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Running header: DIALECTICAL BEHAVIOR THERAPY AND EATING DISORDERS

Dialectical Behavior Therapy and Eating Disorders: The Use of Contingency Management

Procedures to Manage Dialectical Dilemmas

LuceneWisniewski

Cleveland Center for Eating Disorders

& Case Western Reserve University

Denise D. Ben-Porath

John Carroll University

All correspondence regarding this article can be sent to the author, Lucene Wisniewski---
Cleveland Center for Eating Disorders, Beachwood, OH, Case Western Reserve University,
Cleveland, OH. e-mail: [email protected]
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Abstract

Several researchers have adapted and/or applied dialectical behavior therapy (DBT) for eating

disordered populations. There is a growing body of research that indicates that DBT is an effective

treatment option for this population, including those who have co-occurring Axis II disorders. The

goal of the current paper is to first summarize the research conducted in the area of DBT with those

individuals who present with eating disorders only as well as those who present with both eating

disorders and Axis II disorders. Next, we describe a dialectical dilemma, apparent compliance vs.

active defiance, commonly observed in the comorbid group. A DBT change strategy, contingency

management, is discussed as an intervention used to target apparent compliance and active defiance.

Key Words: dialectical behavior therapy, eating disorders, contingency management

Several randomized controlled trials have indicated that DBT is an efficacious treatment

for suicidal patients diagnosed with borderline personality disorder (Koons et al., 2001; Linehan,

Armstrong, Suarez, Allmon, & Heard, 1991; Linehan, Comtois, Murray, Brown, Gallop, &

Heard, 2006; Linehan, Heard, & Armstrong, 1993). Indeed, Division 12 (Clinical Psychology)

of the American Psychological Association listed DBT as one of four empirically supported

treatments (ESTs) for borderline personality disorder and the only EST that has “strong”

research support (Society of Clinical Psychology, 2013).

Since its inception, several researchers have adapted and applied DBT to other

populations that stand to benefit from this treatment. Because medical complications associated

with eating disorders are common and can become life-threatening, the treatment hierarchy in

DBT provides a useful frame to address the myriad complex therapy issues. Additionally, some

theorists have argued that eating disorder symptoms represent a maladaptive method to regulate

negative affect (Heatherton & Baumeister, 1991; Safer, Telch, & Agras, 2001; Telch, Agras, &

Linehan, 2001). Therefore, DBT has been suggested to be a promising intervention for those

with eating disorders due to its efficacy in treating emotion dysregulation and the corresponding

maladaptive behaviors used to regulate affect in this population (e.g., binge/purge behaviors)

(Federici, Wisniewski, & Ben-Porath, 2012; Wisniewski, Safer, & Chen, 2007).

DBT Applied to Clients Diagnosed with Eating Disorders: A Review

To date, several studies have examined the effectiveness of DBT for the treatment of

individuals with eating disorders, including those diagnosed with binge eating disorder (BED),

bulimia nervosa (BN) and anorexia nervosa (AN). In the first randomized study of DBT and

binge eating disorder, Telch, Agras, and Linehan (2001) randomly assigned women to DBT

skills training and a wait list control condition. Results indicated that 89% of participants who
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received DBT skills were abstinent from binge eating as compared with only 12.5% in the wait

list control condition. Similarly, Masson, von Ranson, Wallace, and Safer (2013) randomly

assigned participants to a DBT or a wait list control condition. DBT treatment was self-directed

and consisted of an orientation, a copy of the DBT skills manual, and six 20-minute supportive

phone calls over 13 weeks. At the end of treatment 40% of DBT participants were abstinent

from binge eating as compared to 3.3% in the wait list control condition.

In order to control for the possible non-specific effects of therapy, Safer, Robinson and Jo

(2010) compared DBT with an active comparison group therapy (ACGT) modeled after

Markowitz and Sacks' (2002) manual of supportive therapy for chronic depression. Participants

were randomly assigned to either 20 group sessions of DBT or ACGT. Results indicated that

reductions in binge frequency were greater, achieved more quickly, and abstinence rates for

bingeing were higher for the DBT group than for ACGT group (e.g., 64% vs. 36%, respectively).

Despite these earlier gains, reported differences between groups were not maintained upon the 3,

6, and 12-month follow-up suggesting that DBT may be responsible for the initial rapid

treatment gains but not long term therapy gains in those with BED.

