By Anita Federici, Ph.D C.Psych. FAED
Given very high rates of suicidal and self-injurious behaviours among adolescents with eating disorders, it is crucial that families receive training and support to manage these complex behaviours. Rates of suicide are 12 times higher in those with anorexia nervosa and almost 8 times higher in bulimia nervosa. Regardless of the type of eating disorder, suicidal behaviours are significantly elevated and represent a leading cause of death among those who suffer. The frequency of self-injury is also very high with studies showing that 50% to 80% of individuals with an eating disorder also have a history of self-injurious behaviour.
Family-based treatment (FBT) is considered the front-line treatment for adolescents with an eating disorder. While two-thirds of those with anorexia nervosa are weight-recovered with treatment, not all individuals respond adequately to FBT. Research shows that adolescents with greater emotion regulation difficulties, additional diagnoses (e.g., PTSD, social anxiety), and those with personality disorder traits (e.g., borderline personality disorder) likely require modified or innovative treatment approaches. For example, in our clinic we often hear that treatment isn’t working because the child becomes suicidal when the parents attempt to re-feed. Parents will say that they don’t know what to do and that they feel afraid, burnt out, and frustrated.
Over the past decade, researchers have been evaluating the use of DBT either as a supplement to FBT or as a stand-alone treatment for complex eating disorders marked by suicide and self-injury. DBT is a comprehensive treatment that targets emotional dysregulation. Due to its widespread effectiveness in treating a disorder once described as “treatment resistant” (e.g., borderline personality disorder), it has evolved into the go-to treatment for anyone for whom emotion regulation deficits are at the core of the illness. In its full offering, DBT consists of 4 components: weekly individual DBT therapy, weekly DBT skills training, phone coaching, and a consultation team for the providers. In this post, I will focus on how the DBT skills component can help caregivers manage suicidal and self-injurious behaviours to keep their child safe.
Research shows that families who learn DBT skills either in multifamily skills groups or on their own (i.e., parents attend group without their child), have better treatment outcomes compared to focusing only on teaching skills to kids. In fact, most DBT programs will require that parents take part in the skills training groups in order to be effective in treating their child.
There are five core modules in the adolescent version of DBT:
Mindfulness Training: Mindfulness is the ability to be in the present moment without judgment. When trying to help your child recover from an eating disorder, we know that it can feel impossible to focus on the “here and now” and not jump to conclusions or have judgments about what is happening. Some parents we work with feel highly emotional themselves and struggle to stay grounded. Others are more “logically” minded and struggle to understand why their child is so intense and dysregulated. Kids will often describe that nobody understands them or their emotions, which causes even more upset. In this module we teach families to access “wise mind” – the place within all of us that can feel and pay attention to emotion without losing sight of what is effective in a given moment. Instead of emotions driving the bus, we coach families to made “wise mind decisions” which helps alleviate tense situations. We also work on building core strategies such as observing and describing feelings, thoughts, or behaviours without judgment, how to participate in a given moment (without distracting or avoiding), and how doing one thing at a time and staying effective can transform how a family navigates difficult moments.
Distress Tolerance: This module is all about getting through crises without making them worse. Standard eating disorder treatments do not offer concrete skills training in regulating emotion and tolerating discomfort. Often, caregivers will say “our daughter was always told to use her skills but she didn’t have any skills that helped when her emotions were really high“. This module encompasses more than 35 skills to help kids and parents identify, and temporarily step away from, high intensity emotional situations long enough to get into a more “wise mind” state. It is so difficult for someone with an eating disorder to eat feared foods or tolerate weight changes. The body perceives these experiences as threats, the “fight or flight” centre of the brain is activated, and the child may lash out or escalate in an effort to get away from what feels intolerable. We work with families to learn a common language and a set of skills around crisis management. On one hand, we teach a series of temporary distraction techniques that help re-regulate the nervous system and shift attention. On the other hand we work with families to practice radical acceptance, which is the opposite of fighting reality. Radical acceptance might mean helping kids and parents accept treatment, emotional pain, set point theory, the need to follow a meal plan, and so on. A hard skill to master AND one that empowers families to move forward with less suffering. These skills have helped our families manage meals and snacks more effectively and enabled them to reduce suicidal thoughts and urges when they arise.
Emotion Regulation– Those struggling with suicide and self-injury have difficulty identifying, understanding, and communicating emotions. The ability to regulate emotion is partly linked to genetics and biology. For example, chronic suicide and self-injurious behaviours have been linked with differences in the limbic system (the emotional centre of the brain). Things like risk tolerance and impulsivity are also largely genetically driven, meaning that people are born with particular temperaments that can make dealing with urges and emotions much more difficult. In this module, we teach families how to understand the function of emotions, reduce vulnerability to intense feelings, change their responses to emotions that aren’t so helpful, work together to build positive emotions and experiences, and to help the family connect with their specific values and priorities. Parents will often tell us that they wish they had learned this information much earlier in their journey and that learning how to work with (as opposed to against) emotions was incredibly helpful in the recovery process.
Interpersonal effectiveness – It is very common for families to struggle with ways to talk to one another, especially when emotions run high. Often we see a lot of anger, judgment, and conflict. We also see situations where parents feel terrified of making things worse or saying the “wrong thing” (particularly when suicide and self-injury are present) and so patterns of walking on eggshells or avoiding the hard conversations persist. This powerhouse of a module empowers families to learn new ways of communicating that are very specific to navigating emotional outbursts and dealing with explosive and highly charged interactions. These strategies help parents assess what interferes with communication, challenges myths and misconceptions (e.g., “people should know what I need”), and outlines three pathways (e.g., DEAR MAN, GIVE, FAST) for how to talk to one another. Each acronym represents a skill to be used when communicating to your child. We see dramatic shifts when parents and adolescents both use these strategies and share a common language when talking to one another.
Walking the Middle Path – This section teaches parents to adopt a dialectical stance when interacting with their child and with each other. This means that instead of looking for what is right vs wrong, fair vs unfair, we look for the middle ground and seek what is true about the other’s perspective. Families can get locked into “tug of war” dynamics, fighting over whose position is more valid or “right”. This elevates emotion responses and catapults the family into more chaos. Maintaining a dialectical and non-judgmental approach will make a significant and positive impact as families learn that there can be more than one way to think about an issue or solve a problem. Similarly, validation skills are integral for individuals struggling with suicide/self-injury and eating disorders. We spend a lot of time role-playing and coaching families how to harness the ability to communicate what makes sense about their child’s thought, emotions, or behaviour. It is important not to validate what is invalid (e.g., it doesn’t make sense to solve problems with suicide) and to focus on what is valid (e.g., it makes sense that someone is looking for a way to reduce their pain and suffering). Research has shown that when people feel validated, it reduces emotional arousal or physiological activation (you can actually calm a dysregulated biology with validation!). When done effectively, validation strategies can stop a crisis from evolving. This module also teaches caregivers how to reinforce adaptive behaviours and extinguish maladaptive ones. We find that it is very difficult for parents to know what limits to set and how to observe those limits in a way that is consistent and effective.
Click here to learn more about DBT (https://behavioraltech.org/)