Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2019) 24:373–377

[Link]

BRIEF REPORT

Impact on mindfulness, emotion regulation, and emotional overeating

of a DBT skills training group: a pilot study
Julie Beaulac1,2 · Daniella Sandre1 · Deanna Mercer3,4

Received: 30 May 2018 / Accepted: 7 November 2018 / Published online: 15 November 2018
© Springer Nature Switzerland AG 2018

Abstract
Purpose The current study investigated the impact of a modified Dialectical Behavior Therapy skills (DBT) training group
for patients at a hospital outpatient weight management clinic. Emotional eating is a problematic strategy for managing
unpleasant feelings that can have a deleterious impact on weight management. DBT addresses emotional dysregulation via
incorporation of skills aimed at coping with unpleasant affect.
Methods This study examines outcomes for 18 patients who participated in a 12-week DBT skills building group. A pre-post
design with 3-month follow-up investigated the impact of the group on emotional eating, psychological distress, emotion
regulation, and mindfulness.
Results Four repeated measures ANOVAs were run to assess for changes related to life difficulties and functioning, emotional
overeating, emotion regulation, and mindfulness. Fisher’s LSD tests assessed for linear and quadratic trends. Improvements
in mindfulness, emotion regulation, and emotional overeating were found; these were maintained at follow-up.
Conclusions This study demonstrated the utility of a group-based intervention aimed at improving emotion regulation and
mindfulness skills among weight management patients. Further study is needed to determine whether improvements in
the constructs studied in this research would translate to improved weight management outcomes and in determining the
pathway for improvements.
Level of evidence Level IV, multiple time series with intervention.

Keywords DBT · Weight management · Obesity · Mindfulness · Emotion regulation · Emotional overeating

Introduction weight management outcomes. Affect regulation theory sug-

gest that individuals who lack more adaptive coping strate-
Emotional and/or binge eating could be a problematic strat- gies use food to distract from uncomfortable emotions—a
egy for managing unpleasant feelings among patients pur- behaviour which is subsequently reinforced and/or main-
suing services for weight management, and is dispropor- tained by the accompanying (though temporary) reduction
tionately common among individuals living with obesity as in negative affect [2]. Given the relationship between emo-
compared to the general population [1]. This reliance on tional and/or binge-type eating, affective dysregulation, and
food as a source of comfort can have a deleterious impact on obesity [3, 4], it stands to reason that interventions aimed at
addressing the underlying factors which contribute to prob-
* Julie Beaulac lematic eating behaviours are necessary to optimize weight
jbeaulac@[Link] management outcomes.
Dialectical behaviour therapy (DBT) was developed by
1
Department of Psychology, The Ottawa Hospital, 501 Smyth Linehan [5] as a treatment for borderline personality disor-
Road, Room 7300 General Campus, Ottawa, ON K1H 8L6,
Canada der (BPD). Affective dysregulation is a core feature of BPD,
2 which involves an over-reliance on impulsive, maladaptive
The Ottawa Hospital Research Institute, Ottawa, Canada
behavior in attempt to cope with emotional distress [6].
3
Department of Psychiatry, The Ottawa Hospital, Ottawa, There is preliminary evidence for the use of DBT in reduc-
Canada
ing binge-type and/or emotional eating [7, 8]. Researchers
4
Department of Psychiatry, University of Ottawa, Ottawa, in the field of obesity and bariatrics have been exploring
Canada

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374 Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2019) 24:373–377