Given that bulimic symptoms have also been theorized to play a role in regulating affect,

several researchers have applied DBT treatment to those with bulimia. For example, Safer,

Telch, and Agras (2001), in a randomized treatment study assigned individuals diagnosed with

binge/purge behaviors to once weekly individual DBT treatment or a wait list control group. At

the end of 20 weeks, 28.6% of participants in the DBT treatment were abstinent from binge

eating/purging behaviors as compared with no participants in the wait-list control condition.

Hill, Craighead, and Safer (2011) randomly assigned participants to weekly sessions of DBT

skills plus appetite awareness training or to a six-week delay treatment control. The appetite
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awareness training done in conjunction with DBT skills assisted clients in identifying and

responding to internal hunger and satiety cues. At 6 weeks, the participants who were receiving

DBT plus appetite awareness training reported significantly fewer bulimic symptoms, had

greater abstinence rates from binge/purge behaviors, and were more likely to no longer meet full

or subthreshold criteria for BN as compared to the delay treatment control. At post treatment,

after both groups had received DBT treatment for a total of 12 weeks, 26.9% of the entire sample

who had received DBT treatment was abstinent from binge/purge episodes within the last month

and 61.5% no longer met criteria for bulimia.

Anorexia nervosa (AN), the eating disorder most refractory to treatment, has received

considerably less attention in the DBT literature. In an effort to close this gap, two preliminary

uncontrolled studies have been conducted (Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl,

and Miller, 2008). Salbach-Andrae, Bohnekamp, Pfeiffer, Lehmkuhl, and Miller in their 25-week

DBT program, found that women diagnosed with anorexia demonstrated an appreciable weight

gain post treatment and all individuals diagnosed with AN-restricting type no longer met

diagnostic criteria post treatment. However, approximately half of the sample still met criteria

for AN-purging subtype, BN or eating disorder-not otherwise specified (ED-NOS). Lynch et al.

(2013) have developed an adaptation of DBT titled, Radically Open-DBT (RO-DBT) treatment

specifically for those individuals who present with the restricting subtype of AN by targeting

emotional overcontrol (This adaptation is described more in depth in this volume). In an

uncontrolled trial with women diagnosed with anorexia nervosa-restricting subtype, Lynch et al.

(2013) found that after an average of 21.7 weeks of RO-DBT treatment, 35% of these patients

were in full remission, and an additional 55% were in partial remission. A significant increase in

BMI post treatment was also found.

While the aforementioned studies show promise for the use of DBT in those with eating

disorders, none of these studies specifically sought out to research eating disordered individuals

who also present with axis II pathology, such as borderline personality disorder. Approximately

56% of patients with ED present with Axis II pathology (Milos, Spindler, Buddeberg, & Crameri,

2003). Indeed, some researchers have speculated that eating disordered patients who typically do

not respond to treatment are likely individuals who are also diagnosed with borderline

personality disorder (Johnson, Tobin, & Dennis, 1990). Several studies suggest that ED patients

suffering from co-morbid personality disorders are likely to be those who do not respond to

traditional ED treatment and are perceived negatively by treatment providers (Woollaston &

Hixenbaugh, 2008). Research supports that patients with Axis II pathology are likely to respond to

difficult interpersonal situations with anger or lying (Mandal & Kocur, 2013). Our clinical

experience with this population supports these data and leads us to believe that those with Axis II

pathology are more likely to engage in willful behaviors such as lack of transparency, angry

outbursts, lying behavior and refusing medical advice when prescriptive and proscriptive approaches

around their ED are employed. While these behaviors may be evident in many individuals with

borderline personality disorder, the rule-bound nature of traditional eating disorder programs in

which proscriptive and prescriptive behaviors are enforced exacerbates these behaviors and tends to

increase willfulness.

The Problem: Being told how to manage the ED. The Result: Apparent Compliance vs. Active

Defiance

Traditional ED treatment programs are rule bound by design. Patients attending ED

treatments generally receive a prescription regarding what, when and how much they can eat, drink,

and move while at the same time other behaviors, such as excessive cutting of food or use of
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condiments are proscribed (i.e., prohibited). The prescriptive and proscriptive model employed in

traditional ED programs is effective for many, but not all ED patients. Specifically, the prescriptions

typically encountered in ED treatment (e.g., you must …) result in eating disordered patients who are

also diagnosed with borderline personality disorder refusing or rebelling against treatment providers

(I won’t…, you can’t make me….). The typical proscriptions (e.g., you cannot…) result in similar

responses (I will…. And you can’t stop me!). These reactive responses to being told “what to do”

may cause patients to be discharged from treatment prematurely, be seen by providers and loved ones

as signs of “not wanting to get better” and be those that negatively impact the therapeutic

relationship. The prescriptions and proscriptions typical of traditional ED treatments may

unintentionally lead to a dialectical dilemma, or extreme style of coping, for some patients.

