Dialectical Behavioral Therapy to treat addictions

In 1993 Marsha Linehan developed Dialectical Behavior Therapy (DBT) in her work with clients who had an Axis II diagnosis of Borderline Personality Disorder. A very common occurrence in the treatment of chemically dependent (CD) clients is that there is a strong overlap of Axis II diagnosis of a personality disorder along with the Axis I diagnosis of CD. The most common personality disorders among CD clients are antisocial personality disorder (not addressed here) and borderline personality disorder. Therefore, more and more therapists in the treatment of CD clients are utilizing the DBT skills developed and utilized by Linehan. Therapists are also turning to these skills because, even without an Axis II diagnosis, early recovery from addictive substances is marked by vulnerability to intense negative emotions and hypersensitivity to stress. There is also a strong incident of early childhood traumas such as any form of abuse or neglect in CD clients as well as BPD clients. The skills that have been effective most effective in the treatment of drug and alcohol dependency are distress tolerance skills, mindfulness, and emotional regulation skills. N. Roes stated that “Historically, the addiction field has had a dialectical approach. We have combined the seemingly opposite strategies of confrontation and affirmation to help clients change. DBT offers a similar dialectic that synthesizes two apparently opposite goals: validating clients as they are and challenging them to change.”

The distress tolerance skills of distraction, self-soothing, radical acceptance, and visualization are effective for the following reasons. These distress tolerance skills are effective for CD clients because the skills can be used as a way of overcoming overwhelming emotions of early recovery, as well as a way of dealing with cravings which occur more frequently in early recovery. Distraction was developed by Linehan as a way of distracting clients from self-destructive behavior. This skill teaches clients alternative actions that will help distract them from current painful emotions. Some of the distraction methods that are utilized are pleasurable activities, paying attention to someone else, using distracting thoughts, completion of some task or chore. Another way of distracting attention way from the painful emotion is self-soothing. Self-soothing is a form of relaxation in which the client learns to relax through some activity using one of the five senses. Radical acceptance increases the client’s ability to tolerate distress by changing their attitude. This skill is utilized by Alcoholics Anonymous (AA) through the concept of the Serenity Prayer which teaches to focus on the things you can change and accept the things you can not change. Radical acceptance is a means of tolerating those things that you cannot change that happened earlier in your life. According to Mckay, Wood, and Brantley the client is taught “to recognize that your present situation exists because of a long chain of events that began far in the past.” Visualization is a method of relaxation in which the client is taught to visualize themselves in a safe, calm place. For the CD client this serves two functions. First it lowers the level of stress and early recovery is a time when the client is hypersensitive to stress. Secondly relaxation calms down the area of the brain where cravings occur.

Mindfulness skills are also known as meditation. Meditation has long been a valuable skill in twelve step recovery programs; in fact one of the twelve steps is seeking the will of the higher power through prayer and meditation. Studies have shown that using nonreligious mindfulness skills helps in the treatment of various mental and physical illnesses. It also helps individuals cope with difficult situations. McKay, Woods, and Brantley offer this explanation of mindfulness “mindfulness is the ability to be aware of your thoughts, emotions, physical sensations, and actions—in the present moment—without judging or criticizing yourself or your experience.” There are various mindfulness exercises not only in the McKay, Woods, and Brantley’s workbook but also in Linehan’s Skills Training Manual. In both cases the mindfulness exercises are easy to do and easy to teach clients to do on their own. The aim of the mindfulness skills is to get in touch with what Linehan called the individual’s “wise mind” which is the “reasonable mind”, the counterbalance for the emotional mind. This “wise mind” or “reasonable mind” is what helps an individual in their decision-making process.

Clients are also taught what Linehan called “emotional regulation skills” which include: emotional awareness, recognition of self-destructive behaviors, recognition of cognitive distortions, opposite actions, and problem solving. In order for clients to begin recognizing their emotions both Linehan, and Mckay, Wood, and Brantley utilize worksheets that are available in their books. The client then maintains a record of their emotions. This worksheet also helps them recognize their various behaviors associated with their emotions. Once the clients recognize the link between their emotions and their behaviors they can begin to identify which emotions are connected to their self-destructive behaviors, whether that is using or cutting or other self-destructive behaviors. Then they are aided in recognizing the link between their thoughts and their emotions. This is most often connected to what is known as cognitive distortions. Clients can then be taught to replace their cognitive distortions with thoughts that help them cope with their emotions in distressing situations. Linehan also postulated that every emotion had an “action urge” or “emotional urge” and that if clients could recognize that action urge and do the opposite they would be able to actually change their body language and behaviors. Next the client learns to problem solve using behavioral analysis. Again they can utilize a worksheet to analyze a problematic emotion and a precipitating event. They would then problem solve by means of the “ABCs of problem solving” described by Linehan. “A” is to brainstorm alternative responses. “B” is to select the better of one or two of these alternatives to implement. “C” would be for the client to commit to utilizing these new responses and actually identify a time and place where they would try to utilize these new techniques.

Therapists working in the field of CD treatment are finding that if they teach their clients these skills, they increase their chances of recovery and have fewer relapses and fewer clients returning to treatment.