Using Dialectical Behavioral Therapy (DBT) in Nutrition Counseling
One of the therapy modalities that informs my work is Dialectical Behavioral Therapy (DBT). Since I am not a therapist, I wanted to take the time to unpack DBT and explain it’s strengths, limitations and how I use it in my practice as a dietitian.
What is DBT?
DBT is a treatment modality developed by Marsha Linehan in the 1980s and 90s as a new, evidenced-based and effective treatment for Borderline Personality Disorder (BPD). Over time, the treatment was studied and found to be effective for various groups including those with eating disorders.
One of the core elements of this treatment is to constantly strike a balance between acceptance and change. DBT is considered a “principle-driven” treatment, meaning that it does not have a rigid protocol to follow but rather a key set of skills and treatment modes that work in concert with each other.
The full package of DBT treatment includes several components:
Skills training - typically in the form of a group that meets weekly
Individual therapy - meeting 1 on 1 with a DBT-trained therapist
Phone coaching - contact with therapist between sessions to get support practicing skills in the context of “real life”
Case consultation (for the treatment team) - a space where therapists and any other members of the DBT treatment team meet to get support and supervision
Ancillary treatments - any other support the client is receiving simultaneously with DBT treatment (nutrition counseling, medication support, attending support groups, etc.)
So time for a couple disclosures. I am not a therapist and I do not offer most of these components or modes of comprehensive DBT treatment. I have worked on a DBT treatment team in the past that used many of these treatment modes. I was also fortunate enough to complete Foundational DBT training through Behavioral Tech which is a 16 week course covering the essential components of DBT.
Read on to find out how I incorporate elements of DBT into my practice.
How do I use DBT in my work?
As a registered dietitian, there are several ways that I incorporate my knowledge and experience of DBT in my practice.
I take a dialectical approach with my clients.
What the heck is that, you ask?
It is difficult to give a concise definition. The simplest way I can think to put it is viewing the world through an “AND” lens rather than a “BUT” lens.
Ok seriously what are you talking about?
Dialectical thinking is the antithesis of “all or nothing” thinking. It is accepting that two seemingly opposing truths can both exist without us having to choose which one is right.
A silly example of “AND” vs “BUT” thinking:
“I am really enjoying eating this peach BUT I wish it was riper” vs. “I am really enjoying this peach, AND I wish it was riper”. See the subtle difference?
Dialectical thinking is accepting that we can move forward without resolving all the tensions and oppositions that live within us and within our world. We can still enjoy the peach in this moment while acknowledging that we also love peaches that are even riper.
An excerpt from the book Cognitive-Behavioral Treatment of Borderline Personality Disorder by Marsha Linehan puts this more seriously than my peach example :)
“A dialectical perspective…suggests that within dysfunction there is also function; that within distortion there is accuracy; and that within destruction one can find construction” (pgs 32-33).
Dialectical thinking also recognizes that change is constant and that our experiences are a part of a larger context beyond the “self”.
I incorporate DBT skills where appropriate.
DBT skills are broken down into 4 categories:
Mindfulness
Distress Tolerance
Emotion Regulation
Interpersonal Effectiveness
While the skills are meant to function together, I also find that pulling a couple relevant skills into sessions with my clients can be a helpful addition to our toolbox.
For my clients who have had more intensive DBT skills training, I might encourage them to use and practice skills they already know and I can help troubleshoot barriers to using these skills.
Whenever using DBT skills with clients, the focus is always on your relationship with food and body. We might use skills at mealtime or to help manage distressing emotions that come up around body image.
I believe my clients have inherent wisdom about their own experiences.
The concept of Wise Mind in DBT is the idea that every individual has a place of wisdom within them at the intersection of emotion and reason. They may not always be able to access it but it never goes away entirely.
I have areas of expertise in nutrition counseling. At the same time, I recognize that my clients know their own lived experience better than I do. I strive to help my clients create a relationship with food and body that is authentic to them rather deciding for them what it “should” look like.
Limitations of DBT
I’m highlighting a few limitations and criticisms of DBT below. This is certainly not an exhaustive list and I am always open to hearing from those who have other criticisms from their own experiences with DBT. Feel free to send me an email at madison@unravelnutrition.com if you have some thoughts you’d like to share.
Many of my clients have had long histories of masking their neurodivergent traits in order to fit into a neurotypical world and I recognize that some DBT skills can feel like an encouragement to mask. I do my best to consider the individual client when considering which skills to teach, if any.
While this is an evidence-based treatment, we always have to remember that research is imperfect and often misses key demographics, especially the most marginalized populations that may be even more impacted by the mental health diagnoses DBT seeks to address.
Marsha Linehan spent some time studying Zen Buddhism and used many principles from these teachings in the development of DBT. While she does acknowledge this as a source for her, it is also important to acknowledge that Linehan is a white woman who is financially benefitting from a cultural and spiritual practice that is not her own.
Comprehensive DBT treatment involves a significant time (and likely financial) commitment which may not be accessible many people.
Getting Unstuck
If you have been feeling stuck in your relationship with food or your body and you think this type of nutrition therapy may be helpful for you, please reach out to schedule an intro call with me. My treatment approach is always individualized to you, and I’d love to help you start living a life that is more aligned with your authentic self.
Linehan, Marsha M. Cognitive-Behavioral Treatment of Borderline Personality Disorder. The Guilford Press, 1993.
