Eating Disorders

The Journal of Treatment & Prevention

ISSN: 1064-0266 (Print) 1532-530X (Online) Journal homepage: https://www.tandfonline.com/loi/uedi20

Dialectical behavioral therapy skills group as an

adjunct to family-based therapy in adolescents
with restrictive eating disorders

Claire M. Peterson, Ashley M. Kroon Van Diest, Constance A. Mara & Abigail
Matthews

To cite this article: Claire M. Peterson, Ashley M. Kroon Van Diest, Constance A. Mara
& Abigail Matthews (2019): Dialectical behavioral therapy skills group as an adjunct to
family-based therapy in adolescents with restrictive eating disorders, Eating Disorders, DOI:
10.1080/10640266.2019.1568101

To link to this article: https://doi.org/10.1080/10640266.2019.1568101

Published online: 23 Jan 2019.

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EATING DISORDERS
https://doi.org/10.1080/10640266.2019.1568101

Dialectical behavioral therapy skills group as an adjunct to

family-based therapy in adolescents with restrictive eating
disorders
Claire M. Petersona,b, Ashley M. Kroon Van Diestc,d, Constance A. Maraa,b,
and Abigail Matthews a,b
a
Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center,
Cincinnati, Ohio, USA; bDepartment of Pediatrics, College of Medicine, University of Cincinnati,
Cincinnati, Ohio, USA; cDepartment of Pediatric Psychology and Neuropsychology, Nationwide
Children’s Hospital, Columbus, Ohio, USA; dDepartment of Pediatrics, The Ohio State University,
Columbus, Ohio, USA

ABSTRACT ARTICLE HISTORY

Dialectical behavior therapy (DBT) is commonly used in the Received 16 October 2018
treatment of eating disorders (ED), yet few studies have Revised 31 December 2018
examined the utility of DBT skills groups as an adjunct to Accepted 07 January 2019
evidence-based therapy for ED. Thus, we sought to examine
the preliminary efficacy of a DBT skills group as an adjunct to
Family-Based Treatment (FBT) for adolescent restrictive ED.
Our preliminary pilot study included 18 adolescent girls
ages 13–18 (M = 15.3, SD = 1.64) with restrictive ED, including
Anorexia Nervosa (AN; N = 10), Atypical Anorexia Nervosa
(AAN, N = 5), and Other Specific Feeding or Eating Disorder
(OSFED; N = 3). All participants were enrolled in a 6-month,
weekly DBT skills group and were concurrently receiving
family-based treatment (FBT). Participants who completed
the intervention experienced large effect sizes for increases
in adaptive skills (Cohen’s d = .71) and decreases in general
dysfunctional coping strategies (Cohen’s d = .85); and small to
medium effect sizes for decreases in binge eating (Cohen’s
d = .40) and increases in percent expected body weight (%
EBW; Cohen’s d = .32). Finally, small effect sizes were evi-
denced in decreases in Global EDE-Q scores (Cohen’s d = .26),
EDE-Q restraint (Cohen’s d = .29) and CDI scores (Cohen’s
d = .28). Our study presents promising preliminary data sug-
gesting that adolescents with restrictive EDs receiving FBT
could benefit from an adjunctive DBT skills group. Feasibility
of and considerations for tailoring a DBT skills group to an
outpatient ED treatment program are discussed.

Clinical Implications
● Dialectical behavior therapy skills group is a promising adjunct to out-
patient family-based treatment in patients with restrictive eating disorders

CONTACT Claire M. Peterson claire.peterson@cchmc.org Division of Behavioral Medicine and Clinical

Psychology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati, Ohio 45229, USA
Color versions of one or more of the figures in the article can be found online at www.tandfonline.com/uedi.
© 2019 Taylor & Francis
2 C. M. PETERSON ET AL.

