DBT Expert Interviews: From Trauma to Eating Disorders

Practical DBT tips on substance use, trauma, chronic pain, and other conditions.

Emotional Regulation, Interpersonal Conflict, and DBT Skills for Eating Disorders

By Dr. Kirby Reutter, DBTC, LMHC, MAC & Dr. Michael Maslar.

This presentation is an excerpt from the online course DBT Expert Interviews: From Trauma to Eating Disorders“.




In this segment, Dr. Michael Maslar explores the application of distress tolerance, emotion regulation, and interpersonal effectiveness in clients with eating disorders. In particular, he explains a wide variety of DBT skills.

Michael identifies 2 important skills for the therapist: validation and radical genuineness. In discussing this kaleidoscope of skills, he highlights some of the unique challenges and nuances when applying DBT, specifically to clients with eating disorders.

Applying Distress Tolerance Skills

Kirby: How do you apply distress tolerance skills to clients with eating disorders? What particular skills work well?

Michael: It’s impossible with any certainty to tell in advance which skills will be helpful to which person, regardless of their specific diagnosis or problem behaviors. It’s always a process of learning which strategies are going to be primary and which will be called upon when the primary ones fail.

It’s important to work on crisis survival skills. The whole thrust of crisis survival skills is the idea of not making it worse.

If you’re in a crisis, for example, there’s been a problem at work and it’s after hours. You have to get yourself through that period where you are intensely worried about what’s going on at work without making the situation worse, like relapsing. That’s when the patient can use the crisis survival skills.

People sometimes put this into the mindfulness module in DBT. I tend to think of this also as a distress tolerance skill, the skill of alternate rebellion.

For example, a teenager gets upset with his parents. He’s upset with society. He wants to rebel. If he can identify that urge to rebel, the idea is finding some way of doing it that doesn’t cause him problems. For example, get a tattoo, dye your hair, put on some loud angry music, whatever it might take for you to address that urge to rebel in a way that isn’t going to become a problem for you. These are crisis survival skills, alternate rebellion.

As we get into the acceptance skills in DBT, we can conceptualize bingeing, purging, restricting, and compensatory behaviors as willfulness, so we can work with willingness. This means turning the mind and beginning to work on radical acceptance, rather than rebelling against what’s going on by bingeing or purging.

Part of radical acceptance in working with eating disorders, as well as other behaviors like substance use, is the idea of burning bridges. It is committing to close off excuses for using.

Again, this means closing off in one’s mind those bridges to using and, in a radical deep way, committing to abstinence. Burning bridges is an additional part of the acceptance skills and distress tolerance.

Self-soothing skills are very important in helping people with eating disorders, but they also have their difficulties. This is the case with any specific thing you might do as part of any of the crisis survival skills. There are certain activities as part of the acceptance skills that wouldn’t work for some people. It’s the same with self-soothing.

I might use the sense of smell or the sense of taste as a way of soothing. But when I’m practicing distress tolerance, I may need to make sure that I am careful about what smells and tastes I choose to self-soothe. There’s that caveat, in particular, about using those 2 senses in distress tolerance self-soothe skills.

Kirby: People with substance abuse issues experience intense urges and cravings. I would assume that also applies to the population with eating disorders. Are you using distress tolerance skills also to address urges and cravings at the moment either for bingeing, purging, or other behaviors?

Michael: We do. And I’ll often address that when we’re talking about mindfulness, for example. We practice mindfulness of urges, or what we call urge surfing in DBT. This means getting used to observing urges without acting on them.

You can start with doing a seated mindfulness practice. When you notice urges to shift in your chair, practice not acting on those urges. Building that awareness of urges, along with the ability to not act on urges, is important.

DBT Emotion Regulation Skills

Kirby: How do you apply DBT emotion regulation skills?

Michael: These behaviors function to regulate emotion, and learning emotion regulation skills can be a substitute for bingeing, purging, restricting, compensatory behaviors, etc.

Emotion regulation skills can help in the same way, producing the same short-term effect. The patients can feel better if they practice these skills. They wouldn’t have the longer-term consequences of feeling shame later.

These skills can serve the same function at the moment; they can work better and better over time. Using skills wouldn’t give the patient the long-term negative consequences that make their life worse.

Also, make sure that people understand that eating disordered behaviors are not opposite actions. They’re part of acting on the urge that comes up with painful emotion. That opposite action is what is required in situations like that.

Opposite Action Behavior

Kirby: Even though bingeing and purging are opposites to each other, do they both have the same opposite action behavior whether the urge is to binge or purge?

Michael: From the standpoint of doing behavioral therapy, the behaviors have different forms. A binge looks and is a very different behavior on the surface from purging. So the form is very different, but the function is the same.

“I’m really angry with my partner and I’m having urges to binge, so I binge and I regulate that anger. I don’t feel as angry because I have just binged. I’ve numbed out. Very shortly thereafter, I’m feeling full. I’m thinking about how I binged and I start to feel shame, to feel angry with myself. Then I purge and that helps with that feeling of shame that I had binged. It can help with that feeling of anger at myself for having let myself slip.”

Both of those behaviors serve to regulate emotions, even though they look very different.

Kirby: Opposite action is not necessarily acting opposite to the behavior itself at the surface level. It means going in an opposite direction in a way that meets the underlying need, but much more effectively.

Michael: Yes. This is where there is a lot of confusion with the opposite action. It’s not opposite the behavior. It’s not opposite the emotion because, fundamentally, emotions are just different experiences that we have, and they’re not opposites, per se, although we can think of them that way.

Each emotion is just simply different from other emotions. It’s understanding the urge that is connected with the emotion. When you can understand the urge that’s connected with the emotion, then you can act opposite the urge.