the use of adapted DBT skills training groups in addressing things or say no to unwanted requests, while at the same
binge-type and emotional eating, with promising outcomes time maintaining or improving relationships. The emotion
in terms of eating behaviour, emotion regulation, and weight regulation skills module included skills to help reduce the
management [3, 4, 8–10]. intensity of painful emotions, skills to help “surf” emo-
Traditionally, cognitive-behavioral treatment (CBT), tions and skills to help change emotions. Distress tolerance
interpersonal psychotherapy (IPT), and pharmacotherapy skills included crisis survival and acceptance strategies. The
have been the treatments of choice for binge eating dis- modules involved psychoeducation, skills development, and
order (BED). However, these treatments have not directly homework. A guidebook (unpublished) based on Linehan’s
addressed affective dysregulation. Further, although mind- skills training manual was developed for this adaptation.
fulness-based stress reduction (MBSR) and mindfulness- Each session was 1 h and 45 min in duration. The group
based cognitive therapy (MBCT) involve skills building room was open 10 min prior to group start to facilitate “set-
techniques aimed at the development of conscious aware- tling in”; 10–15 min were dedicated to a mindfulness exer-
ness to the here-and-now, as well as increased attention to cise; 40–45 min were allotted for homework review; and
emotional triggers and automatic thought patterns, these approximately 45 min for the introduction of new material.
interventions also lack the emotion regulation component A 15 min grace period following group allowed for crisis
that is central to DBT. intervention. In addition to homework, participants had
The current study investigated the impact of a modified the option of completing a diary card which recorded use
12-week DBT skills training group for outpatients of the of core mindfulness skills, and explored goals and values.
weight management clinic (WMC) at The Ottawa Hospi- Group discussion and sharing of experiences was encour-
tal, a clinic that provides treatment for patients who are aged during homework review. Group members were either
overweight. The goal of this pilot project was to determine self-referred or referred by their WMC health care provider
whether a DBT skills-training group, adapted for use within from the surgical, medical, or behavioural stream.
a weight management population, would prove useful in Patients experiencing emotion regulation or interpersonal
improving affect regulation skills among its participants. difficulties, emotional eating, who had current or historical
More specifically, we hypothesized that participation in this diagnoses of BPD (and/or sub-clinical traits) were included.
group would help patients develop adaptive coping strategies Medical stability was ensured by requiring a minimum of 6
to assist in better managing unpleasant emotions. In turn, weeks post-surgery. Patients with unstable medical condi-
it was anticipated that improvements in participants’ affect tions, with acute psychosis, mania, or substance abuse were
regulation skills would translate to improvements in meas- excluded and referred elsewhere. Patients attended a 1-h
ures of general distress, emotional eating, mindfulness, and pre-group screening to provide education about the group,
interpersonal relationships which together, could positively discuss goals, and confirm treatment fit. This pilot study
impact weight management. included three groups, each with six participants. Group 2
included an additional patient who declined research partici-
pation. Group 3 ended two weeks early due to unexpected
Method provider leave (i.e., 10 rather than 12-weeks in duration).
The study was approved by the Ottawa Health Science Net-
The interventions studied were three consecutive 12-week work Research Ethics Board and all participants completed
psychotherapy groups held at the WMC (June–August 2015, a signed consent form.
September–December 2015, December 2015–February A longitudinal pre-post non-randomized design with
2016). The first group was facilitated by the third author a 3-month follow-up was used for this study. Outcome
(DM) who completed DBT training and has been practicing measures were completed in person at weeks 1 and 12,
DBT since 2004. The clinic psychologist (DS), and a clinic and patients then received the measures by mail with a
social worker observed the first group as part of their train- postage paid envelope 3-months following termination
ing and co-facilitated subsequent groups. The groups were of group. Outcome measures included: (1) The Outcome
semi-closed such that new patients could join every 4 weeks Questionnaire-45 (OQ-45), a 45-item validated scale that
at the beginning of a new module. asks respondents to rate difficulties across different life areas
The 12-week intervention comprised three modules, each (e.g., personal distress, relationships, and responsibilities)
spanning four once weekly sessions. Each module began on a 5-point Likert scale (0 = never; 4 = almost always); (2)
with one full session of core mindfulness. The remaining The Emotional Overeating Questionnaire (EOQ), a 9-item
three sessions in each module then introduced and expanded validated scale that asks respondents to rate how likely they
upon the topics of emotion regulation, interpersonal effec- were to overeat over the past month in response to differ-
tiveness, and distress tolerance. Skills taught in the inter- ent emotions on a 7-point Likert scale (0 = not likely at all;
personal effectiveness module focused on helping to ask for 6 = extremely likely); (3) The Difficulties with Emotion

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Table 1  Outcome measures from baseline to 3-month follow-up: examination of general distress, emotional overeating, mindfulness, and emo-
tion regulation
Measure N Pre mean (SD) Post mean (SD) Follow-up mean (SD) F df p Effect size (η2)