● Dialectical behavior therapy skills group increases adaptive skill use such as
emotion regulation and distress tolerance in patients with restrictive eating
disorders
● Dialectical behavior therapy skills group decreases maladaptive coping
strategies in patients with restrictive eating disorders

Family-Based Treatment (FBT) is the most effective intervention for anorexia

nervosa (AN) among adolescents. Randomized clinical trials (RCTs) show
that FBT leads to recovery in approximately 50% of the adolescents by the
end of treatment, with few relapses among those who achieve recovery status
at treatment termination (Eisler et al., 2000; Le Grange et al., 2014; Lock & Le
Grange, 2015). Other studies indicate that FBT is superior to individual
therapy alone for reduction of eating disorder (ED) symptoms (Lock et al.,
2010). Compared to systemic family therapy (SyFT), FBT resulted in fewer
hospital admissions and more rapid weight gain (Lock et al., 2015).
In the course of AN, the neurobiological changes that occur secondary to
malnutrition make it difficult for the adolescent to appropriately feed them-
selves and parents are looked upon as the primary resource for recovery
(Lock et al., 2010). FBT applies a family systems approach and mobilizes
parents to take control over the adolescent’s eating via behaviorally focused
interventions, including setting concrete goals for caloric intake and weight
gain, coaching parents to support each other and their child throughout the
weight restoration phase of treatment, and reducing other illness driven
behaviors, such as excessive exercise (Lock & LeGrange, 2015). In FBT,
weight restoration is prioritized and the development of coping skills to
manage distress and emotion dysregulation is not a primary focus. It is
noteworthy that interventions prescribed within FBT can prompt and/or
exacerbate negative emotion states and parent-child conflict, given adolescent
resistance to and parent discomfort in taking control over eating behaviors
during the weight restoration phase. For example, depressive symptoms are
often co-morbid with AN and are thought to occur secondary to the effects
of malnutrition (Pollice, Kaye, Greenco, & Weltzin, 1997). Despite this
hypothesis, individuals in long-term recovery from AN still exhibit lingering
symptoms of depression (Holtkamp, Muller, Heussen, Remschmidt, &
Herpertz-Dahlmann, 2005). It has been suggested that the lack of focus on
skills development in FBT is a potentially limiting factor and could account
for the lack of recovery in up to 50% of the patients who complete the
intervention (Eisler et al., 2000).
For adolescents with AN, dialectical behavior therapy (DBT) could be
particularly useful for increased awareness of and ability to identify emotions,
rather than avoid them as is characteristic of many individuals with the
disorder (Casper, Hedecker, & McClough, 1992). Further, a growing body
of literature has focused on the role of emotion dysregulation in AN which
 EATING DISORDERS 3