Dialectical Dilemmas in EDs: Apparent Compliance vs. Active Defiance

In standard DBT, Linehan identified three dialectical dilemmas, or behavioral extremes,

common in BPD patients: Emotional Vulnerability vs. Self Invalidation, Unrelenting Crisis vs.

Inhibited Grieving, and Apparent Competence vs. Active Passivity (Linehan, 1993). Within DBT

theory, emotionally vulnerable individuals have been reinforced and therefore learn to alternate

between these extremes of over- and under- regulation, thereby continuing to engage in ineffective

behavior. In previous writings, we have described a common dialectical dilemma of eating behavior:

Rigid, Over-controlled Eating vs. Absence of an Eating Plan (Wisniewski & Kelly, 2003). We have

recently identified a second dilemma: Apparent Compliance vs. Active Defiance.

The authors suggest that the term Apparent Compliance describes behavior in which the

patient reports engaging in a sufficient amount of a behavior to demonstrate effort but not enough to

make appreciable change. When engaging in apparently compliant behavior, the ED patient’s

behavior and words result in the illusion that she is following through (i.e., complying) with
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treatment recommendations. As in standard DBT’s apparent competence, when the patient engages

in apparently compliant behavior, the environment will often attribute lack of change to not trying or

to manipulation. A typical example of Apparent Compliance is represented in the following

example. In a traditional ED program, a client who is suffering from dehydration might receive a

prescription to drink 32oz of a calorie beverage daily and be told to refrain from exercise until this

medical problem is resolved. This client may report to her therapist “I am drinking Gatorade every

day and haven’t gone to the gym!” Taken at face value, the statement “I am drinking Gatorade every

day and haven’t gone to the gym” appears as if the patient is compliant with the treatment

recommendations. However, upon further questioning by the therapist, the patient eventually

describes that she drank only 2oz. of Gatorade each day and was jogging in her neighborhood. So

while the statement “I am drinking Gatorade and haven’t gone to the gym” may be true, it is also

apparently compliant behavior.

Active Defiance, at the other end of the dialectic, connotes behavior that is willful and in

opposition to treatment recommendations. An ED patient is thought to be engaging in Actively

Defiant behavior when she directly refuses to follow treatment recommendations or program limits.

The patient who refuses to eat in her therapeutic meal after having an argument with another patient

may be exhibiting actively defiant behavior.

The authors conceptualize Apparent Compliance and Active Defiance as problematic since

these behaviors necessitate that the therapist act like a detective in order to obtain the full clinical

picture. If apparently compliant or actively defiant statements are taken at face value, they would

mislead the therapist regarding the patient’s progress and may block the therapist from accurate

assessment and recommendations regarding the patient’s problems.

The authors further conceptualize the patient’s apparently compliant or actively defiant

behavior in view of social learning theory. Specifically, we theorize that in the development or

maintenance of ED behavior, the patient may have learned that apparently compliant behavior

distracts people (therapist, family, friends, teacher, or coach) from focusing ED behaviors while

actively defiant behaviors may prompt individuals to decrease expected/desired change from the

patient. Take for example, the patient who, after returning from a friend’s house, was asked by her

mother “Did you and Jackie order pizza?” When the patient answers yes, mom’s anxiety and focus

on patient’s eating decreases and the conversation ends. However, if the mom had asked more

questions, she may have found that her daughter’s answer was indicative of Apparent Compliance, as

although the pizza was ordered, she hadn’t eaten any of it! The consequence of this Apparently

Compliant behavior is that mom’s focus on the patient’s eating decreases in that moment and the

patient is not blocked from or punished for ED behaviors.

An example of actively defiant behavior is noted in the case of Sue, who suffers from

anorexia nervosa, binge/purge type and Borderline Personality Disorder. Sue comes to her

individual therapy session stating that she is following her meal plan 100% and is not exercising nor

purging, though her weight is down 3 lbs from the week before. When the therapist recommends that

she may need to increase her intake, she becomes dysregulated and angry. She states that she is

“doing everything that is asked” and so therefore she “shouldn’t be expected to eat any more” than

she is currently. Without the conceptualization of the angry/aggressive behavior as Active Defiance,

a therapist may “blame the victim”, potentially see this weight loss as intentional, and fail to

understand the help that patient actually needs.

In order to address Dialectical Dilemmas, DBT therapists must focus on secondary targets.

