DBT in the Treatment of Addiction

One of the more promising therapies for addiction, Dialectical Behavioral Therapy, or DBT, was developed to help treat compulsive patterns of self-harm with simple, practical, and effective techniques.

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What is addiction? There are many definitions, but one of the most basic features of any addiction is that there is a compulsive repetition of behaviors that are known to be harmful—no matter how good they feel initially—but are chronically engaged in nonetheless. The tools for harming oneself might be alcohol, drugs, cutting, overeating and unsafe sexual practices (amongst others) but the result is the same.

One of the more promising therapies for addiction, Dialectical Behavioral Therapy, or DBT, was developed by its inventor, Dr. Marsha Linehan to help treat compulsive patterns of self-harm with simple, practical, and effective techniques. For Linehan, DBT is anything but an exercise in abstraction. As she only recently revealed, its methods come from insights gained, at a huge personal cost, from her own struggles with mental illness. Though Linehan was never a substance abuser per se, she was nonetheless, like many substance abusers, trapped in a downward spiral of shame, self-loathing, psychic pain, and self-harm from which there seemed to be no escape.

Linehan originally developed DBT as a treatment for highly suicidal patients often with a compulsion to injure themselves. Such patients are now often diagnosed with Borderline Personality Disorder, a psychiatric illness characterized by sometimes lifelong patterns of violent mood swings, unstable relationships, poor self-image, and a tendency to act impulsively. Often, there are also persistent feelings of abandonment and the majority of those with a BPD diagnosis harm themselves, as well as make repeated suicide attempts. Dr. Linehan believed that if these individuals could be taught skills to better deal with emotional and life issues and thus lessen psychic pain, then the desire to be dead or harm themselves would be greatly diminished. The goal of DBT is to acquire skills to deal with the mental anguish the sufferer experiences and create a life worth living. The tools offered in DBT are meant to aid in the achievement of these goals.

Dr. Linehan was, at first, diagnosed with schizophrenia at the age of 17. As a teenager she was, according to an in-depth look at her struggles with mental illness published in the New York Times in 2011, "precocious" but also dangerously violent towards herself. "The girl," wrote Times correspondent Benedict Carey, "attacked herself habitually, burning her wrists with cigarettes, slashing her arms, her legs, her midsection, using any sharp object she could get her hands on." In the same story Linehan said, "I felt totally empty, like the Tin Man; I had no way to communicate what was going on, no way to understand it." She was "dosed with Thorazine, Librium, and other powerful drugs, as well as hours of Freudian analysis; and strapped down for electroshock treatments ... nothing changed, and soon enough the patient was back in seclusion on the locked ward."

In 1967, Linehan had what can only be described as an epiphany: she had been regularly praying at the Cenacle Retreat Center in Chicago, and had suddenly felt transformed. "It was," she told the Times, "this shimmering experience, and I just ran back to my room and said, 'I love myself.' It was the first time I remember talking to myself in the first person.'"

"The high," Carey writes, "lasted about a year, before the feelings of devastation returned in the wake of a romance that ended. But something was different. She could now weather her emotional storms without cutting or harming herself."

Quite simply, she accepted herself as she was. She referred to this as “Radical Acceptance”—acceptance of life as it is, not as it is supposed to be; and the need to change, despite that reality and because of it. These seem to be opposites: on the one hand, you have to take life as it is; on the other hand, that change is essential for survival. But for real change to happen, both self-acceptance, and acceptance of the need for change have to come together. This blending of two seemingly opposite views is called a dialectic—and it's the vision behind the name of Dialectical Behavioral Therapy.

Dr. Linehan acknowledged that the self-harming behavior she saw in suffering patients made sense and had a purpose.

Over time and study (she earned a Ph.D. at Loyola in 1971), Dr. Linehan acknowledged that acceptance and change alone were not enough and people needed tools to handle the feelings and circumstances in their lives that led to self-harming behavior.

