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Dialectical Behavioral Therapy in the Treatment of Binge Eating Disorder

Molly Carmel, LCSW-R

How many of us who struggle with binge eating and/or weight management have been given the guidance to simply eat less and exercise more? Well, if you’re anything like me and my clients, this is not the solution; rather, it is a setup for a cycle of deprivation and demoralization. 

A diet and exercise plan alone will not suffice for someone who binge eats. Those who are struggling are typically best served by a treatment plan that addresses the complexity of the behaviors, thinking patterns, and relationship with food.

Enter dialectical behavior therapy (DBT)—a type of therapy that combines parts of cognitive behavioral therapy with principles of mindfulness from Zen Buddhism. DBT has been proven an effective theoretical framework to foster the changes incumbent with binge eating disorder (BED) treatment. Traditional DBT focuses on concrete behavioral skills for four domains: emotional regulation, interpersonal effectiveness, distress tolerance, and mindfulness. In adapting traditional DBT to target binge eating, it also includes developing an individualized food plan that will support their goals.

I have found the most effective way to treat binge eating behavior is a concept straight from DBT—it's called dialectical abstinence, and it really gets to the heart of the bind inherent in binge eating treatment. One of the core concepts of DBT is finding a dialectical “middle path,” or a synthesis, between two opposing ideas. For people with BED, the two great opposing ideas in dialectical abstinence are 1) You need to be fully adherent and comply with your food plan that includes abstinence from certain triggering foods AND 2) Doing just that perfectly is a complete and utter impossibility. What a pickle! 

On the one hand, in order to make long-term solutions, you need to follow an individualized food plan, and work your program like a boss, with a serious level of precision. But, if it were as easy as “go follow a food plan perfectly,” then no one would be in any sort of food struggle predicament. The problem here is that with those who binge eat, the alternative to being on plan is historically getting off the road completely. Or, as we formally call it in DBT, the abstinence violation effect: if you have a longstanding struggle with a food plan, it's easy to fall off track in major ways. And, you don't usually return to any level of a healthy program until cued by health concerns or shame. 

The opposing idea to food plan compliance is that food plan imperfection (having slips) is inevitable. And, if you allow yourself to ONLY hang out in that headspace, slipping becomes the norm, and treatment is not effective. Four of the most dangerous words that I hear from clients are "It's No Big Deal" in reference to a slip from the food plan. The fact is, if you don't pay attention to slips, they become relapses, and our slips become slides. The problem here is that you don’t see any long-term or sustainable change. 

So what's the solution? What's the synthesis? What does dialectical abstinence tell us to do? It tells us that the answer doesn't lie solely with perfection of food plan and imperfection of food plan; it lies in the balance. Dialectical abstinence says that lapses are going to happen AND you can't plan for them. Dialectical abstinence says that we strive for recovery/adherence all day every day—and calls for acceptance that lapses are an inevitable part of the journey. 

The DBT framework of dialectical abstinence is a new way of looking at BED treatment, with specific skills to navigate an individual's behaviors around food. Emotion regulation skills help navigate those inevitably tricky emotions that come up that impact food behaviors. Interpersonal effectiveness skills give concrete solutions to relational challenges, as well as skills for conversations to keep in alignment with values and needs. 

In DBT for BED, distress tolerance skills are used to help clients get through a hard moment (including a food craving or lapse) without making the situation worse by engaging in a harmful eating coping behavior. Finally, mindfulness skills are introduced to increase awareness and combat the out-of-body-and-mind experience of many binge eaters. Having an effective, evidence-based, tangible behavioral toolkit of skills to support the dialectical abstinence framework in DBT provides solutions and hope during the recovery journey. 

Editor's note: What is successful for one person in treatment may be different for someone else. Opinions expressed on our blog are those of each individual writer and should not be considered a NEDA endorsement

Molly Carmel is among the leading behaviorists in the field of obesity. She specializes in the treatment of weight management, eating disorders, and addictions. After battling an eating disorder for over 20 years and finding no solution in available treatment, she began her professional path toward creating The Beacon, which offers a sustainable approach to food and weight issues. Molly also served as the Founding and Senior Clinical Director of Wellspring and now serves as Wellspring’s Chief Clinical Consultant.  

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