DBT and Radically Open DBT for Eating Disorder Dietitians
By Stefanie Boone, MS, RD, CEDRD
While eating disorder dietitians (EDRDs) are responsible for clients’ nutritional healing, they must also be highly competent in counseling to be able to navigate the strong emotions, negative or inappropriate affect, and relational issues that present in nutrition sessions. Because an eating disorder (ED) is a psychiatric diagnosis, registered dietitian nutritionists (RDNs) should be psychologically informed. ED clients often have co-occurring psychiatric diagnoses, as well as trauma, and attachment issues, and as a result, can exhibit certain maladaptive patterns in the way they think, feel, and behave. Though these psychological issues are primarily addressed in psychotherapy, they often play out in nutrition therapy as well.
In 2011, the American Dietetic Association published “Standards of Practice and Standards of Professional Performance for Registered Dietitians in Disordered Eating and Eating Disorders”, which highlights the nutritional, medical, and counseling-related competencies required to be an expert EDRD. These competencies include “using higher level advanced therapeutic modalities to promote behavior change….”, and “using expert level counseling skills to guide decision-making in complicated, unpredictable, and dynamic situations.” To achieve these expert competencies, EDRDs often acquire specialized training in various psychotherapeutic modalities in order to elevate their counseling skills.
I have long found Dialectical Behavioral Therapy (DBT) to be of great value in nutrition therapy for EDs, particularly in clients who struggle with impulsivity and mood dependent ED behaviors such as overeating and purging. DBT is an evidence-based treatment for Bulimia Nervosa and Binge Eating Disorder. Importantly, research supports the effectiveness of DBT skills training outside of the Comprehensive Model DBT was originally created. In fact, a wide array of clinicians who aren’t psychotherapists can and do learn and apply DBT skills in their work with clients (RDN, RNs, CDACs, etc.)
Radically-Open DBT (RO-DBT) has recently emerged as an evidence-based treatment for disorders that have maladaptive overcontrol (OC) as a core feature. These disorders include Anorexia Nervosa, maladaptive perfectionism, and obsessive-compulsive disorder (OCD), among others. Clients with OC issues have a bio temperament characterized by superior distress tolerance skills, inhibited emotional expression, high threat sensitivity/low reward sensitivity, rigid thinking, and aversion to novel experience. These neurobiological tendencies manifest in the form of mood disorders (maladaptive perfectionism, obsessive-compulsive personality disorder (OCPD)) and eating disordered thinking and behaviors (food restriction, overexercise, orthorexia, and rigid/rule governed behavior around food and exercise). RO-DBT teaches clients skills that combat the inflexible and rigid thinking that make it so difficult for these clients to think and behave differently around food and exercise. Included are skills to increase openness, flexible responding, enhanced social connectedness, and vulnerable expression of emotion. Due to social signaling deficits that are both a cause and a consequence of OC, these clients can be hard to read, difficult to connect with, and easy to misinterpret. They have difficulty with direct communication of their authentic internal experience, and this can result in not saying what they really mean, acting like everything is fine when it is not, and even abandoning the counseling relationship without warning. Consequently, RO-DBT is a valuable counseling skills guide for the EDRD, as the relational issues that are the consequence of this coping style can be equally if not more challenging than resistance to changing ED behaviors.
Radical openness (RO) is the core skill of RO-DBT. RO encourages receptivity to disconfirming feedback and flexibly responding to a situation by doing what’s needed in the moment. From the RO-DBT perspective, we can help OC clients cultivate “flexible mind” via a variety of skills. Some skills are to increase awareness of emotions and thoughts that signify a “closed” mindstate. Other skills are for fighting the action urges to fix, control, or avoid action urges that are triggered when we feel “closed” (a closed mind is a threatened mind). We can teach the practice of self-enquiry (asking oneself questions that help us lean into our discomfort) to promote open-mindedness and flexibility (e.g. “Is there something I can learn here? Is it possible I don’t know all the answers? Is there another way to look at this?”). There are a multitude of areas for clients to work on Radical Openness in their ED recovery, including giving up dieting, moving toward intuitive eating, challenging food fears, body acceptance, changing their exercise routine, and any other new experience or change in behavior that causes discomfort.
The skill “Flexible Mind VARIES (Engaging in Novel Behavior)” breaks the process of doing something new into its individual components and provides a roadmap for navigating novel behaviors. Trying a new food, making dietary changes, changing exercise, or resisting compensatory behavior are just some of the novel behaviors our clients are working on during the recovery process. I have found this skill to be a great catalyst for change in OC clients.