Substance abuse is a self-harming behavior. Addicts will often suffer numerous negative consequences from their substance use (failing health, job and relationship losses, legal difficulties, and economic problems to name a few) yet despite the negative consequences, many will continue to use to experience even a short reprieve from discomfort or pain. Many studies show a strong connection between BPD and substance abuse disorders.

DBT, for people struggling with substance abuse problems, is a way to achieve self-acceptance while simultaneously accepting the need for change. There are four basic aspects to DBT: mindfulness, interpersonal relations, emotion regulation, and distress tolerance.

Mindfulness is an idea originally borrowed from Zen Buddhism. Mindfulness is quite simply about becoming focused on the present moment as opposed to the past or future and to be aware and accepting of what is happening both within and outside without making judgments about the experience. This can also be described as acceptance of the self and of the circumstances.

The next skill-set in DBT focuses on interpersonal relations. This “module” (as the training experience of DBT is presented) teaches how to set limits and safeguard oneself and relationships.

The emotion regulation aspect of DBT teaches how to identify, regulate and experience emotions without becoming overwhelmed and acting on impulse. The skills aim to reduce vulnerability and increase positive experiences.

The fourth area of DBT is distress tolerance. This area is focused on the development of skills to cope with crises when emotions become overwhelming and the individual is unable to immediately solve the problem (a death, sickness, loss of job, etc.) but needs to persevere and live through the crisis without making it worse by impulsive actions (for example, getting high or drunk).

In the quest for abstinence, DBT pushes for immediate and permanent cessation of drug abuse (change) while also offering the idea that a relapse, should it occur, does not mean that the individual cannot achieve the desired result (acceptance). The dialectical approach therefore joins unrelenting insistence on total abstinence with nonjudgmental, problem-solving responses to relapse, which include techniques to reduce the dangers of overdose, infection, and other adverse consequences.

DBT treats a lapse into substance abuse as a problem to solve, rather than as evidence of patient inadequacy or treatment failure. When a patient does slip, the therapist shifts rapidly to helping the patient fail well—that is, the therapist guides the patient in making a behavioral analysis of the events that led to and followed drug use, and gleaning all that can be learned and applied to future situations. Additionally, the therapist helps the patient make a quick recovery from the lapse. This approach may lessen the intense negative emotions and thoughts that many people feel after a lapse and that can hinder reestablishing abstinence. (“What’s the point? I’m a failure. I can’t do this. I give up. I might as well keep using.”)

The idea of failing well also involves repairing the harm done to oneself and others during the lapse. This concept is similar to making amends in steps eight and nine of the 12 steps of Alcoholics Anonymous, and serves two functions. It increases the awareness and memory of the negative consequences of using drugs while also directly dealing with the adverse effects of using—specifically, "justified guilt" that is, being able to accept that it's appropriate to feel guilt, regret, and a desire to change, as a result of negative acts. (For example, stealing money to buy drugs.)

In DBT with substance abusers, the clinician enters into an agreement (“abstinence pledge”) with the patient that he/she will remain abstinent for a specific amount of time. Since many substance abusers would find a lifetime of abstinence overwhelming, the “contract” is for a set period of time and “renewed” when the time period ends. The rationale behind this is that the goal needs to feel “achievable” so the amount of time is negotiable between the therapist and client. In some ways, this mirrors the “one day at a time” philosophy found in 12-step programs.

Clients are then taught strategies for dealing with potential problems including “triggers” to use drugs and/or alcohol. This “coping ahead” skill is the DBT equivalent of relapse prevention. It acknowledges that an addict’s fallback coping mechanism in many situations is to use and it is essential that the individual identify other tools for addressing difficult situations ahead of time.

During her first psychiatric hospitalization, Dr. Linehan remarked, “I was in hell. And I made a vow: when I get out, I’m going to come back and get others out of here.” Addiction is very often described as a sort of hell—a world of dependence, pain (both physical and mental), desperation, and loss. DBT may be a useful roadmap out of hell—a way of realizing that feelings aren't something to avoid or diminish with drugs or alcohol, but the actual fabric of life itself.

Regina Walker is a regular contributor to The Fix. She last wrote about what to do now you're sober.