- What is Dialectical Behavior Therapy?
- Next Steps: How to Get Started with Dialectical Behavior Therapy
- Medical Disclaimer
- Key Sources
Substance use disorder is a painful disease, and it can often lead people to develop serious mental health symptoms, like suicidal thoughts and self-harming behaviors. Suicide and addiction have an interesting but tragic relationship: having a substance use disorder is one of the biggest risk factors for suicide attempts.
Even if you aren’t actively suicidal, you may be self-destructing by using drugs and alcohol.
Thankfully, there is a treatment that targets these exact behaviors (behaviors like self-harm, suicidality, and drug use). It’s called dialectical behavior therapy (or DBT), and although it was originally developed to help chronically suicidal people, there’s emerging research that shows that it could also be helpful for substance use disorders.
What is Dialectical Behavior Therapy?
Suicide and other self-destructive behaviors are some of the most difficult mental health symptoms to treat. Sometimes, people who are battling addiction feel suicidal, and heavy drug and alcohol use alone could be viewed as self-destructive behavior. As already mentioned, drug and alcohol use is one of the main risk factors for suicide.
If you are struggling with substance use and also have strong, painful emotions that cause you to do drugs or drink heavily, then a type of therapy called Dialectical Behavior Therapy (DBT) might be right for you.
The History of Dialectical Behavior Therapy
Before the arrival of DBT, borderline personality disorder (BPD) was widely thought of as a virtually untreatable mental illness. The stigma against borderline personality disorder continues today, and many therapists even refuse to treat patients who are diagnosed with this disorder. The general judgment was that patients with borderline personality disorder would never change, and that their high risk for suicide made them too much of a liability.
However, the prognosis of borderline personality disorder improved greatly with the development of dialectical behavior therapy. Dr. Marsha Linehann, a psychologist working toward finding a treatment for suicide, developed DBT in the 1970s and 80s. She actually didn’t know about borderline personality disorder at the time; she simply wanted to find a way to help people who were chronically suicidal. She came up with DBT, which combines cognitive behavioral techniques with Eastern spiritual practices, like mindfulness.
Dr. Linehann has since been open about the fact that she suffers from symptoms of BPD herself, so it’s clear that she understands the needs of this community intimately.
Since its introduction, DBT has been applied to the treatment of more than just borderline personality disorder. In general, experts think that it has the potential to be effective in the reduction of any self-destructive behavior, including self-harm and substance abuse.
On top of treating borderline personality disorder, DBT is often used in the treatment of eating disorders, depression, and substance use disorders. It’s also been suggested as a possible treatment for complex post-traumatic stress disorder (CPTSD). No matter the underlying diagnosis, this treatment method can help people learn the skills they need to cope with (and accept) difficult feelings without resorting to unhealthy behaviors.
Main Concepts of Dialectical Behavior Therapy
Many different skills are taught as part of DBT, and in essence, all of these skills help people to stabilize and improve their emotions. At its heart, DBT helps people to realize the “dialectical” nature of things: that two viewpoints or ideas, even when they seem like they’re opposites on the surface, can co-exist.
For example, “I accept myself the way I am, and I want to change,” or “I am doing the best I can, and I need to do better,” are two common dialectic ideas that people might hold, especially if they are suffering from mental health issues.
This type of thinking allows DBT clinicians to accept and validate clients’ experiences. Instead of pushing clients to abandon “incorrect” perspectives, DBT allows space for both a client’s existing worldview and a completely opposite (often more helpful) one. This is the opposite of many previous interventions for suicidal people, which tended to see people with these types of behaviors as simply not trying hard enough to change.
DBT clinicians hold several well-defined, sacred assumptions about their clients. These are:
- Patients are doing the best they can, and they want to improve.
- Even though patients may not have caused their own problems, they need to work harder and be more motivated to solve them, anyway.
- The lives of these patients, as they’re currently being lived, are unbearable.
- Patients need to learn new skills to improve. They cannot fail.
- DBT therapists need support.
These assumptions help therapists to always hold their clients in high regard, and provide the validation necessary to build a solid therapeutic relationship. The last assumption allows therapists to have their own feelings about the difficult work they’re doing, and get support.
These underlying assumptions are held by therapists as they work through the process of DBT. The actual delivery of DBT is quite structured, and includes four components:
- Skills Training Group
- Individual Therapy
- Phone Coaching
- Consultation Team (for therapists)
DBT Skills Training
Learning life and relational skills in a group setting is a big part of going through DBT. The life skills you will learn are split up into four areas:
- Mindfulness: The conscious practice of being fully aware of the present moment, including your thoughts and feelings.
- Distress Tolerance: Learning how to tolerate difficult emotions in healthy ways; learning that some painful situations can’t be changed, and you just need to accept them.
- Interpersonal Effectiveness: Interpersonal skills that help people to improve their relationships and communication.
- Emotion Regulation: Learning specific tools to self-soothe when feeling strong, painful emotions; these skills are especially useful when feeling suicidal.
Skills training groups typically last for 2 hours each.
Some specific skills that are taught in DBT groups are:
- Opposite Action: Doing the exact opposite of what your feelings are telling you to do; for example, if you want to isolate, then see friends. If you feel sad, then watch a funny movie with a happy ending.
- Self-Soothing and Grounding: There are several self-soothing skills in DBT; one of them is using all five senses to ground yourself in the present moment.
- Radical Acceptance: Learning the wisdom and skill to accept the present situation, even if you don’t like it.