posits that eating disordered behaviors perpetuate a cycle of invalidation by

loved ones and subsequent emotion dysregulation. Eating disorder symptoms
then intensify as they are used as maladaptive ways of coping with emotion
dysregulation (Haynos & Fruzzetti, 2011). DBT is an empirically supported
treatment originally designed to treat borderline personality disorder
(Linehan, 1993) with a primary focus on skill development targeting
increased mindfulness, distress tolerance, emotion regulation, and interper-
sonal effectiveness. The theoretical rationale for applying DBT to eating
disorder treatment is that ED behaviors are maladaptive attempts at reducing
negative affect and that DBT could reduce ED behaviors by promoting more
effective ways of managing distress (Telch, Agras, & Linehan, 2001). Research
consistently highlights that negative urgency or the tendency to act rashly in
response to negative mood states, is highly predictive of both objective binge
eating (OBE) and self-induced vomiting (SIV; Davis-Becker, Peterson, &
Fischer, 2014; Fischer, Peterson, & McCarthy, 2013; Fischer, Smith, &
Cyders, 2008; Peterson & Fischer, 2012).
In recent years, DBT has been utilized for the treatment of adolescent ED
(Wisniewski & Kelly, 2003) and has been shown to be effective in reducing
ED symptoms on both inpatient, intensive outpatient, and outpatient levels
of care (Johnston, O’Gara, Koman, Wood Baker, & Anderson, 2015; Salbach,
Klinkowski, Pfieffer, Lehmkuhl, & Korte, 2007; Salbach-Andrae, Bohnekamp,
Pfeiffer, & Lehmkuhl, 2008). A recent pilot study demonstrated that DBT was
effective in reducing binge eating, purging, self-harm, and depressive symp-
toms in adolescents with bulimia nervosa (Fischer & Peterson, 2015).
However, the only study to examine DBT in outpatient treatment for ado-
lescents with restrictive EDs assessed the use of the traditional DBT protocol
among individuals with ED (i.e., simultaneous individual and skills group
DBT, regular telephone check-ins with DBT therapists) and not in conjunc-
tion with FBT (Salbach-Andrae et al., 2008). One study to date has shown
preliminary efficacy of DBT skills as an adjunct to FBT in reducing ED
symptoms in adolescents in an intensive outpatient setting where youth were
attending treatment for 3 h per day, three days per week (Johnston et al.,
2015). Participants in the study gained a significant amount of weight and
experienced a significant reduction in ED cognitions from pre- to post-
treatment. Despite these improvements, the frequency of binge eating and
self-induced vomiting did not decrease (Johnston et al., 2015). No studies to
date have examined the efficacy of DBT skills as an adjunct to FBT in
restrictive EDs in the outpatient setting.
This preliminary pilot study sought to evaluate the effectiveness of
a 6-month DBT group intervention as an adjunct treatment to FBT for
adolescents with restrictive ED. Of note, the DBT skills group had rolling
admissions and thus, participants entered the group throughout different
time periods while already in FBT. The primary aims of this pilot study were
4 C. M. PETERSON ET AL.

to assess changes in ED and depressive symptoms in adolescents who

completed a DBT skills group while concurrently receiving outpatient FBT
and to evaluate the frequency by which participants implemented adaptive
DBT coping skills throughout the intervention. We hypothesized that DBT
group pilot participants would experience a decrease in ED symptoms and
depression from beginning to end of group. We also hypothesized that
participants would exhibit a significant increase in their use of DBT-
specific coping skills for distress tolerance, emotion regulation, and inter-
personal effectiveness from beginning to the end of group.

Methods
Participants
Participants included 18 adolescent females ages 13–18 (M = 15.3 years,
SD = 1.64) who met criteria for a restrictive eating disorder (AN, AAN,
OSFED) and received FBT within a multidisciplinary ED program at
a Midwestern children’s hospital. Twenty-one adolescents were referred for
the study by their FBT therapists during the recruitment period. Of note, the
DBT skills group had rolling admissions and thus, participants entered the
group throughout different time periods while already in phase I of FBT. All
study participants were screened by study staff via chart review prior to their
baseline visit to confirm study eligibility criteria of: 1) meeting criteria for
a restrictive ED; 2) concurrent enrollment in FBT; 3) English speaking. Three
adolescents referred to the study were ineligible to participate due to failure to
meet diagnostic criteria for a restrictive ED. Of the 18 adolescent girls who
initiated the DBT skills group, 11 were diagnosed with anorexia nervosa-
restricting type, 2 with anorexia nervosa-binge eating/purging type, 4 with
atypical anorexia nervosa, and 1 with other specified feeding and eating disorder
(OSFED) with restrictive symptoms. The 1 participant with OSFED other than
AAN had restrictive eating but did not meet diagnostic criteria for either AN or
AAN. Of the 18 initial participants, 10 had co-morbid diagnoses. One partici-
pant had a co-morbid borderline personality disorder, one was diagnosed with
depression, one was diagnosed with an anxiety disorder, one was diagnosed with
gender dysphoria, and 6 were diagnosed with both an anxiety disorder and
depression. In total, 12 of these 18 attended the majority of sessions for the
6-month group and completed baseline and post-intervention questionnaires.
Six participants dropped out of the group: three because they were admitted to
higher levels of care for their ED, one experienced transportation barriers, and
two expressed dissatisfaction with the group (e.g., too skills based, wanted
a process group). Of note, dropped participants were not more likely to have
a co-morbid diagnosis than treatment completers. Participants who dropped out
of group were significantly younger (M = 14.2 years, SD = 1.2) than those who
 EATING DISORDERS 5

completed the intervention (M = 15.9 years, SD = 1.6; t = −2.41, p < .05).

