Understanding Dialectical Behavior Therapy

 

 
In DBT, the term dialectical is meant to imply the notion of integrating opposite points of view. DBT attempts to synthesize the notions of accepting reality and of changing oneself, which seem to be polar opposites to most people. Therapists accept clients as they are while they acknowledge that clients needs to change some aspects of their behavior and attitudes in order to adjust and live comfortably. In addition, clients need to accept the notion that they must change aspects of their behavior in order to avoid distress, and at the same time, they must accept reality regarding aspects of the world that they cannot change. For many individuals who are involved in 12-Step groups, this may sound quite a bit similar to the serenity prayer that is often repeated during these groups and used by individuals to remind them of their limitations; however, this is also a notion that has been accepted in psychological theory for quite some time.

Regardless of the particular therapeutic issue, DBT is typically delivered by means of four standard factors that are all designed to complement one another. These four components are:

• Individual therapy: Individual therapy sessions will typically be held once a week with a trained DBT therapist. During the sessions, the focus is on building the client’s motivation to change and developing skills to change behavior as well as to cope with the specific challenges faced. In the treatment of substance abuse, this component of treatment helps the individual develop coping skills, relapse prevention skills, motivation to be substance-free, and understanding and acceptance of certain aspects of reality that cannot be changed. The therapy typically goes on as long as the individual is in treatment.
• Group therapy: This is accomplished in skills training groups where individuals with similar problems meet with a qualified therapist or group leader who teaches the skills individuals need to implement change and to accept the world the way it is. Groups meet on a weekly basis for 1.5-2.5 hours. The full curriculum will typically take 20-24 weeks to complete, and the regime is often repeated again to create a full one-year program.There are also specialized group skills training sessions that can be applied to therapy. These special sessions are often shorter in duration and may be repeated more frequently. In the case of substance abuse and addiction, these groups work on general coping skills, recovery principles, and techniques specifically designed for substance abuse. Individuals in groups can work together in session on the skills and learn from one another regarding how to implement them.
• Phone coaching: This aspect of treatment is designed to assist clients with on-the-spot coaching regarding difficult situations that come up in their everyday experiences. Clients can call their therapists to receive advice when they need it the most. For instance, someone in a substance abuse treatment program who is experiencing some extremely difficult issues with cravings or other problems can call a therapist and address the issue as it happens.
• Consultation teams: The consultation teams are designed for the therapists. These teams consist of group leaders and other therapists who work together to address specific issues. For instance, professionals involved in substance abuse treatment would engage in skills training to help them develop their therapeutic skills, discuss research in addiction and substance abuse, present cases, and offer feedback to one another.

 

 
DBT uses four specific skills/techniques to assist individuals.  These include:

• Emotional regulation: This involves understanding how emotions affect behavior, and learning to recognize events that trigger emotions and to change attitudes/beliefs that can assist in changing emotional states. For example, many individuals begin to use substances in response to anxiety or stress. Often, if one can reduce feelings of stress or anxiety, one can address substance abuse more effectively.
• Distress tolerance: This is related to emotional regulation; however, it reflects the need to also be able to accept reality. People can’t change the way they feel about everything, and it is often adaptive to be distressed over certain situations that occur in life. Individuals need to accept these situations, the emotional distress that accompanies them, and learn to tolerate and work through these stressful periods as opposed to trying to change them. Clients can also lessen the effects of stress through learning stress reduction techniques.
• Being an effective person: Often, individuals do not understand how to communicate with others, express their needs, how they are perceived by others, and how to effectively communicate their feelings while maintaining their own sense of dignity. These skills are designed to help one become more effective in relations with others.
• Mindfulness: This essentially means maintaining awareness of one’s actions and internal states, and the environmental ramifications of acting in the moment. Maintaining a state of mindfulness can help one better negotiate aspects of reality and apply new skills to situations.

 

Other techniques can be used if the strict DBT approach requires supplementation. Medication can be used in conjunction with DBT to address certain issues, such as detoxification from drugs, psychological problems such as depression and anxiety, and for other maladies, such as seizures or other physical issues.

Exposure therapy can be used in place of certain aspects of DBT or in conjunction with DBT. In exposure therapy, individuals are confronted with situations that produce fear or anxiety. By using a method where individuals learn to relax in the presence of the fear-inducing situation, or by initially exposing people to events that produce minor anxiety and then gradually exposing them to more anxiety-provoking events, individuals learn not to fear the situation. This can be done using imagery or in real situations.

Relapse prevention therapy is a specific type of therapy for substance abuse that focuses on building coping skills and understanding triggers that lead to relapse. Motivational Interviewing can be applied with the process in DBT or, in some cases of substance abuse, can substitute for DBT. Of course, other approaches of Cognitive Behavioral Therapy or other therapeutic paradigms can be used instead of DBT.

 

 
Individuals who enter treatment for substance abuse will have multiple problems that need to be addressed. The therapist uses the first few sessions to understand the client’s specific issues and to work with the client to prioritize issues so the most important issues are dealt with first and then issues are dealt with in order of their relevance to the client’s situation. For instance:

• Issues that are serious to one’s health or life-threatening, such as having suicidal thoughts or issues regarding self-harm, would be addressed first. This could also include chronic abuse of seriously dangerous substances, such as heroin, alcohol, benzodiazepines, cocaine, etc.
• Behaviors that would interfere with therapy, such as missing therapy sessions, habitually showing up late, not doing homework, canceling appointments, etc., are often next. The therapist, team, and client work together to ensure that the treatment will be effective.
• Issues that affect the individual’s quality of life, such as depression, anxiety, other psychological problems, relationships issues, financial issues, and so forth, are deal with next.
• The focus then turns to developing and acquiring new skills to replace behaviors that are not effective in an effort to help the individual achieve goals.

These issues are addressed in the above order in the sessions and as part of the overall therapeutic approach.

 

 

Before discussing research evidence regarding the effectiveness of DBT for substance abuse and addiction issues, it is important to understand that the notion that an individual is “cured” once treatment is complete for any mental health disorder or psychological issue is not applicable. Individuals are not “cured” from psychological and emotional problems in the same way that they can be cured from diseases like the measles or tuberculosis. Psychological disorders are similar to conditions like diabetes or cardiovascular disease where these issues can resurface if the person does not remain diligent regarding the changes made to address them. Relapse rates for substance abuse are similar to relapse rates for conditions like diabetes.

There are a number of studies that have provided evidence that DBT is effective in the treatment of substance use disorders that occur in conjunction with borderline personality disorder or other personality disorders.  There are also studies that look at the effectiveness of DBT in treating substance abuse and other disorders, such as eating disorders, that report significantly positive findings. Thus, DBT is particularly useful when individuals have substance abuse issues that are comorbid (co-occurring) with other disorders and in the treatment of addiction and substance abuse in general.