MED-DBT (Multi-Diagnostic Eating Disorder Dialectical Behaviour Therapy) exists to address a clinical reality: some individuals with eating disorders do not respond adequately to first-line treatment when additional complexity is present.
MED-DBT is the delivery of comprehensive DBT for individuals with eating disorders who present with significant behavioural, psychiatric and relational complexity.
It involves implementing the full DBT model with fidelity — including all treatment modes — while integrating specialist eating disorder knowledge, including established approaches such as CBT for eating disorders (e.g., CBT-E), alongside medical and nutritional risk management within the DBT framework.
MED-DBT was developed to address a clinical reality: while treatments such as CBT-E and Family-Based Treatment (FBT) are effective for many individuals, some patients present with additional complexity.
This often includes significant emotion dysregulation — including difficulties identifying, experiencing and/or tolerating emotions (such as alexithymia or dissociative experiences) — alongside chronic suicidality, self-injury, trauma histories, substance use, or neurodivergence. In these cases, a more intensive and structurally integrated approach is required.
In MED-DBT, eating disorder treatment principles — including behavioural strategies central to CBT-ED — are delivered within the structure of comprehensive DBT, rather than DBT being used as an adjunct or modification. The DBT hierarchy, functions and modes organise treatment, while specialist eating disorder expertise is integrated within that framework.

MED-DBT maintains all modes of comprehensive DBT:

• Individual therapy
• Skills training
• Phone coaching
• Consultation team

These modes work together to ensure behavioural change, motivational work, skills generalisation and therapist adherence.
Eating disorder behaviours are targeted within the DBT hierarchy, ensuring that life-threatening and therapy-interfering behaviours are addressed without losing focus on medical stability and nutritional rehabilitation.

MED-DBT relies on disciplined and sophisticated use of the DBT treatment hierarchy. In complex eating disorder presentations, clinicians must continually assess what is most crucial to address in each session — balancing life-threatening behaviours, medical risk, therapy-interfering behaviours and eating disorder symptoms.

Targeting is not static. It requires ongoing behavioural analysis and careful prioritisation, ensuring that treatment remains responsive without becoming reactive. The hierarchy guides decisions about when to focus on suicidality, when to address medical instability, when to target disordered eating directly, and when to strengthen motivation or repair therapy-interfering patterns.

This structured flexibility allows clinicians to move between targets based on clinical necessity while maintaining coherence and fidelity to the model.

MED-DBT is designed for individuals who have not responded adequately to first-line eating disorder treatments.
In many cases, treatment does not fail because the model is ineffective, but because additional maintaining factors are not sufficiently addressed. These may include:

• Significant emotion dysregulation
• Severe depression and chronic suicidality
• Self-injury and high-risk behaviours
• Multi-diagnostic complexity
• Neurodivergence
• Difficulties identifying or articulating internal states (e.g., alexithymia)
• Shifting or unstable presenting problems
• Fragmented or siloed care across multiple services
• Limited clinician confidence in managing high psychiatric risk

Standard eating disorder treatments are highly effective for many individuals. However, when these additional factors are present, treatment may stall, destabilise or fail to generalise.

MED-DBT simultaneously addresses these maintaining variables while continuing to target eating disorder behaviours directly. This includes treating emotion dysregulation, strengthening behavioural self-management, improving coordination across services, and identifying and replacing the reinforcing functions served by the eating disorder with alternative behaviours that meet those same needs in safer and more sustainable ways.

Importantly, treatment also focuses on helping clients clarify values, define meaningful goals and build a life that extends beyond symptom reduction. As motivation strengthens and life becomes more coherent and purposeful, the eating disorder no longer serves the same function — allowing established eating disorder treatment principles to take hold more effectively.

Rather than replacing first-line models, MED-DBT creates the conditions in which they can work.

MED-DBT emphasises collaborative treatment planning within a structured model. While therapy occurs within the parameters of comprehensive DBT, clients actively identify and define their goals.

Clients ultimately guide their treatment direction within the MED-DBT framework. This includes defining what recovery means to them and identifying meaningful life goals beyond symptom reduction.

Where avoidance, ambivalence or fear of change are present — particularly in restrictive or high-risk presentations — these are addressed through standard DBT commitment strategies, behavioural analysis and motivational work, rather than through coercive or externally imposed agendas.

The structure provides safety and containment; the client’s values provide direction.

MED-DBT is not about recovering from an eating disorder for its own sake. It is about creating a values-aligned life worth living — a life worth recovering into.

MED-DBT is not delivered in isolation. It is designed as a whole-of-system treatment, integrating the multiple services and professionals often involved in the care of individuals with complex eating disorders.
This reflects DBT’s explicit emphasis on structuring the environment as a core treatment strategy. In MED-DBT, the treatment environment extends beyond the therapy room to include medical providers, dietitians, psychiatrists, schools, family members and other supports involved in the client’s care.
Many clients move between levels of care — outpatient, inpatient, day programmes — and may be simultaneously engaged with multiple services. Fragmentation across these systems can undermine progress and create inconsistent messaging.
MED-DBT therefore supports the development of a coordinated treatment map to recovery. Clients are supported to communicate effectively across services, clarify roles and responsibilities, and align providers within a shared DBT-informed framework. The aim is not parallel treatment delivered in silos, but coherent and collaborative care.
In this way, structuring the environment becomes an active and ongoing component of treatment, strengthening consistency, accountability and safety across systems.

MED-DBT is not an introductory model. Clinicians must have prior training in comprehensive DBT and work within a structured DBT framework, including participation in consultation team.
In addition, clinicians should be trained and competent in delivering evidence-based treatments for anorexia nervosa and other eating disorders. MED-DBT does not replace specialist eating disorder knowledge; it integrates this expertise within the comprehensive DBT model.

MED-DBT has evolved through clinical programme implementation within public sector services and through ongoing evaluation and research examining outcomes in complex eating disorder populations.
Its development has been informed by collaboration with international colleagues working at the intersection of comprehensive DBT and eating disorder treatment. Over the past decade, I have contributed to shaping and refining the treatment through programme design, implementation and research within specialist services.
MED-DBT represents a principled and fidelity-consistent application of comprehensive DBT in contexts where psychiatric complexity, medical risk and multi-diagnostic presentations require careful and disciplined implementation