Secondary targets in DBT are those issues addressed after the primary targets (i.e., staying alive,

behaviors that interfere with therapy; behaviors that interfere with quality of life), yet still must be
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tackled throughout treatment in order for an individual to learn to effectively manage their emotions.

For each dialectical dilemma in DBT, there are at least two secondary treatment targets (see Miller,

Rathus, & Linehan, 2009, for a more complete discussion) whose aim includes decreasing

maladaptive behaviors and increasing adaptive responses. With respect to the dialectical dilemma of

Apparent Compliance, the therapist needs to target increasing actual compliance and decreasing

passive, noncompliant behavior while for Active Defiance the therapist focuses on increase willing &

open behaviors and communication and decrease refusal. The authors also propose that the

therapist’s use of contingency management strategies can aid in the effective targeting of these

dialectical dilemmas.

Using Contingency Contracting to Address Apparent Compliance & Active Defiance

Contingency management is a general term in behavior therapy that is based on the notion

that the consequences of a behavior influence the probability of the behavior’s recurrence. Thus, it is

possible to increase or decrease the frequency of a behavior by influencing its associated

consequences. Reinforcement, punishment, extinction, shaping, and contingency contracting are all

examples of contingency management. Contingency management has been widely used to treat

various psychological problems including substance abuse (Hartzler, Lash, & Roll, 2012), autism

(Kohler, et al., 1995), obesity (Stalonas, Johnson, & Christ, 1978), and depression (Brannan &

Nelson, 1987) by reinforcing adaptive, skillful behaviors and extinguishing maladaptive behaviors in

the client. Contingency management strategies may be a highly effective and valuable intervention

for patients with complex and multi-diagnostic presentations or patients with recurrent therapy

interfering behaviors (e.g., angry outbursts, lack of weight gain, lying, etc.).

In response to our conceptualization of the dialectical dilemma of Apparent Compliance vs.

Active Defiance being triggered by being told how to manage ED symptoms , our private group
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practice treatment center in the Midwest (Cleveland Center for Eating Disorders), has adjusted the

way we approach setting and evaluating goals with ED patients who attend our DBT Day Treatment

Program (see Federici & Wisniewski, 2011; 2013; Federici, Wisniewski & BenPorath, 2012 for a

more through description of the program and for whom this treatment is appropriate). We propose

that a collaborative use of contingency contracting can prevent or directly address issues of

Apparent Compliance and Active Defiance in eating disorder patients.

Setting Step up and Step down criteria using Contingency Contracting

In our ED DBT program, we ask patients to make a commitment to DBT for one year at any

level of care (weekly DBT individual therapy (IT) and skills group, IOP, DTP). While our goal is to

help patients move themselves to the lowest level of care possible, the treatment of ED behaviors

generally requires treatment and accountability at various levels of care over the course of the illness.

In standard ED programming, changes in level of care and goals of treatment may be based

exclusively on the American Psychiatric Association (APA) practice guidelines for eating

disorders (American Journal of Psychiatry, 2000), the program itself, or insurance company

criteria. Instead, we propose setting these criteria collaboratively between the patient and her DBT

therapist. This model allows the patient to decide how to manage their own behavior. A patient sets

goals and criteria for moving levels of care, rather than this being set by the program. We attempt to

link the patient’s goals with what we have to offer (DBT treatment). We believe that decreasing

arbitrary consequences (something that seems to provoke ac/ad behavior) allows the patient to take

ownership of the goal as well as if she is meeting the goal.

When a patient begins DBT for ED treatment at our center, she works with her DBT therapist

using contingency contracting to determine how they will know that the patient will need or is ready

to step up or down a level of care. These criteria are set collaboratively and consider APA and
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insurance criteria, case conceptualization, learning history, response to previous treatment and

perhaps most importantly, the patient’s wise mind. These criteria include observable information

such as weight & vitals, but also data reported by the patient on DBT diary cards such as self-harm,

suicidality, restriction, binge eating, purging, compulsive exercise & drug use (for a discussion

around conceptualization of Targets in ED behaviors see Wisniewski, Safer & Chen, 2007).

All attempts are made to set contingencies collaboratively while practicing wise mind

(Linehan, 1993; a DBT skill that involves a synthesis of logic and emotion), and holding with the

therapist’s and patient’s needs/beliefs and understanding of the problem at hand as equally relevant.

If a disagreement in criteria arises, the therapist and patient continue to discuss the difference until a

synthesis is found or one of the parties offers enough wise-minded evidence to convince the other

party to alter her opinion.