Participants who completed the intervention did not differ from participants
who dropped on ED symptoms, BMI, depressive symptoms, negative urgency,
adaptive skill use, or dysfunctional coping strategies.

Measures
The eating disorder examination questionnaire (EDE-Q; Fairburn & Beglin, 2008)
The EDE-Q is a 28 item self-report questionnaire that assesses the frequency
of ED attitudes and behaviors over the past 28 days (Fairburn & Beglin, 2008;
Luce & Crowther, 1999). It yields four subscale scores: Restraint, Shape
Concern, Weight Concern, and Eating Concerns, as well as a Global Score.
Further, the EDE-Q assesses the frequency of specific eating disorder beha-
viors over the last month including OBE episodes and SIV episodes. The
EDE-Q shows good convergence with the interview-based Eating Disorder
Examination (EDE; Berg, Peterson, Frazier & Crow, 2011). Reliability for the
EDE-Q Global Scale was acceptable in the current study (α = .94).

The DBT ways of coping checklist (DBT-WCCL; Neacsiu, Rizvi, Vitaliano,

Lynch, & Linehan, 2010)
The DBT-WCCL is a 59-item self-report measure to assess the use of DBT
skills. There are three factors: DBT Skills, Dysfunctional Behaviors, and
Blaming Others. Of note, for the purposes of this study, the Dysfunctional
Behaviors and Blaming Others subscales were combined to form
Dysfunctional Coping Skills (Neacsiu et al., 2010). The DBT Skills scale
assesses the degree to which individuals are using the four skill sets from
DBT skills training: distress tolerance, emotion regulation, mindfulness, and
interpersonal effectiveness. The measure has shown to be a valid assessment
of the use of DBT skills in prior studies (Ward-Ciesielski, 2013).

The child depression inventory-2 self-report short version (CDI 2:SR[S];

Kovacs, 2011)
The CDI 2: SR[S] examines the presence of depressive symptoms over the
past 2 weeks in children (younger than the age of 18). The questionnaire
contains 12 items, which describe an idea or feeling in three different ways,
and the patient is instructed to pick the sentence that best describes them.
Higher scores are indicative of greater depressive symptoms.

DBT diary card

Diary cards are used in DBT to facilitate the self-monitoring and assessment
of symptom change and skill use. All participants were asked to complete and
return diary cards on a weekly basis. Specifically, participants recorded the
frequency of target ED behaviors, including restriction, SIV and OBE
6 C. M. PETERSON ET AL.

episodes; rated urges to engage in target behaviors; identified challenging

emotional experiences (e.g., anxiety, sadness); and recorded whether or not
coping skills were implemented (See Appendix 1). Diary cards were collected
weekly at the start of each group and were not reviewed in the group since
standard practice in DBT skills group is to not explicitly discuss target
behaviors. Instead, participants were encouraged to share their diary cards
with their FBT therapists who were asked to review symptoms and reinforce
diary card use. Participants were reinforced for diary card completion with
a sticker to add to their skills group binder in group and non-completion was
discussed.

Expected body weight (EBW)

For all study participants, weight (kg) and height (cm) were within 7 days of
baseline and again within 7 days at the end of the 6-month DBT skills group.
These data were extracted from the medical record and were obtained from
multidisciplinary follow-up visits within the outpatient ED program. EBW
was calculated for each time point based on CDC growth charts specific to
age and sex (Kuczmarski et al., 2000).

