FBT) is predicated on the notion that parents instinctively know how to feed an unwell adolescent. But in cases like Isabel’s, guidance is needed especially for all the other concomitant behaviors. Dr. Karowski Anderson presented the FBT/DBT (dialectical behavior therapy) hybrid that has been developed to better address these kinds of cases.
I have recently posted Dialectical Behavior Therapy: Shame, Guilt and Emotional Distress on the blog and it will provide a bit more background on the ways in which the kind of emotional dysregulation for someone like Isabel can take root.
FBT is not really designed to address the kind of chaos that Isabel (and her family) is experiencing. Parents can often find the eating disorder so overwhelming that there is an adaptation that ends up embedding the behaviors within the homeostasis of the family as a whole. The FBT/DBT hybrid uses the focus on empowering the parents within the FBT model with the following facets of DBT treatment:
- Specific treatment hierarchy
- Behavioral treatment approach: contingency management
- Dialectical thinking: validating and changing
- Non-judgmental stance
- Emotional regulation theory
Biosocial theory of emotional regulation suggests that biological dysfunction within the emotional regulation system combines with an invalidating environment to generate pervasive emotional dysregulation. Again, you’ll find more detail on this theory in the Dialectical Behavior Therapy: Shame, Guilt and Emotional Distressblog post. An invalidating environment does not always suggest abuse and neglect. It can also occur when there is a poor temperamental fit within the family or a trend within the family to mislabel or deny emotions: “You’re not scared Isabel, you’re just being silly.”
Dr. Karkowski Anderson provided a list of published studies on DBT for those with eating disorders. One study followed 31 bulimic patients and after 20 weeks of DBT, compared to the control wait-listed group, had 28.6% of participants abstinent of binge/purge episodes compared to none within the wait-listed group. 4 In another study of AN and BN patients with borderline personality disorder who had previously failed to realize any improvement with CBT, 54% of those with BN and 38% of those with AN realized remission with a DBT program. 5 A case series for reviewing DBT for adolescent patients with AN or BN showed significant improvements in behavioral indices of disordered eating and general psychopathology when treated with outpatient DBT services. 6 And another small pilot study for adolescents with BN given outpatient DBT found significantly reduced non-suicidal self-injury, bingeing and purging. 7
Many of the areas that were covered off in the remainder of the presentation involve specifics of dialectical behavior therapy techniques such as diary cards, DEARMAN (Describe, Express, Assert, Reinforce, stay Mindful, Appear confident, Negotiate), PlEASE skills (treat PhysicaL illness, balance Eating, avoid mood-Altering drugs, balance Sleep, Exercise), GIVE skills (be Gentle, act Interested, Validate, use an Easy manner)— you may recall I mentioned in earlier installments in this series that acronym usage is a competitive sport in this field, so there you have it.
A really good resource for understanding these tools in more depth can be found at DBTSelfHelp. com. The skills taught and tools provided replace problem, or maladaptive, behavior with skillful behavior. Identity confusion, difficulty identifying and naming emotions and cognitive dysregulation get replaced with mindfulness skills. Interpersonal skills begin to override interpersonal chaos and invalidation. Excessive anger and labile affect (mood instability) become regulated. And the eating disorder behaviors, suicide threats, and other impulsive behaviors are overcome with distress tolerance skills.
Dr. Karkowski Anderson just touched on these DBT skills and frameworks as most in the audience were if not DBT practitioners, then certainly very familiar with the treatment modality. Therefore the focus naturally turned to what is most important within the FBT/DBT hybrid: how the parents fit in.
The specific treatment hierarchy means that the most dangerous behaviors are addressed first—a triage of emotional dysregulation behaviors basically. Within the FBT/DBT hybrid, the contract that is usually signed between the DBT therapist and her patient incorporates the parents into the contract.
Parents receive training so that they can support the DBT process for their adolescent child. Removing the means to apply dangerous behaviors (money, substances, self-harm implements) takes precedence. There is specific guidance for both parents and teachers as to what they should do when the teen has a behavior that is a problem. The focus is to reinforce skillful behavior and ignore or consequence anything other than skillful behavior.
Alongside orienting the parents, the teen is taught to be assertive and to advocate for herself as well.