In order for this model/intervention to be effective, the patient needs to understand behavior

management and theory. We therefore teach patients the way that both classical and operant

conditioning work. Patients are taught to notice both the intended and potentially unintended

consequences of their behavior as well as the fact that consequences can affect behavior even without

their awareness. Patients therefore better understand how to set goals that she wants to meet and how

to hold herself accountable for meeting or not meeting the goals, thereby decreasing the situations

that are likely to trigger apparently compliant or actively defiant behavior. The therapist’s job in

contingency management is not to require the patient to set a particular contingency for a target

behavior. Rather, the therapist’s goal is to notice with the patient how her choice of contingencies

does or/does not lead to the patient’s desired outcome. By having the patient set her own goals and

contingencies, thereby decreasing the therapist’s role in pre- or proscription, we believe that this will

decrease the need for the patient to employ apparently Compliant or Actively Defiant behaviors.
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Let’s consider the case of Mary who is trying to decrease purging behavior and is currently

purging several times per day. Mary has also decided that decreasing to purging to once/day or less

would be an indicator (among others) that she is ready to step down from day treatment to outpatient

care. Mary wants to step down to outpatient as soon as possible, as she really wants to get back to

her job as a barista. That being said, Mary and her DBT therapist agree that in past treatments, Mary

has lied about symptoms to get be able to be allowed to step down (demonstrating Apparent

Compliance) and that she wants to do things differently this time.

In order to meet her step down criteria, Mary may set a goal of decreasing purging behavior

to 1/day or less and believes that the natural consequences of feeling better about herself will

motivate her to meet this goal. They also discuss the potential for Mary to report apparently

compliant behavior and how they will attempt to block this behavior (rating urges to lie on diary

card; asking her friends at work not to call her to cover shifts). The DBT therapist suggests to Mary

that given how hard it has been in the past for Mary to change this behavior, relying on natural

consequences alone may not be sufficient to elicit change. Mary feels strongly that she is “in a

different place” and wants to try to set this goal using the natural consequences for motivation for

one week. The DBT therapist and Mary agree that since she is currently medically stable, trying this

goal for one week is a reasonable plan. After this one week period, Mary and her DBT therapist

observe that Mary is purging >2/day. As part of DBT treatment, they collaboratively conduct a

behavior chain analysis to understand what is getting in the way of Mary meeting her goal. They

discover jointly that the thoughts of “I will feel better about myself if I limit my purging” are fleeting

and quickly overwhelmed by the anxiety of not purging. They note urges to lie about purging

behaviors are somewhat elevated and discuss. The DBT therapist then reviews learning theory and

how new behavioral patterns develop. Based on past personal experience, Mary believes that

working to avoid a negative consequence will likely be more motivating for her to change behavior
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than setting up a reward for limiting purging. Mary further believes that if the negative consequence

she is avoiding is in her control (rather than in the control of others), she will be less likely to employ

apparently compliant behaviors. Mary therefore decides to look at a picture of tooth decay (a natural

negative consequence of purging) for 15 minutes on each day that she purges more than once.

Based on previous behavior chain analyses that Mary and her therapist have conducted on purging

episodes, she is aware that one of the intended effects of purging are to “get rid of food” that she has

eaten to potentially avoid weight gain. Mary decides that if she purges more than once each day, she

will plan to eat to replace the food she purged in order to block this goal. Once these goals are

collaboratively set, it is the therapist’s job to gently but firmly guide the patient to hold herself to the

criteria they have jointly identified.

Conclusion

There are strong data to support the use of modified, skills only DBT in treating ED patients

diagnosed with BED or BN. While the data are still emerging, there does appear to be promising

evidence for the use of DBT in individuals who are also diagnosed with any ED as well as with BPD.

Future research in the form of randomized controlled trials will be needed to solidify effectiveness of

this model. That being said, there is a need in the literature for papers delineating conceptual and

practical strategies for use with this difficult population. The current paper detailed a previously

undescribed dialectical dilemma in the ED/DBT literature: Apparent Compliance vs. Active

Defiance. The authors suggest that the term Apparent Compliance describes behavior in which the

patient reports engaging in or appears to display, a sufficient amount of a behavior to demonstrate

effort but not enough to make appreciable change; while Active Defiance connotes behavior that is

willful and in opposition to treatment recommendations. The authors propose the development of

this dialectical dilemma in the context of learning theory, and offer that the use of collaborative

contingency contracting to effectively address these behaviors. While there is some preliminary
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evidence to suggest that a more flexible approach with ED patients also diagnosed with BPD is

effective (Federici & Wisniewski, 2013), future studies should attempt to isolate whether this aspect

of treatment may be contribute to better outcome.

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