DBT for Eating Disorders: How It Works

Dialectical behavior therapy (DBT) is a type of talk therapy where you learn skills to manage emotions, cope with distress, and improve your relationships.¹ In DBT for eating disorders, you use those skills on the emotions that can contribute to bingeing, purging, and restricting.²

Early research supports DBT for binge eating disorder and bulimia nervosa.² You practice the skills between sessions, so they’re easier to use even when emotions feel overwhelming.³

What Is Dialectical Behavior Therapy?

Psychologist Marsha Linehan developed DBT while working to create a treatment for people with suicidal behavior.³ Clinicians first used it to treat borderline personality disorder (BPD), and it's effective for people with BPD and chronic suicidal behavior.⁴ Since then, clinicians have adapted DBT to treat other conditions, including eating disorders, particularly when difficulties managing emotions play a role.⁴

DBT uses cognitive and behavioral techniques, the same family of tools you'd find in cognitive behavioral therapy (CBT).¹ The difference is what you and your therapist focus on. In DBT, a major focus is learning to manage strong emotions, and improving your relationships is a core goal, too.^2,1

The word "dialectical" refers to balancing two things that seem opposite.³ You work on accepting yourself and your feelings while also striving toward change and a better life.^2,3 Part of that acceptance is validation, which means your therapist acknowledges what's true and understandable in your experience, emotions, and thoughts.³ You can learn to do this with yourself, too. For example, "My urge to restrict makes sense right now, and I can still choose to eat this meal."

You'll learn four areas of dialectical behavior therapy skills: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.⁴ Some people learn them through comprehensive DBT, which includes individual therapy and a weekly skills group.³ Some eating disorder programs use only certain parts of DBT.²

Why DBT Is Used for Eating Disorders

Eating disorder behaviors, like purging or binging, can make painful emotions feel more distant and easier to handle, but the relief doesn’t last.² Over time, overeating and restriction can make you more vulnerable to emotional dysregulation, which can keep the cycle going.²

Emotional dysregulation means having difficulty managing emotional responses, which may feel especially intense, overwhelming, or hard to calm down from.² People with every type of eating disorder can struggle with emotion regulation, which is a big part of understanding eating disorders and why the behaviors are so hard to stop.⁵

Body image is part of this, too. Researchers have observed links between distressing thoughts about your body, like "I'm fat," and eating disorder behaviors.² For example, you may see an unflattering picture of yourself or home in on a part of your body you don’t like and binge, purge, or skip a meal to feel better.

Therapists who use dialectical behavior therapy for eating disorders focus on helping you build healthy emotion regulation skills. This helps you get through tough moments without restricting, bingeing, purging, or other eating disorder behaviors.²

CBT Is Helpful Too, But Not Always for Everyone

Many people find CBT helpful for eating disorders, but some people don’t experience much improvement. DBT offers another approach by helping people cope with their emotions in new ways, with a greater emphasis on emotional regulation skills rather than challenging or changing unhelpful thoughts, as is common in CBT.³

DBT Skills for Eating Disorders

In DBT for eating disorders, you learn the same four skill areas as in standard DBT, usually in a group.² Then, in individual therapy, you and your therapist work on using them with specific behaviors like restricting, binge eating, and purging.²

Here’s those four skills explained.

Mindfulness Skills

Mindfulness means paying attention to the present moment and noticing what you're experiencing without judging it.³ DBT therapists consider it the core skill of the whole approach.²

You might practice mindfulness while you’re eating by checking in with your hunger before and during a meal, paying attention to tastes and texture as you eat, and eating without distractions like your phone or a movie. Mindfulness also helps you catch urges earlier, which can help you start your coping skills before the urge gets too strong.

Distress Tolerance Skills

Distress tolerance is about getting through a painful moment or a crisis without making things worse.³ In standard DBT, people typically spend six to eight weeks learning these skills.⁶ One of them is radical acceptance, where you accept the present moment for what it is instead of fighting against it.³

Say you feel an urge to binge or purge after a stressful phone call. Instead of acting on it, you use a skill to ride out the urge until the intensity drops. With practice, this gets easier and feels more natural.

