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Temperament-Based Therapy with Supports (TBT-S) is a therapeutic model for ALL eating disorders

Written by Laura Hill, PhD, LLC, Ohio, USA; Stephanie Peck, PhD and Christina Wierenga, PhD, UC San Diego, California, USA.


Temperament is one’s natural disposition. It is an umbrella term that includes the underlying roots of one’s temperament, which comprise the genetics, the neurobiological responses to gene and environmental expression, and personality traits that develop in each person that are the foundation to how one thinks, interacts, and responds. Each person has personality traits unique to their own genetic script. One is born with a variety of traits that govern responses throughout life. They never go away like symptoms of an illness. The expression of personality traits can range from productive to destructive. For example, it takes an aggressive trait expressed productively to lead a company in conflict to resolution; and yet an aggressive trait can also be expressed destructively through bullying those impacted. How does one learn to use and express one’s personality traits productively instead of destructively?

Generally eating disorder (ED) treatment approaches have ignored temperament. When it is included, it tends to be approached from a pathological perspective with the implication that traits need to be eliminated. Personality traits are compilations of gene and development over time, taking shape as one ages. ED clients are left with feelings of failure that they cannot change and invalidated by currently available treatments that are focused on changing these stable phenotypes. TBT-S upholds the philosophy that ED symptoms can be minimized or eliminated but traits such as perfectionism, impulsivity, harm avoidance and determination are a part of our being who we are. Harm avoidance is common in AN while harm avoidance and impulsivity are common traits in persons with AN who binge and/or purge. Impulsivity is also common among those with bulimia nervosa (BN) and Binge Eating Disorder (BED). Approaching core ED vulnerable traits in those with AN, BN and BED from the biological perspective, knowing they are fundamental to a person’s natural make up, the “roots” that feed trait expression and symptoms, is central to a new treatment approach.

Temperament-Based Therapy with Supports (TBT-S) is a new treatment for ED that goes to the “roots” of EDs and provides a foundation for clients, their supports, and the clinical team to better understand and develop responses to the many “why’s” asked about EDs. Clinicians may ask, does this new treatment mean, “Do I throw out the ED other therapies in which I have been trained?” No!

Current evidenced based therapies are a major part of the eating disorder treatment picture. The key that has been missing is the temperament; the biology that explains why these symptoms occur. Clients with ED overwhelmingly report that understanding the neurobiological, genetic and personality traits of their illness and the tools that help them better manage their personality traits, have been groundbreaking to them. Client motivation to actively participate in the treatment process increases because they no longer hold guilt, shame and loss about their inability to simply eat like everyone else. Furthermore, Support persons, a key active ingredient in this treatment, feel less blame and more empathy and can mobilize to support their loved ones in more effective ways. Participating clients and support persons alike learn that when it comes to eating, they simply can’t, (meaning while the illness is acute, they are not neurobiologically able to eat like those without eating disorders). Not that they won’t, they can’t. Why? That is where TBT-S comes in.

Nature is the natural metaphor to make show where TBT-S fits within the whole treatment picture. A pine tree will never be an oak tree. They are genetically distinct. One sheds its leaves, one stays ever green. Yet both make contributions to the balance of nature and both have different vulnerabilities.

The first picture below shows a healthy tree, a metaphor for a person.



The leafy branches are the expressions that grow out of the tree trunk where one’s thoughts, feelings and actions originate as seen in the next picture.


When the tree becomes ill, its strength diminishes as shown in the next picture, showing loss of leaves.



The leaves do not grow. It has shed its green growth and is simply trying to survive.

Traditional eating disorder therapies, treat the limbs: the expressions of the thoughts, feelings and actions that grow out of the depressed person. But what is missing?

The roots! AND the supports for both adolescents AND adults!


The branches of a tree are fed from the roots. Most therapies focus on the branches or the outward expressions of the illness, not the underlying contributing factors, the roots or traits, genetic and neurobiological underpinnings.

In addition, most treatments approach ED patients in individual or groups consisting of the ED patients, leaving out primary support persons, such as family members, friends, roommates etc. FBT includes family members for those who are children and adolescents, but a large proportion of persons with ED are adults. Adults need support as well, even if they don’t want to ask for it. It would be like asking the tree to exist without the sun and the rain. It simply can’t happen and continue to grow.


To continue the tree metaphor, see the summary picture below showing how TBT-S relates to ED as an illness and how other ED therapies compliment TBT-S approach after the temperamental foundation is established.



Temperament Based Therapy with Supports (TBT-S) fills in a major gap in ED treatment.

ICAT is Integrated Cognitive Affective Therapy; DBT is Dialectical Behavioral Therapy, RO-DBT is Radically Open Dialectical Therapy; CBT-E is Enhanced Cognitive Behavioral Therapy; FBT is Family Based Therapy, IPT is Interpersonal Therapy; and ACT is Acceptance and Commitment Therapy

TBT-S is a research and client informed NEW treatment approach developed based on an empirically-supported understanding of underlying mechanisms of ED and studied via open trials on anorexia nervosa. The model as a whole is open for application with ALL eating disorders. Discussion will include this. Portions of the core treatment, such as the Behavioral Agreement have been tailored and studied specifically for the traits of persons with AN. Behavioral agreements for BN and BED can and will need to be developed. New research continues to contribute to how the brain is affected by those with BN and BED. This information is and will continue to be integrated into the TBT-S model and treatment approach as understanding of the genetic, neurobiological and trait findings continue to discover new truths about EDs.


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