OQ-45 (max total = 180) 9 88.0 (26.6) 73.4 (36.4) 73.6 (32.5) 2.98 2 0.080 0.27
EOQ (max total = 6) 10 1.5 (1.2) 0.5 (0.3) 0.4 (0.5) 6.91 1.1 0.022* 0.43
FFMQ (max total = 195) 8 106.3 (15.2) 132.9 (31.0) 134.3 (29.3) 5.18 2 0.021* 0.43
DERS (max total = 180) 10 124.3 (21.9) 89.7 (32.1) 88.7 (41.5) 7.28 2 0.005* 0.45

*p < 0.05, **p < 0.01, ***p ≤ 0.001

Regulation Scale (DERS), a 36-item validated scale that Patients attended on average 9.7 sessions (range 2–15;
asks respondents to indicate how closely they relate to vari- SD = 3.0).1 Three patients discontinued prior to the group
ous statements on emotion regulation, awareness, under- completion. Using the CSQ-3, satisfaction with the group
standing, and acceptance of emotions, using a 5-point Lik- was high (average of 3.71 out of 4 for the three item total).
ert scale (1 = almost never; 5 = almost always); and, (4) The Patient’s comments about what they liked most related to
Five Facet Mindfulness Questionnaire (FFMQ), a 39-item three main themes. The first theme, support from the group,
scale that asks respondents to rate their experience of the spoke to participant experiences of non-judgement and
five facets of mindfulness (e.g., observing, describing, act- feeling cared for by group members and leaders. They also
ing with awareness, non-judging of inner experience, and appreciated the information and tools learned, such as skills
non-reactivity to inner experience) along a 5-point Likert for regulating emotions, and the experience of sharing and
scale (1 = never or very rarely true; 5 = very often or always not being alone in their struggles. In terms of what could
true). Total score was computed for these four measures and have been better about the group, suggestions clustered
higher scores reflected greater difficulties, except for FFMQ, across three main themes. Many expressed a preference for
whereby higher scores reflected greater experiences of mind- more programming, for example: a longer duration for group
fulness. Demographic information was collected at baseline, or more follow-up beyond the group. A second theme related
and attendance, collected throughout. The Client Satisfac- to group rules around attendance—with a few members
tion Questionnaire (CSQ-3), a 3-item measure that evaluates suggesting that group leaders could have been more firm to
satisfaction along a 4-point Likert scale, was administered facilitate greater cohesion. Some commented on the group
at the end of the final session; patients were also asked what discussion related to homework, indicating that less time
they liked most about this group, what could have been bet- on this portion of the group would have been preferred in
ter, and whether there were other services needed. favor of more time for education. When asked whether there
were other services needed, many participants indicated that
nothing was lacking, while some others expressed to needing
Results additional psychological services; one participant requested
medical monitoring for weight.
Of the 18 study participants, three were male and 15 were Data were prepared for analysis in SPSS by first verify-
female. Eleven participants were in the surgical treatment ing accuracy for approximately 20% of the data and sub-
stream and seven were in the medical stream. The mean age sequently computing a weighted mean for missing values
was 46.3 years (range 25–67). The majority reported their within measures containing more than 75% of the items. A
maternal language as English (72.2%) and as having been comparison of the three therapy groups involving a one-way
born in Canada (88.9%). Most reported having graduated ANOVA was run to investigate for baseline differences in
from college/university (66.7%) or having completed some dependent measures; no significant differences were found.
college/university (22.2%). Over a third were divorced or Independent sample t tests were run to assess for possible
separated (38.9%), a third single (33.3%), and the remaining differences in baseline dependent measures between par-
were married or common law (27.8%). 38.9% were working ticipants who attended eight or more sessions to those who
full-time, 33.3% on disability leave, and the remaining were
retired, studying, or working part-time.

1
The range in attendance of greater than 12 weeks is a result of two
patients whom attended some sessions from both Groups 2 and 3,
which was permitted to provide one patient with additional needed
support and to facilitate a second patient in completing the program
after having missed many sessions due to medical complications.