For example, I might have an urge to binge and I act opposite. Or I have an urge to lash out and so I act opposite that urge.

Interpersonal Effectiveness Skills

Kirby: What interpersonal effectiveness skills do you find particularly helpful for clients with eating disorders?

Michael: For many people with eating disorder problems, one of the prompting events can be an interpersonal conflict. The idea is to use interpersonal skills to address the conflict, to do problem-solving with the problem in the relationship, rather than resorting to an eating disorder behavior. The latter will just regulate the emotion, but doesn’t address the problem in the relationship. That doesn’t work well in the long run.

Addressing problems in relationships is helpful for anyone. It makes it less likely that they’re going to experience negative or painful emotions that then lead to urges to binge.

With this population, in particular, I help them to use the DEAR MAN skill to effectively say no to people who might be intentionally or unintentionally prompting binge behaviors. This means learning how to say no like you would with any addictive-looking behavior.

We also work on the skill of asking for healthy portions of food. Many people will find it difficult to assert themselves in these kinds of ways. It is important to be able to ask more effectively for what one wants so that one can get it.

It can be important with this population as well as others to find ways of expressing emotions accurately to people around them. When they can do that, they can express themselves emotionally in an effective way.

An important thing to do is the practice of DEAR MAN to ask someone to just listen and understand you. That can be important to regulate emotion as well.

Kirby: Do you find that it’s useful to teach clients interpersonal effectiveness skills to do damage control within the relationship?

Michael: Certainly. It’s relevant to be able to deal with other people in the aftermath of bingeing or purging behaviors. Quite often, these kinds of behaviors are done in private. They end up having effects on people’s relationships. Being able to identify those problems and using interpersonal skills to help address them is important.

Finding Validation

Kirby: How do you apply validation when you’re working with this population?

Michael: Looking for opportunities as often as possible to validate a person’s experiences is useful. The idea within DBT is finding the kernel of truth in a person’s thinking, their emotions, and their behaviors. For example, you had a fight with your partner, you got angry, and you had urges to binge. Having those urges to binge makes perfect sense given everything that’s happened to you.

This is, in DBT, what’s called finding validation in terms of past experiences or biological dysfunction. It is noticing with the person that it makes perfect sense that they had urges. On the other hand, be careful not to validate what is invalid. For example, “It wasn’t so great that you ended up acting on that urge to binge and you binged.”

Be willing over and over again to find the kernel of truth in a person’s behavior. For example, “It makes sense you felt angry. It makes sense given your history that you had urges. It’s not so great that you binged.” Also, have the willingness not to validate the invalid.

That’s always a difficult path for the therapist to take to be able to identify that kernel of truth without inadvertently validating the invalid. Of course, you wouldn’t say, “It makes perfect sense that you end up acting on that impulse,” stating that this is true. But that is also not valid in terms of what the client’s goals are. It ends up being a dialectic by working with what’s valid and what isn’t valid in a person’s behavior.

Invalidation and the Etiology of Eating Disorders

Kirby: Do you see invalidation as part of the etiology of eating disorders?

Michael: What we focus on, in standard DBT for borderline personality disorder, is the invalidation of one’s emotional experience: “No, you’re not feeling this. You’re feeling that.” Also, invalidation of the person’s thoughts and behaviors over and over again.

With eating disorders, there might be an invalidation of a person’s internal experience of being hungry or of being full. For example, “Oh, you didn’t. That’s all you ate. No! You should eat some more,” or, “You’re not hungry. You just want sweets. You’re not really hungry.” These are communications that can complicate things for people and that can be part of that pathway to developing eating disordered behaviors.

Part of the function in the therapy of using validation with a client is ultimately helping them learn to validate themselves. Clients with eating disorders often engage in a lot of self-invalidation, making things much more difficult for themselves. We need to help them to learn how to self-validate, and validating what is valid rather than validating what is invalid.

Kirby: Over time all of this external invalidation probably becomes internalized and it probably becomes self-invalidation. That’s how they can ignore basic cues from their bodies regarding hunger or satiation. Self-validation is extremely important in DBT because we’re never going to get all of the external validation that we need to heal. So we have to learn to become our self-validators.

Main Points

  • Since both food and substances can be used as maladaptive forms of emotion regulation, DBT skills typically used for substance abuse (such as alternate rebellion, urge surfing, and burning bridges) can also be applied to eating disordered behaviors.
  • When applying self-soothing skills to clients with eating disorders, be careful with taste and smell since these 2 senses are so closely related to eating. Both senses can still be effective forms of distress tolerance, but they can also be triggering, so clinical judgment is required.
  • When applying opposite action to clients with eating disorders, it would be easy to assume that bingeing and purging are already opposites. However, both extremes are unhealthy, non-dialectical behaviors. Even though bingeing and purging seem like opposites on the surface, they both serve the same underlying function of attempting to regulate emotions.
  • Regardless of which extreme your client is experiencing, opposite action must focus more on addressing the underlying maladaptive attempt at emotion regulation than on the actual surface behavior.
  • There is a vicious cycle between interpersonal conflict and eating disordered behavior. As with substance abuse addicts, it can be difficult for eating disordered clients to say no, be assertive, or set inappropriate boundaries. Therefore, even though interpersonal effectiveness doesn’t seem diagnostically related to eating disorders, it’s an important part of treatment.
  • There is also a vicious cycle between invalidation and eating disordered behavior. Therefore, it’s especially important for DBT therapists to provide appropriate validation, which also includes radical genuineness.

More DBT Expert Interviews: From Trauma to Eating Disorders