Procedure
Participants completed a battery of self-report questionnaires including mea-
sures of depressive symptoms, trait impulsivity, disordered eating symptoms,
and ways of coping. At the baseline assessment, participants agreed to parti-
cipate via assent while their parents provided consent. Participants were
allowed to participate in DBT skills groups regardless of their decision to
allow their data to be used for research purposes. All participants completed
questionnaires even if they opted not to be part of the study, as data were used
for clinical purposes in addition to research. Participants completed all base-
line study measures prior to participation in their first DBT skills group. They
were asked to arrive approximately 15–30 minutes before their first group
session began in order to complete questionnaires and provide assent/consent
if they chose to participate in the research study. All participants who com-
pleted the 6-month skills groups completed the same questionnaires, with the
exception of trait impulsivity as this was not expected to change in 6 months’
time, immediately following completion of their last skills group. This study
was approved by the Institutional Review Board.
The DBT skills group was led by a licensed clinical psychologist and co-led
by a post-doctoral fellow. Study participants were all concurrently receiving
outpatient FBT and were in phase I at the same eating disorders treatment
program. They attended skills group on a different night of the week than
their FBT appointment. DBT skills group leaders communicated with FBT
therapists each week to update them on the material covered in the group
 EATING DISORDERS 7

and if there were any concerns for their patient (e.g., patient endorsing SI;
asking to speak with a group leader due to feeling overwhelmed). Individual
concerns were encouraged to be saved for discussion in each participant’s
FBT session (e.g., target behaviors).
The format of the DBT skills group was adherent to Marsha Linehan’s
24 week Standard Adult DBT Skills Training Schedule (Linehan, 2014). All
study participants received a binder of the DBT skills workbook to take home
with them and bring back to each group. This schedule of skills included:
Introduction to DBT and review of group rules, 2 weeks of mindfulness, 6
weeks of distress tolerance, 2 weeks of mindfulness, 7 weeks of emotion regula-
tion, 2 weeks of mindfulness, and 5 weeks of interpersonal effectiveness. New
patients could join the group at the beginning of a new module. The structure of
each skills group session included: mindfulness activity, collect diary cards,
homework review, the overview of new content, and assignment of homework.
Participants received a sticker and verbal praise for reinforcement of homework
completion. Since the group had rolling admissions, we would conduct group
introductions and review of group rules each time a new group member joined.
Group rules were consistent with the DBT treatment manual (Linehan, 2014).
Upon completion of the group, participants received a graduation certificate,
verbal praise from the group, and then completed a post-assessment.
Participants also had the option of completing a second round of skills group
if they chose. Study participant weights were obtained at their medical appoint-
ments and for study, purposes were obtained via chart review.

Planned analyses
Pre and post data on the 12 DBT skills group completers were used for
analyses. Descriptive statistics of treatment completers were analyzed and
presented in Table 1. Cohen’s d effect sizes were calculated for pre to post-
treatment changes in OBE episodes, SIV episodes, Global EDE-Q scores, CDI
scores, and DBT skill use. OBEs and SIV were assessed using the EDE-Q, not
diary cards. Finally, statistical process control charts were used to plot
variation in our outcomes over the course of the study from the weekly
diary cards. This is a common method for presenting and analyzing data over
time to drive improvement (Davidoff, Batalden, Stevens, Ogrinc, & Mooney,
2008). Data are plotted in time order. A control chart always has a central
line for the average, an upper line for the upper control limit and a lower line
for the lower control limit (where the control limits correspond to approxi-
mately ± 3 standard deviations from the mean). These charts help to differ-
entiate common cause variation (unknown, random) from special cause
variation (attributable to a specific reason). A special cause variation can be
determined by using the following rules: 1) A point outside either the lower
or upper control limits; 2) Two out of three consecutive points near a control
8 C. M. PETERSON ET AL.

Table 1. Assessment data at baseline and end of treatment.

Baseline End of Treatment
EDE-Q Global 3.80 (1.52) 3.41 (1.51)
DBT Adaptive Skill Use 1.57 (.50) 1.89 (.39)
DBT Dysfunctional Coping 2.17 (.48) 1.72 (.58)
DBT Blaming Coping 1.24 (.50) 1.09 (.68)
CDI 12.17 (5.37) 9 (5.53)
Objective Binge Eating .50 (1.0) .17 (.58)
Self-Induced Vomiting 6.58 (13.93) 4.0 (8.57)
Percent Ideal Body Weight 94.7 (11.17) 98 (9.14)
Values are means (standard deviations)

limit; 3) Eight consecutive points above or below the centerline (mean); or 4)

Six consecutive points increasing or decreasing.