Parents are taught to be attentive but not over-reactive. Validating emotions (not behaviors) and avoiding criticism while making sure that there is no inadvertent reinforcement for damaging behaviors is a critical facet of their role. Rewards need to be tangible and set at a high baseline with both physical and verbal reinforcement (lots of hugs). Attention is a very reinforcing response and many parents get caught in attending to to the teen when she is acting out and this only serves to reinforce the behavior.
If the only time that the parents seem to focus on the teen is in the aftermath of a suicide attempt, then that reinforces all the wrong things. Additionally, Dr. Karkowski Anderson pointed out that Facebook and other online connections with friends can easily reinforce suicidality and self-harm. The teen posts a cryptic update on FB eg. “I’m so done with all of this,” and that post triggers numerous responses asking whether she is ok and what’s going on. Limiting internet usage is often an important part of helping the teen create a positive behavior spiral.
Consequences have to be pre-arranged, planned and assigned. Punishments cannot end up being punishments for the parents as well: as an example, the entire family doesn’t get the opportunity to go on holiday because the teen has failed to follow her contract.
There are apps now to disable the teen’s phone and that tends to be a successful consequence for most teens. The contract will have an overarching goal with 2-3 specific target behaviors and the teen provides feedback on actual motivators. The target behaviors have concrete rules attached with short-, medium, and long-term rewards and consequences.
The therapy process is a team effort where there is on-call support at all times and phone coaching is always available.
The foundational dialectical strategy is embracing the paradox of “both/and”. It is the acceptance of it being hard while also committing to keep changing and improving in the same moment, that is the dialectic paradox. Black and white thinking and failure loom large for those in recovery and a slip cascade towards “Why bother?” self-sabotage spiral. Dialectical strategy halts that self-sabotage spiral in the face of a slip or mistake.
Metaphors and stories feature prominently in DBT. When you remove the dysregulation from those with emotional sensitivity, you reveal the underlying creative, lateral-thinking folk who inspire the rest of us with their depth and purpose. It is likely that metaphors and stories help them connect to that underlying truth.
Here is a wonderful metaphor provided by Dr. Christine Dunkley, a consultant psychological therapist and senior DBT trainer in the UK:
Take a tall glass vase and fill it two thirds with water. Now gently lower some intact eggs into the water, being careful not to break the shells. The level of the water will rise. There is no additional water in the vase, but it seems like more.
When we have a painful event our pain equates to the water in the vase. When we use radical acceptance, we accept the amount of water but we can remove the other things—the fighting of reality, the rumination on past pain, the prediction of future pain.
These are the eggs.
When we take those out, the level of the water goes down—even though the amount hasn't changed.
Recommended reading from Dr. Karkowski Anderson:
1. R Peebles, Rebecka, JL Wilson, JD Lock, Self-injury in adolescents with eating disorders: Correlates and provider bias, Journal of Adolescent Health, Vol48(3), pp.310-313, 2011.
2. SJ Crow, SA Swanson, D le Grange, EH Feig, KR Merikangas, Suicidal Behavior in Adolescents and Adults with Bulimia Nervosa, Comprehensive Psychiatry, Vol55(7), pp.1534-1539, 2014.
3. S Fischer, D le Grange, Comorbidity and high‐risk behaviors in treatment‐seeking adolescents with bulimia nervosa, International Journal of Eating Disorders, Vol40(8), pp.751-753, 2007.
4. DL Safer, CF. Telch, WS Agras, Dialectical behavior therapy for bulimia nervosa, American Journal of Psychiatry, Vol158(4), pp.632-634, 2001
5. C Kröger, U Schweiger, VSipos, Sören Kliem, R Arnold, T Schunert, H Reinecker, Dialectical behaviour therapy and an added cognitive behavioural treatment module for eating disorders in women with borderline personality disorder and anorexia nervosa or bulimia nervosa who failed to respond to previous treatments. An open trial with a 15-month follow-up, Journal of behavior therapy and experimental psychiatry, Vol41(4), pp.381-388, 2010.
6. H Salbach-Andrae, I Bohnekamp, E Pfeiffer, U Lehmkuhl, AL Miller, Dialectical behavior therapy of anorexia and bulimia nervosa among adolescents: A case series, Cognitive and behavioral practice, Vol15(4), pp.415-425, 2008.
7. S Fischer, C Peterson, Dialectical behavior therapy for adolescent binge eating, purging, suicidal behavior, and non-suicidal self-injury: A pilot study, 2014.