Emotion Regulation Skills

With emotion regulation skills, you learn to recognize, understand, label, and manage your emotions.³ Eating in a balanced way is part of this work, since overeating and restriction appear to make people more vulnerable to emotional dysregulation.²

Therapists make these skills a main focus of DBT for eating disorders.² In one study of guided self-help for binge eating disorder, the more people’s emotion regulation improved, the more likely they were to stop binge eating.⁷ In other words, getting better at managing your emotions may be one of the main reasons DBT can reduce certain disordered eating behaviors.

Interpersonal Effectiveness Skills

Interpersonal effectiveness is about handling conversations and relationships well, like asking for what you need or saying no.³ Improving your relationships is one of the core goals of DBT.¹

In recovery, that might mean setting a boundary when a relative comments on your plate or your body image at a family meal. It could also mean asking your partner for support after a hard day instead of turning to food for comfort.

Types of DBT Used for Eating Disorders

There's more than one version of DBT for eating disorders, and the approach your care team recommends may depend on your diagnosis, symptoms, and individual treatment needs.²

DBT for Binge Eating and Bulimia

Researchers at Stanford University adapted DBT for bulimia nervosa and binge eating disorder (BED), and most DBT research in eating disorders has focused on these two conditions.^2,8 Studies have tested it as 20 weekly individual sessions or as a 20-week skills group.^8,3 You and your therapist focus on emotion regulation, with the goal of replacing binge eating and purging with healthier ways to cope.²

There's also a guided self-help option for BED. You work through a self-help manual and get one orientation session plus six short support calls over about 13 weeks.⁷

Radically Open DBT (RO-DBT)

Radically open-dialectical behavior therapy (RO-DBT) is for people who struggle with overcontrol.⁶ Overcontrol can look like holding back your emotions, being overly cautious, following rigid rules, keeping your distance from others, and comparing yourself to everyone else.² The researchers who developed RO-DBT view anorexia nervosa as a disorder of overcontrol.⁶

In standard DBT, the main target is emotional dysregulation. In RO-DBT, therapists treat emotional loneliness as the core problem and help you build flexibility and connection with others.⁶ The main skill is "radical openness," which means staying open to new ideas and feedback instead of holding tightly to rigid rules.⁶ You also learn to show your feelings instead of masking them, and to handle the envy and bitterness that can come from comparing yourself to others.⁶ The goal is for you to feel safer and more connected with the people around you.⁶

Your sessions look a little different, too. In RO-DBT, you spend about one week on distress tolerance, compared with six to eight weeks in standard DBT.⁶

Does DBT Work for Eating Disorders?

There’s preliminary support for DBT in binge eating disorder and bulimia nervosa, but as of 2019, researchers hadn’t run any randomized controlled trials of DBT for anorexia nervosa.² These early findings are encouraging, but more research is needed to establish how effective DBT is for different eating disorders.²

DBT for Binge Eating Disorder

Binge eating disorder has been studied in more randomized controlled trials of DBT than other eating disorders.² Across DBT trials, people in DBT did better than people on a waitlist by the end of treatment, but they didn’t do better than people in other active treatments at follow-up.² Put simply, DBT is better than waiting for help, but researchers haven’t found it to work better than the other active treatments they compared it with.

People in everyday treatment settings improved, too. In a community eating disorder service, 56 adults were offered a 20-week DBT group.⁹ About 60% had no binges in the month before treatment ended, and about 50% were still binge-free at a one-month follow-up.⁹ Their mood didn’t significantly improve, but their eating disorder symptoms did, which suggests that DBT can help by teaching emotion regulation skills rather than by changing mood.⁹

DBT for Bulimia Nervosa

Fewer studies have examined DBT for bulimia nervosa, and the evidence from randomized controlled trials remains relatively limited.² In an early trial, 31 women with bulimia nervosa either got 20 weekly individual therapy sessions of DBT or waited for treatment.⁸ After 20 weeks, 28.6% of women in the DBT group had stopped bingeing and purging, compared with none of the women on the waitlist.⁸