Results
Descriptive statistics are presented in Table 1.
For the 12 individuals who completed the 6-month DBT skills group, there
were large effect sizes for both increases in adaptive skills (Cohen’s d = .71)
and decreases in general dysfunctional coping strategies (Cohen’s d = .85)
from pre-treatment to post-treatment. There were small to medium effect
sizes for decreases in OBE episodes (d = .40) and increases in % EBW
(Cohen’s d = .32). At post-treatment, 92% of the participants were abstinent
from OBE episodes compared with 75% at pre-treatment. Finally, there were
small effects sizes in decreases in global EDE-Q scores (Cohen’s d = .26),
EDE-Q restraint (Cohen’s d = .29) and CDI scores (Cohen’s d = .28).

Change in target behaviors

For the 12 participants who completed diary cards each week for six months, we
plotted the average reported behaviors each week over the entire group using
control charts (See Figure 1 for an example of behaviors that were tracked using
diary cards). At week 9, restriction started to decrease significantly. We saw this
same trend with other target behaviors such as restricting which also trended
down on self-report form diary cards, but did not reach significance because of the
rebound at about week 17. Of note, for all target behaviors, we saw a trend of
behaviors decreasing at week 9 and then increasing at week 17. Mean weekly
adaptive skill use increased from 19 in the first 16 weeks to 25 in the last 10 weeks.

Discussion
This pilot study is the first to examine the preliminary, exploratory efficacy of
an adjunct DBT skills group to outpatient FBT in adolescents with restrictive
ED. In line with our hypotheses, adolescents who completed the 6-month
 EATING DISORDERS 9

40

35

30
Restricting

25

20

15

10

0
Week 1
Week 2
Week 3
Week 4
Week 5
Week 6
Week 7
Week 8
Week 9
Week 10
Week 11
Week 12
Week 13
Week 14
Week 15
Week 16
Week 17
Week 19
Week 20
Week 21
Week 22
Week 23
Week 24
Week 25
Week 26
Week 27
Labels
Score Baseline Average Control Limits

Figure 1. Control chart of restriction as a target behavior from baseline to end of treatment.

DBT skills group experienced reductions in ED and depressive symptoms,

increases in adaptive skill use including emotion regulation and distress
tolerance, and, notably, gained significant weight. This is consistent with
Johnston and colleagues’ (2015) findings among adolescents who received
concurrent DBT and FBT during intensive outpatient treatment (Johnston
et al., 2015). We also found that adolescents who completed the DBT skills
group reported a decrease in frequency of dysfunctional coping skills from
pre- to post-treatment. This is particularly promising, given that individuals
with ED may experience deficits in managing negative mood states and
consequently, use illness behaviors as a maladaptive means of coping
(Fischer, Smith & Anderson, 2003). In FBT, the focus of treatment is weight
restoration. Coping skills development is de-emphasized, particularly in early
treatment. Thus, adolescents who receive FBT may not receive adequate
training to manage negative mood states. Further, in FBT, adolescents and
their caregivers may be ill-equipped to navigate distress and conflict that
often accompanies the weight restoration process. As such, our findings
provide some preliminary support that an adjunctive DBT skills group
could be an effective complement to outpatient FBT. However, a control
group is needed to compare FBT + DBT skills versus FBT alone to determine
how much DBT skills add to treatment outcome above and beyond FBT
only.
In our sample, symptoms of depression decreased significantly over time.
This finding is interesting because while we see significant increases in weight
and decreases in eating disorder behaviors in individuals undergoing FBT,
10 C. M. PETERSON ET AL.

