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Treating Trauma and Eating Disorders with DBT and Exposure Therapies

Kathryn J. Brewer, PhD, LCPC, CCTP, Clinical Director at McCallum Place Kansas

I began my career over 15 years ago working with adult survivors of trauma. Throughout my career, I have gained interest and experience working with many co-occurring symptoms and diagnoses, including eating disorders. It is common for patients with trauma and eating disorders to avoid emotions, thoughts, interactions, and experiences. This avoidance often results in patients engaging in harmful behaviors in an attempt to avoid, stop, or prevent uncomfortable feelings from emerging. For example, many patients engage in self-injury, impulsivity, eating problems, and give in to addictions to cope in the moment, seeking immediate relief. While this does work in the short-term, it results in long term negative consequences as the symptoms are maintained and not treated. The therapies known to be the most effective are those that involve the patient experiencing what they avoid in a safe environment. This desensitization makes the experience less negative and more neutral for the patient. What we know in the treatment of trauma is that memories, thoughts, and emotions cannot be forgotten or eliminated, instead our patients can learn to react and respond differently to them with compassion.

In McCallum Place Kansas City’s partial-hospital program, we will be providing trauma-focused individual and group therapy for our patients. Individually, patients will receive evidence-based exposure therapies to guide them through learning how to respond differently and become less avoidant and fearful. We will offer several different types of exposure therapy including eye movement desensitization and reprocessing (EMDR), dialectical behavior therapy (DBT), prolonged exposure (PE), narrative therapy, and psychodrama.

EMDR was developed by Francine Shapiro in the late 1980’s as a phase-oriented systematic treatment approach most well-known for treating PTSD (Grant, 2009; Shapiro, 2001). EMDR follows a protocol to access and address past events, reprocess the events in the present moment related to distressing circumstances, and desensitize the events along with acquiring new skills to increase effectiveness in the future (Grant & Threlfo, 2002; Grant, 2009; Shapiro, 2001). Patients that could benefit from this intensive desensitization will work with one of our EMDR trained therapists. EMDR will be an effective treatment option for many of our patients struggling with symptoms related to trauma, chronic pain, and anxiety.

DBT was developed by Marsha Linehan for the treatment of borderline personality disorder primarily using a cognitive behavioral framework (Linehan, 1993; Linehan, 2015). As with many of the evidence based treatments we rely on, DBT has since been found to be effective with other symptoms and disorders including PTSD, anxiety, bulimia nervosa, binge-eating disorder, and substance abuse (Grilo & Mitchell, 2011; Linehan, 2015; Safer, Telch, & Chen 2009). DBT trains patients to develop more wholesome strategies to manage stress through skills in mindfulness, interpersonal effectiveness, distress tolerance, and emotion regulation. Binge eating and purging can be seen as unskillful strategies for emotion regulation. Letting go involves developing the capacity to allow emotion to arise with less reactivity. Treatment will help patients develop skills to reappraise problematic thinking that contributes to unpleasant emotional states. At McCallum Place, inflexible thinking, restriction, and avoidance is transformed by mindfulness practices. We encourage the use of DBT skills in our PHP for ongoing stabilization to help our patients more safely and effectively engage in our more intensive treatments. There is also new evidence emerging supporting the use of DBT during other treatments like PE (Harned, Korslund, & Linehan, 2014; Harned, Korslund, Foa, & Linehan, 2012).

Utilizing PE, patients at McCallum Place will experience many exposures continually throughout their treatment and specifically they will complete exposure tasks in meals three to four times per day, with their bodies in yoga and dance/movement groups, and with their thoughts and emotions in individual and group sessions. Exposures are intended to be emotional experiences that allow our patients to process through their trauma and anxiety. PE therapy was originally developed by Edna Foa, PhD to treat PTSD (Foa, Hembree, & Rothbaum, 2007) and is also commonly used to treat anxiety disorders (Craske & Barlow, 2007). This treatment works for PTSD and anxiety because it addresses the patient’s avoidance and fear (Craske & Barlow, 2007; Foa et al., 2007).

Narratives are one resource used in exposure therapies giving patients a way to tell their story through cognitive, emotional, and sensory re-experiencing (Schauer, Neuner, & Elbert, 2011). Patients may be asked to write a narrative of a specific traumatic event that they will then process, including reading it aloud, in an individual therapy session. We find that patients may be avoidant or fearful of their entire life story, not just of a specific traumatic event. For instance, one of our assignments involve patients writing a timeline of their life experiences, including a timeline of their eating disorder. This assignment is then shared in individual therapy and in our Life Narratives Group. Our patients find this shared experience to be empowering, creating significant connections among those in group, and begin a process of reshaping how they understand their past.

In psychodrama, patients are exposed to significant experiences from their history that they may be avoidant or fearful of (Kellermann, 1992), many of which may be identified in their Life Narrative assignment. Patients re-enact the experience through role play in our Psychodrama Group. The role play may support a patient re-experiencing the interaction in a safe and supportive environment where they learn how to react and respond differently or it may guide a patient through re-writing the interaction in a way that gives them more control and power. The goal of psychodrama is for the patient to find resolution of the experience.

Exposure therapies, while quite effective, are difficult for our patients to participate in without the right support. Our PHP setting is ideal for exposure therapies as we provide the needed support and structure for the treatments to be more tolerable for the patient and therefore more effective.

References

Craske, M. G., & Barlow, D. H. (2007). Mastery of your anxiety and panic (4th ed.). New York, NY: Oxford University Press.

Foa, E. B., Hembree, E., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional processing of traumatic experiences. New York, NY: Oxford University Press.

Grant, M. (2009). Pain control with EMDR. Australia: Mark D. Grant.

Grant, M., & Threlfo, C. (2002). EMDR in the treatment of chronic pain. Journal of Clinical Psychology, 58, 1505-1520. doi:10.1002/jclp.10101

Grilo, C. M., & Mitchell, J. E. (2011). The treatment of eating disorders: A clinical handbook. New York, NY: Guilford Press.

Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialectal Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7-17.

Harned, M. S., Korslund, K. E., Foa, E. B., & Linehan, M. M. (2012). Treating PTSD in suicidal and self-injuring women with borderline personality disorder: Development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure protocol. Behavior Research and Therapy, 50, 381-386.

Kellermann, P. F. (1992). Focus on psychodrama: The therapeutic aspects of psychodrama. Philadelphia, PA: Jessica Kingsley Publishing.

Linehan, M. M. (1993). Cogntive-behavioral treatment of borderline personality disorder. New York, NY: Guilford Press.

Linehan, M. M. (2015). DBT Skills Training Manual (2nd ed.). New York, NY: Guilford Press.

Safer, D. L., Telch, C. F., & Chen, E. Y. (2009). Dialectical behavior therapy for binge eating and bulimia. New York, NY: Guilford Press.

Schauer, M., Neuner, F., & Elbert, T. (2011). Narrative exposure therapy: A short-term treatment for traumatic stress disorders (2nd ed.). Cambridge, MA: Hogrefe Publishing.

Shapiro, F. (2001). Eye movement desensitization and reprocessing: Basic principles, protocols and procedures (2nd ed.). New York, NY: Guilford Press.