That's still a good result. With so few studies, though, the evidence for DBT in bulimia is still limited.²

DBT for Anorexia Nervosa

Researchers haven't yet published results from a randomized controlled trial of DBT for anorexia nervosa.^2,17 Most of what they know comes from RO-DBT, the version built for overcontrol.⁶

In one inpatient program, 47 adults with restrictive anorexia received RO-DBT, and those who finished treatment stayed an average of 21.7 weeks.⁶ People in the program gained weight and had fewer eating disorder symptoms.⁶ Among the 20 people who finished and had full data, 35% reached full remission and another 55% reached partial remission.⁶ When researchers also included people who dropped out, those rates were 20.5% and 41%.⁶

About 72% of people finished the program, and nearly all of them were women.⁶ The study didn’t have a comparison group, and researchers didn’t follow up after people left the program, so the results are early and it’s not clear how long the improvements lasted.⁶

If you have anorexia, your treatment will likely center on nutrition rehabilitation and therapy.¹⁰ Your medical safety comes first, too. If you have unstable vital signs or concerning lab results, you may need hospitalization for medical stabilization before beginning or continuing outpatient therapy.¹¹

DBT for Teens With Eating Disorders

In a 2021 review of newer “third-wave” therapies for teens with eating disorders, 11 of the 12 studies used DBT or parts of it.¹² When they pooled the results, teens showed a moderate improvement in eating disorder symptoms, and the improvement appeared stronger for bulimia nervosa and binge eating disorder.¹²

Most of those studies were low quality, though, mainly because they didn’t compare teens in DBT with teens who got a different treatment or none.¹² That makes it hard to know whether DBT caused the improvement, so researchers can’t yet say how well DBT works for teens.¹²

For teens with anorexia nervosa, family-based treatment (FBT) is the treatment of choice.^2,18 The American Psychiatric Association recommends it for teens and young adults with anorexia who have a caregiver involved in their care.¹⁸

What About ARFID and OSFED?

Avoidant/restrictive food intake disorder (ARFID) and other specified feeding or eating disorder (OSFED) are both recognized eating disorders.¹³ So far, researchers have focused their DBT studies on binge eating disorder, bulimia nervosa, and anorexia nervosa.² If you have ARFID or OSFED, you may still learn DBT skills as part of a broader treatment plan, so ask your care team whether they could help you.

What to Expect in DBT Sessions

Starting a new kind of therapy can feel intimidating for anyone. Here’s a general idea of what to expect if you start DBT for an eating disorder.

Session Structure

Comprehensive DBT usually has four parts: individual therapy, a skills group, phone coaching between sessions, and a consultation team where your therapist gets support from other DBT therapists.² With phone coaching, you can contact your therapist between sessions for help using your skills in a hard real-life moment.^2,3

In individual therapy, you and your therapist work one-on-one on using your skills with your specific behaviors.² In standard DBT, these sessions last about an hour.³ In group sessions, you learn and practice skills with about 4 to 10 other people.³ Standard DBT groups meet for about 1.5 to 2.5 hours a week.³

You'll also fill out diary cards as homework to track your symptoms and the skills you used, and your therapist reviews them with you.^2,3

Some eating disorder programs use only parts of DBT.2 If a program says it offers DBT and you want to make sure you get all four aspects, check with admissions staff.

Typical Duration and Frequency

Many DBT programs studied for eating disorders last about 20 weeks, with one session or group each week.^8,9 People who finished the inpatient RO-DBT program for anorexia stayed an average of 21.7 weeks.⁶ People using guided self-help for BED worked through it in about 13 weeks.⁷ In studies of DBT for other mental health conditions, programs ranged from 8 weeks to 6 months.⁴

Standard DBT can take longer. In the early research on DBT for borderline personality disorder, people stayed in treatment for 12 months.³

Who Is a Good Candidate for DBT?

