Finding a Life Worth Living: Dialectical Behavior Therapy in the Recovery Journey - Kay Watt

Finding a Life Worth Living: DBT in the Recovery Journey

Insights from Kay Watt, MAPC, LPC, CEDS, Co-Founder and Co-Executive Director, EDCASA

The treatment philosophy in the Eating Recovery Center family of programs leverages various evidence- based therapeutic interventions proven to effectively address eating disorders, including Dialectical Behavior Therapy (DBT). Ongoing use and mastery of DBT skills in the recovery journey can help root out the last strongholds of an eating disorder. In this month’s edition of Lasting Recovery, Kay Watt, MAPC, LPC, CEDS, Co-Founder and Co-Executive Director of Eating Disorder Center of San Antonio ( (EDCASA), shares insights about foundational DBT principles and offers simple strategies for applying DBT skills throughout the recovery journey.

DBT is rooted in the development of emotional regulation skills that teach adaptive affective regulation abilities so that individuals no longer uses maladaptive and/or impulsive behaviors and instead learn how to modulate emotions in an effective way. (Linehan, 1993)  DBT emphasizes the development of four core skill sets to support a life of recovery: mindfulness skills, distress tolerance skills, emotional regulation skills and interpersonal effectiveness skills. While rooted in skill development, DBT is much more than a set of skills. Rather, it is a set of assumptions, principles and strategies that help patients build a life worth living. For individuals navigating eating disorder recovery following discharge from the structured treatment environment, there are three primary goals:

• Practice skills in all relevant contexts.  For example, if you can use your voice with your clinician, practice using it with your friends, your parents and your boss.
• Achieve and embrace “ordinary happiness,” and manage the ups and downs of everyday life.
• Gain a sense of spiritual fulfillment, or a sense of connectedness to the greater whole. In other words, move from being “apart” to being “a part of,” with a capacity for experiencing joy and freedom.

Working toward these goals can be challenging.  Fear of failure, uncertainty, the overwhelming nature of a return to daily life and even therapy fatigue can get in the way of recovery. Fortunately, the DBT framework includes awareness and acceptance of where you are and the feelings you have now, balancing your recovery stage with skills to push for the change you need to stay on the recovery path.  This compassionate yet practical stance is reflected in the assumptions DBT makes about patients:

• Patients are doing the best they can.
• Patients want to improve.
• Patients find that life is unbearable with the eating disorder.
• Patients must learn new behaviors in all relevant contexts.
• Patients may not have caused all of their own problems, but they have to resolve them regardless.
• Patients need to do better, try harder and be more motivated to change.
• Patients cannot fail at DBT.

In an effort to support you at any stage of the recovery journey, below are several key principles and assumptions of DBT, as well as simple strategies for applying those principles in daily life.

Nurture Your Wise and Flexible Mind

DBT teaches that effective action and a life worth living are attained by developing, through skill mastery, the ability to do the next right thing as determined by one’s wise and flexible mind. This is the ultimate goal of all skill development.

• Our wise mind is a synthesis of our emotional mind and our reason mind. Wise mind arises as a felt sense of what the next effective action is.
• Our flexible mind is a synthesis of the fixed mind and fatalistic mind. Finding the balance can be particularly helpful for individuals with a rigid approach to life. “I already know the answers,” “I don’t have a need for more information” “—have you ever uttered these phrases, or felt an active resistance to new information? That’s your fatalistic mind telling you, “The things that are causing me pain are not going to change, so what’s the point?”

Access to your wise and flexible mind can be developed just like any other skill.  Daily mindfulness practice develops your ability to be aware, to observe and to describe while participating in life. Skills to help you nurture a wise and flexible mind include:

• Throwing yourself in all the way
• Adopting a non-judgmental stance towards yourself and others
• Being one-mindful instead of multi-tasking
• Letting go of “It’s not fair” and “It’s not perfect,” and opting instead for effectiveness

Practice Acceptance

A primary assumption of DBT is that we often have to deal with problems that we did not cause. Accepting reality despite sad, painful or frustrating circumstances helps us to move forward, even when next steps may be challenging or emotional. The key to acceptance is validation, and the key to validation is finding the “grain of truth.” To do so, engage in the five levels of acceptance:

• Level 1:  Observe mindfully the sensation, emotion or thought
• Level 2:  Describe the sensation, emotion or thought fully
• Level 3:  Imagine what is unthought and unfelt behind the emotion
• Level 4:  Think about how your sensation, emotion or thought makes sense in the context of your personal history
• Level 5:  Think about how your sensation, emotion or thought makes sense in the present context
• Level 6:  Be real with yourself

It is okay to feel how you feel. Accepting is letting things be as they are. It is also okay to have painful emotions. They have meaning and purpose, and you can regulate these emotions using your skills to safeguard yourself from becoming overwhelmed. The following mantras can help facilitate acceptance in eating disorder recovery:

• I am okay just as I am, and I need to continue to grow and change.
• My parents were and are doing the best they can, and they need to try harder and do better.
• Life lived in awareness and curiosity—while challenging and scary—is also exciting and rewarding.
• My recovery journey is my own, and it is good.