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376 Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2019) 24:373–377

120 176
110 156
100 136
90 88.00 124.30
116
80
73.43 73.56 96
70 89.70 88.70
76
60
50 56
40 36
1 2 3 1 2 3
Note. 1=Baseline; 2=Post-Treatment; 3=3-Month Follow-up Note. 1=Baseline; 2=Post-Treatment; 3=3-Month Follow-up

Fig. 1  Mean score on OQ-45 across time Fig. 3  Mean score on DERS across time

5 179
159
4 139 134.25
132.89
119
99 106.25
3
79
2 59
1.50 39
1 1 2 3
0.50 Note. 1=Baseline; 2=Post-Treatment; 3=3-Month Follow-up
0.40
0
1 2 3
Fig. 4  Mean score on FFMQ across time
Note. 1=Baseline; 2=Post-Treatment; 3=3-Month Follow-up

p = 0.034) and between baseline (M = 0.5, SD = 1.2) and

Fig. 2  Mean score on EOQ across time follow-up (M = 0.4; SD = 0.5; p = 0.018; see Fig. 2). The
third repeated measures ANOVA identified a significant
effect for DERS across time points (F(2,18) = 7.284;
attended fewer than 8 sessions; no significant differences p = 0.005; η2 = 0.447). Post hoc tests using Fisher’s LSD
were found. tests pointed to a significant linear trend (F(1,9) = 7.73;
The effectiveness of the group was assessed through p = 0.021), suggesting reduced DERS scores over time and
repeated measures ANOVAs across the three time a significant quadratic trend (F(1,9) = 6.099; p = 0.0.036),
points (pre-intervention, post-intervention and 3-month suggesting a leveling off of or maintenance of effect over
follow-up; see Table 1). Four repeated measures ANO- time. Significant improvements were found between base-
VAs were run to assess for changes related to general line (M = 124.3, SD = 21.94) and post treatment (M = 89.7;
distress (OQ-45), emotional overeating (EOQ), emotion SD = 32.09; p = 0.008) and between baseline and follow-
regulation (DERS), and mindfulness (FFMQ). Changes up (M = 88.7, SD = 41.46; p = 0.021), suggesting that the
in functioning as measured by the OQ-45 approached treatment led to statistically significant improvements in
but did not reach statistically significant improvement regulating emotions that were maintained at follow-up
(F(2,16) = 2.975; p = 0.080; see Fig. 1). Next, a repeated (see Fig. 3). The final repeated measures ANOVA iden-
measures ANOVA with a Greenhouse-Geisser correction, tified a significant effect for FFMQ across time points
identified a significant effect for EOQ across time points (F(2,14) = 5.179; p = 0.021; η 2 = 0.425). Post hoc tests
(F(1.134,10.21) = 6.909; p = 0.022; η2 = 0.434). Post hoc using Fisher’s LSD tests found a significant linear trend
tests using Fisher’s LSD tests were conducted to assess (F(1,7) = 6.474; p = 0.038), indicating increasing FFMQ
for linear and quadratic trends. Results pointed to a sig- scores across time, but a non-significant quadratic trend
nificant linear trend (F(1,9) = 8.245; p = 0.018) which (F(1,7) = 2.984; p = 0.128) suggesting that FFMQ scores
was indicative of decreasing EOQ scores over time, but a continued to increase over time. Significant improvements
non-significant quadratic trend (F(1,9) = 4.127; p = 0.073), were found between baseline (M = 106.25, SD = 15.20)
suggesting no leveling off of effect over time. Specifically, and follow-up (M = 134.25, SD = 29.27; p = 0.038); a non-
significant improvements were found between baseline significant trend was indicated between baseline and post
(M = 1.5, SD = 1.2) and post treatment (M = 0.5, SD = 0.3; treatment (M = 132.89; SD = 31.03; p = 0.062), suggesting

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Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity (2019) 24:373–377 377

statistically significant improvements in mindfulness at Compliance with ethical standards

follow-up (see Fig. 4).
Conflict of interest On behalf of all authors, the corresponding author
states that there is no conflict of interest.
Discussion Ethical approval The study was approved by the Ottawa Health Science
Network Research Ethics Board.
The present study evaluated the impact of a 12-week, modi-
Informed consent Informed consent was obtained from all individual
fied DBT skills group on measures of general distress,
participants included in the study.
emotional eating, mindfulness, and affect regulation among
a group of patients undergoing weight management treat-
ment. Patients showed increased mindfulness, improved
emotion regulation, and reduced emotional overeating after References
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