decreases in depressive symptoms are inconsistent with some studies showing

lingering depressive symptoms after weight restoration (Loeb et al., 2007; Pollice
et al., 1997). It may be that DBT skills, consistent with prior studies, contributed
to decreases in depressive symptoms (Fleischhaker et al., 2011). Mindfulness
training, a core component of DBT skills, is associated with decreases in
depressive symptoms (Cash & Whittingham, 2010). Thus, the adjunct DBT
skills may have led to decreases in depressive symptoms in our study. However,
future studies utilizing a control group are needed to test this hypothesis further.
The trend of our diary card data was interesting. Although there was an
overall trend for all target behaviors to decrease by week 9, there seemed to
be a rebound in behaviors at week 17. Since the group had rolling admissions
(e.g., week 17 was not the same calendar date for everyone), we cannot
attribute this change to particularly stressful times of the year, for example,
the start of school. It may be that since the final module of treatment is
interpersonal effectiveness (e.g., assertiveness), these skills were not as effec-
tive in reducing target behaviors. However, it was notable that overall, most
target behaviors reduced from baseline to end of treatment.
Overall, an adjunct DBT skills group to FBT for restrictive ED seems
feasible in an outpatient eating disorders program based on rates of atten-
dance to the group and our dropout rate. It was important to have regular
communication with the FBT therapist which did place extra administrative
demand on the DBT skills group leaders. However, this is not unlike the
communication necessary for a DBT skills group leader with an individual
DBT therapist. Further, patients seemed to be able to attend both weekly
skills group and FBT sessions based on their attendance. Although we did
not specifically assess burden, notably burden in terms of the number of
sessions was never a reason cited for dropping from DBT skills group.
Our findings must be taken into context with several limitations. First,
only 12 of 18 participants completed the entire 6-month course of the DBT
skills group. It is notable that half of the treatment non-completers with-
drew to receive more intensive care for ED. Given that individuals with
acute ED often require hospitalizations (Striegel-Moore, Leslie, Petrill,
Garvin, & Rosenheck, 2000) it is plausible that our retention rate is
a realistic representation among this demographic. Further, the retention
rate in our study (76%) is similar to that described in a pilot DBT study for
adolescents with bulimia nervosa (BN), in which a retention rate of 70%
was reported (Fischer & Peterson, 2015). A second limitation to our study
is the absence of a control group. We cannot assume that all of the
improvements experienced among participants were secondary to the
DBT skills group, as FBT was offered concurrently. However, FBT is
primarily a behavioral intervention without an emphasis on coping skills
development. Further, in our analyses, large effect sizes were associated
with our findings that adaptive skill use increased and dysfunctional coping
 EATING DISORDERS 11

decreased among adolescents over the course of treatment. This suggests

that the acquisition of DBT skills, via participation in group intervention,
uniquely contributed to improvements noted in our sample. Future studies
with a control group of FBT only are needed to determine the efficacy of
DBT skills for adolescents with restrictive ED, above and beyond standard
FBT. Additionally, a dismantling study of DBT in the eating disorder
population would be helpful to determine which components are most
effective (e.g., emotion regulation skills). Further, our study was limited to
white, cisgender females from the Midwest region of the US and may not
be generalizable to other populations.
Participants may have been referred to the study at a particularly difficult
point in time for them personally, and improvements in symptoms may
represent regression to the mean. It is impossible to answer these questions
without a control group. Given the small sample size, we were not able to
examine potential mechanisms through which DBT skills improved out-
comes. We hypothesize that the increase in adaptive skills use such as
emotion regulation and distress tolerance reduces the likelihood that they
use maladaptive coping methods such as OBE and SIV. However, due to low
power, we could not test mediation in the current study.
Despite these limitations, this study provides preliminary support for the
provision of DBT skills groups for adolescents receiving outpatient FBT for
restrictive ED. Since FBT is behaviorally based, it does not explicitly teach
adolescents coping strategies for managing distress associated with ED. DBT
skills are an ideal adjunct to FBT in order to bolster adolescent emotion
regulation and distress tolerance. Improvements in these adaptive forms of
coping might facilitate faster recovery, including psychological recovery from
ED. The next step in the treatment of ED is to examine a clinical trial
comparing FBT only to FBT and DBT skills.

ORCID
Abigail Matthews http://orcid.org/0000-0002-1548-2589

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