Make Changes

The notion of change is the balance to acceptance in DBT—individuals know they must change to escape the hold of their eating disorder, and to change they must accept themselves where they are (their starting point). In addition to enacting meaningful change in the treatment environment—ie. weight restoration, interrupting eating disorder behaviors—change often must  occur in our respective home environments. Where you live, who you live with, where you work or go to school are questions that often have to be addressed following structured treatment. The same skills used to stop eating disorder behaviors and to learn to care for the self can be used throughout the recovery journey to make wise and effective decisions in daily life. Change is inevitable in life, and the following DBT strategies can help you evaluate thoughts, feelings and behaviors to ensure they are helping you move in valued directions.

• Pros and Cons—Have a decision to make? Big or small, doing a DBT Pros and Cons is a simple tool to help you explore your options and evaluate the viability of your choices before making decisions about change. Remember to complete all four squares:  advantage of change, advantage of not changing, disadvantage of change, disadvantage of not changing.
• Behavior Chain Analysis –Use chains daily to look at what vulnerabilities, events, actions, thoughts, feelings and sensations led up to your problem behavior. Also, create a solution analysis to determine how you could approach the situation more skillfully next time. Remember to validate, not shame yourself through this exercise. Every problem behavior gives an opportunity to develop a more skillful approach to your life.
• Self-Monitoring—Keep a diary card.  There are several apps for this exercise should you prefer an electronic tool.
• Orienting—It is important to be mindfully aware of your recovery journey.   Check in with yourself regularly, asking:
  • Where have I been?
  • Where am I now?
  • Where am I going?
  • What are my values?
  • What goals do I need to set?

Be Curious

You likely had some profound realizations in the structured treatment environment—these important realizations continue throughout the recovery journey. Learning about yourself and becoming skillful in your life flows naturally from curiosity. Conversely, shaming and punishing ourselves actually may lead to more behaviors. There is no need to search out things to be curious about—each day will bring its own opportunities, including:

• Ineffectiveness in your relationships with others
• A desire to cling to the eating disorder as your identity
• Perfectionism and competitiveness at school, work or just with yourself
• Your relationship with exercise
• Disturbing automatic thoughts
• Unsettling emotional reactions

Connection, Connection, Connection

DBT teaches us how to have strong, effective relationships, how to use our voice and how to establish appropriate intimacy.  Relationships with recovery-minded people are a powerful way to strengthen your own growth and recovery and to encourage others in theirs.  Whether it’s a formal support group facilitated by an eating disorder clinician, a casual meeting of individuals in recovery or a friendly one-on-one over a cup of tea, it is important to maintain and nurture strong connections with others. Below are several themes that a Texas-based recovery group said characterized their time together. Consider working these ideas into your conversations with others:

“We talk about the real world and real people. We keep it raw and vulnerable, sharing our ‘ugly’ and our ‘pretty.’ We experience a sense of spiritual connection. We can be authentic and feel like our connection helps us trust and feel like others “get it.” We find that when the world is crazy we can connect with each other and find sanity/centeredness. We can be honest about all the Pandora’s box of layers that challenge our recovery, and as in her box, we find that the last thing that comes flying out is HOPE.”  

Final Thoughts

Having a life worth living is more than recovery from eating disorder symptoms. I often have patients—current and past—ask the question “When can I say I am recovered?” In responding, I think about the dialectical nature of that question and tell them that they are “recovered” when they realize that that is the wrong question to ask. Things are not black and white, ill and sick. I tell them that they are firmly on the recovery path when they realize that people are sunsets not math problems, and when it is no longer about falling down the hole but knowing the way out.

DBT teaches that you cannot fail on the path of recovery. Every step you take is an opportunity to learn more about yourself and the world you live in.  DBT is a set of skills that helps you stay on the path. It takes practice to learn and use skills in such a life-transforming way. We have to first get the skills into our heads and then move the skills from our heads into meaningful action in our everyday lives. Be skillful, be kind to yourself, remove the word “failure” from your vocabulary and stay connected.  You are not alone—reach out not if, but when you first realize you need help.

About Eating Disorder Center of San Antonio (EDCASA)

A partner of Eating Recovery Center, Eating Recovery Center of San Antonio, formerly EDCASA, is an intensively trained DBT center providing treatment for patients and families with eating disorders. In addition to DBT, Eating Recovery Center of San Antonio also leverages other functional contextual therapies, including Acceptance and Commitment Therapy (ACT) and Cognitive Behavioral Therapy (CBT). In light of the common emphasis on helping patients and families make sense of the “big picture” and understand how thoughts, feelings, experiences and memories impact communication, interactions and relationships,Eating Recovery Center of San Antonio’s eating disorder treatment model moves easily between these therapeutic approaches, incorporating each into the recovery process.