DBT may be a good fit if your disordered eating is closely tied to intense emotions, especially if bingeing or purging feels like the only way to get relief.² Managing those intense emotions with DBT can help you get control without turning to eating disorder behaviors.²

People with eating disorders have a higher risk of depression, anxiety, and substance use disorders, which may also benefit from DBT.¹⁴ Because of this clinicians often use DBT with people who have co-occurring conditions, though there's less research on this group.³

Clinicians use DBT in both inpatient and outpatient settings.^6,8 Some people need a higher level of care before starting outpatient DBT. If you have unstable vital signs, lab results that show a health risk, or are experiencing a psychiatric crisis, you may need hospitalization for stabilization before beginning outpatient DBT.¹¹

DBT vs. Other Eating Disorder Treatments

Clinicians use several well-established eating disorder treatments, including CBT for bulimia nervosa and BED and family-based treatment for teens with anorexia.² Here's how DBT compares.

DBT vs. CBT and CBT-E

In CBT for eating disorders, you and your therapist work on the thoughts and eating patterns that keep the disorder going, especially beliefs about shape and weight.¹⁶

Enhanced cognitive behavioral therapy (CBT-E) is a version of CBT designed for the full range of eating disorders, including anorexia nervosa, bulimia nervosa, BED, and OSFED.¹⁶ In CBT-E, you work on the habit of judging your self-worth mostly by your shape and weight.16 The broader form of CBT-E also covers perfectionism, low self-esteem, and relationship problems.¹⁶

A full course of CBT-E usually takes 20 sessions, or 40 sessions for people who are significantly underweight.¹⁶ Researchers consider the evidence for CBT-E strong in adults, with remission rates after treatment ranging from 22.2% to 67.6% across studies.¹⁶ Results for people with anorexia nervosa are less consistent.¹⁶

DBT is different. Instead of focusing mainly on your thoughts about shape and weight, you learn skills to manage the emotions behind eating disorder behaviors.²

Two Dutch studies compared DBT with an intensive CBT program for BED.^5,15 Here's what researchers found:

• The 2020 study: People in CBT did better on some measures, partly because they got more hours of treatment.⁵ People in both groups made similar clinically meaningful progress.⁵
• The 2022 study: People in CBT saw their overall eating disorder symptoms drop faster by the end of treatment.¹⁵ Six months later, the two groups had similar eating disorder symptoms, though the CBT group showed a trend toward relapse while the DBT group kept improving.¹⁵

In other words, researchers have more evidence for CBT in BED, but in the 2022 study, people who did DBT held onto their progress at least as well over six months.¹⁵

DBT vs. Family-Based Treatment (FBT)

Family-based treatment (FBT) is the treatment of choice for teens with anorexia nervosa.² In FBT, the family takes part in treatment and works on restructuring the home environment.¹⁰

Researchers are still learning how well DBT works for teens.¹² For now, DBT skills may support family-based care rather than replace it. If you're a parent, learning how to help someone with an eating disorder can make your role in your teen's treatment feel more manageable.

How to Find a DBT Provider for Eating Disorders

Start by figuring out what level of care you need, which a doctor or mental health professional can help with. Eating disorder treatment ranges from outpatient therapy to intensive outpatient programs (IOP), partial hospitalization programs (PHP), residential care, and inpatient care.¹¹ Ask any program you're considering whether DBT is part of their care.

Look for a therapist or program trained in both DBT and eating disorders. Ask each provider about their DBT training and their experience treating eating disorders. Virtual care may be an option, too: some clinicians have offered DBT skills groups for teens through telehealth.¹

Questions to ask a provider:

• Do you offer full DBT, or skills groups only?
• Will I have one-on-one sessions as well as group sessions?
• Is phone coaching included between sessions?
• How do you combine DBT with nutrition and medical care?
• Do you accept my insurance?

Find Eating Disorder Treatment

If you're comparing your eating disorder treatment options, ask each program whether DBT is part of their care and how it fits with medical care and nutrition support. It's also valid to ask how their therapists were trained.

You can find eating disorder treatment centers on Recovery.com by location, level of care, and insurance.