The main principles underlying this skill are as follows:
- doing something new requires a willingness to tolerate uncertainty
- taking risks and making mistakes is how one learns
- Learning results from how a behavior is reinforced
A summary of the 5 steps of the skill follows:
First, one needs to check/reconfirm the willingness to do something new. Working on doing something new, though scary, usually is in alignment with a client’s long-term goals in ED recovery, and they need to be reminded of this repeatedly. Once this is established, one must check the accuracy of the hesitancy around doing the new behavior (in other words, check the facts). A great self-enquiry question for this step is “Do I believe I already know the outcome of what might happen if I try the new behavior?” Our OC clients tend to believe they do know the outcome, and the prediction is usually a negative outcome (i.e. once I let myself eat this food I will not be able to stop eating it). However, we can suggest they may not be correct in their prediction. The next step is to relinquish compulsive planning, rehearsal, or preparation – all of which our OC clients tend to do, especially around food and exercise. RO-DBT conceptualizes compulsive planning as a way to avoid discomfort. Next is to activate the social safety system via relaxed posture, deep breathing, and open facial expression, and then initiate the new behavior. Notably, clients need to be reminded (multiple times) feeling awkward or uncomfortable is normal and to be expected, and this will only decrease with continuing to practice the new behavior. Lastly, one must nonjudgmentally evaluate the outcome by practicing more self-enquiry (e.g. “am I more OR less inclined to try this new behavior again? Am I dismissing or minimizing the positive benefits? Is it hard to feel a sense of accomplishment because I didn’t do it perfectly? Do I ever harshly blame myself so others will expect less from me?”). As we know, many clients tend to only notice the negative aspect of the experience while overlooking/minimizing the positive benefit.
In closing, RO-DBT can be of great value in nutrition therapy for eating disorders. As a clinician treating eating disorders for over 20 years, I can attest to the unique challenge it is to treat these clients, due to their bio temperamental tendency towards rigid and inflexible thinking, aversion to novelty, high threat sensitivity, and low reward sensitivity. Radically Open DBT gives clinicians a set of skills for this population I have not come across up to this point.
About the author:
Stefanie Boone, MS, RD, CEDRD is a nutrition therapist for adults and adolescents of all genders with eating and exercise disorders. She has worked with clients in her Private Practice in Santa Monica individually and in groups for the past 20 years, using a combination of philosophies centering around Intuitive Eating, DBT, RO-DBT to help clients heal their relationship with food, exercise, and body image. Stefanie also has an added specialization in treating eating disorders in those with co-occurring mood disorders and addictions. She has held positions as Lead Dietitian at several treatment centers for Eating Disorders, Dual Diagnosis and Addictions, including: Eating Disorder Center of California, Visions Adolescent Treatment Centers, Kaiser Permanente Eating Disorders Program (Hollywood, CA), Clearview Treatment Centers, and Resolutions Therapeutic Services. Stefanie is currently President of IAEDP Los Angeles (International Association of Eating Disorders Professionals). Stefanie received her undergraduate education in dietetics and Masters of Science Degree in Nutrition from California State University, Northridge. She has spoken at numerous professional events, conferences, and panels on Nutrition Therapy for Eating Disorders in past years. She is currently focusing her time and energy on supervising and training other RDN’s on using DBT and Radically Open DBT in nutrition therapy for eating disorders, has spoken on this topic at several CE events as well as the recent Renfrew Conference. Stefanie is one of the contributing authors of Real World Recovery: Intuitive Food Program Curriculum for the Treatment of Eating Disorders, and she has written articles for Today’s Dietitian, The Behavioral Nutrition newsletter, and the Huffington Post.
- American Dietetic Association. Standards of practice and standards of professional performance for registered dietitians (competent, proficient, and expert) in disordered eating and eating disorders (DE and ED), 2011. J Am Diet Assoc. ; 2011;111(8): 1242 – 1249.
- Reiner CS, Graves L. Nutrition therapy for eating disorders. Nutr Clin Pract. 2010;25(2):122-136.
- Herrin M. Larkin, M. Nutrition Counseling in the Treatment of Eating Disorders. 2nd ed. New York: Brunner-Routledge; 2013.
- British Dietetic Association Mental Health Group. Position Paper on Dietitians Working with Patients with Eating Disorders. http://www.montana.edu/hhd/nondegree/mdi/activitiessupplements/dietitianseatingdisorders.pdf. Accessed November 9, 2018.
- Lynch TR. The Skills Training Manual for Radically Open Dialectical Behavior Therapy: A Clinician’s Guide for Treating Disorders of Overcontrol. Oakland, CA: New Harbinger; 2018.
- New Harbinger Publications. How is RO-DBT different from DBT? https://www.newharbinger.com/blog/how-ro-dbt-different-dbt. February 14, 2017. Accessed October 17, 2018.
- Safer DL, Telch, CF, Chen, EY. Dialectical Behavior Therapy for Binge Eating and Bulimia. New York: Guilford Press; 2009.
- Lynch TR, Hempel RJ, Dunkley C. Radically Open-Dialectical Behavior Therapy for Disorders of Over-Control: Signaling Matters. American Journal of Psychotherapy 2015; 69(2), 141-162.
- Lynch TR, Gray KLH, Hempel RJ, Titley, M, Chen EY, O’Mahen HA. Radically Open-Dialectical Behavior Therapy for adult anorexia nervosa: Feasibility and outcomes from an inpatient program. BMC Psychiatry. 2013; [13:29]3. doi: 10.1186/1471-244X-13-293.