Many skills that are taught in DBT have acronyms, like the “DEAR MAN” technique for relationship effectiveness and healthy conflict resolution (the acronym stands for Describe, Express, Assert, Reinforce, Mindful, Appear confident, and Negotiate).
DBT Individual Treatment
On top of learning these skills in a group setting, people receiving DBT also participate in weekly individual therapy. In individual therapy, a strong therapeutic relationship with the therapist is built. The therapist provides affirmation and validation for your experiences.
Your individual therapist will also make sure you’re actually applying the skills you’ve learned in group to your everyday life. They’ll ask you about situations that you’ve faced during the week and what skills you used (or could have used) to cope with them. Individual therapy happens alongside group skills training.
Because DBT was created to work with people who are highly emotional and chronically suicidal, phone coaching is also used for ongoing skills training. If, between sessions, you find yourself facing a stressful situation that’s making you want to engage in an unhealthy behavior (like attempting suicide or abusing substances), your therapist can coach you in the moment to use the skills that you’ve learned.
Consultation (Therapist Support)
The last component of DBT doesn’t have to do with you, the patient, but with the therapist. Since DBT therapists are often working with people who are chronically suicidal, DBT makes sure that support and consultation for therapists doing this work is built into the therapy itself. This helps to prevent therapists from burning out so they can continue doing the important work they do.
What Is Dialectical Behavior Therapy Used for?
As discussed above, DBT was initially developed to treat chronically suicidal women, though it soon became known as the gold standard of treatment for people with borderline personality disorder. It makes sense, as one of the main symptoms of borderline personality disorder is the presence of suicidal thoughts, feelings, and attempts.
Borderline personality disorder (BPD) is a mental illness that affects people’s emotions and relationships. Some common symptoms of BPD are a deep fear of abandonment (which leads to dysfunctional relationships), a chronic sense of emptiness, a lack of self-esteem and a sense of self, and chronic suicidal behaviors or attempts. DBT helps people with these symptoms to manage their strong emotions, build better relationships, and learn to accept and cope with stressful situations.
Recently, DBT has been used in the treatment of other disorders, namely eating disorders and substance use disorder. Researchers are also investigating whether or not it could be helpful in the treatment of mood disorders in elderly patients, and what they’ve found so far has been promising.
Basically, DBT skills are most helpful for people who are engaging in self-destructive or self-harming behaviors. Anyone who meets these criteria is likely to benefit from learning some DBT skills.
How Effective Is Dialectical Behavior Therapy for Addiction?
DBT is used more and more often to help people recover from drug and alcohol addiction. Using drugs and alcohol can be seen as self-destructive behavior, and DBT teaches people how to accept and cope with painful feelings and stressful events without turning to drugs or alcohol.
When DBT is applied, the therapist must choose which behavior or problem area to begin with first. If the person with substance use disorder is actively suicidal, the therapist may help them get through these feelings initially. Then, the therapist would move on to any drug use that poses the most serious threat to the person’s life and well-being.
When DBT is applied to borderline personality disorder, it usually targets self-harming and suicidal behavior. When it’s applied to substance use disorder, it targets other harmful behaviors, including stopping the unhealthy use of drugs and alcohol, withstanding the physical and emotional discomfort of withdrawal, and increasing the use of healthy coping skills (like building a social support network that isn’t based on drug use).
The dialectic nature of DBT (allowing two opposing views to be true at the same time) is applied when it’s used for substance use disorder, as well. For example, when a patient relapses, this is viewed as a problem to be solved rather than an absolute failure. The DBT therapist helps the patient to accept the fact that they have relapsed and work towards not relapsing again.
DBT Effectiveness: Research Outcomes
Most randomized control trials measuring the effectiveness of DBT for helping people with substance use disorder have studied people who have co-occurring substance use disorder and borderline personality disorder. These trials have found that people who receive DBT are more likely to recover from the symptoms of both of their disorders.
The most promising research in terms of DBT and substance use disorder is for women with both borderline personality disorder and substance use disorder. Randomized control trials studying the effectiveness of DBT in treating this specific group have shown promising results.
We need more research to be able to say definitively whether or not DBT is effective for people with substance use disorder without comorbid borderline personality disorder. However, other studies have found DBT to be effective for multiple diagnoses that don’t include BPD, and there’s no reason that DBT wouldn’t be effective for SUD alone.
DBT is especially effective for people, particularly women, who face suicidal thoughts and feelings. Almost every study conducted has found that patients who received DBT were less likely to engage in suicidal or self-harm behaviors compared with the “treatment-as-usual” control groups. If you face suicidal feelings and substance use is a self-destructive behavior for you, then you may find DBT to be especially effective.
Is DBT for Me?
There is a wide array of addiction treatments out there, and you may be wondering whether or not DBT is the one for you. Although some other treatments have more supporting evidence for substance use disorder specifically, DBT might be able to help you learn how to cope with your painful emotions and tolerate distress in healthier ways. The skills you learn in DBT are also likely to improve your relationships.
DBT can be combined with some other treatments, like Motivational Interviewing. Many DBT clinics will ask you to stop seeing your regular, non-DBT therapist during the time you’re in intensive DBT treatment.
While DBT could be a great choice of treatment for many people battling addiction, you might be a particularly good fit for it if:
You Have Comorbid Borderline Personality Disorder
Research almost unanimously supports the use of DBT for treating borderline personality disorder —in fact, it’s considered the gold standard of treatment for this disorder. If you suffer from BPD on top of your substance use disorder, then DBT would be a particularly good choice of treatment for you.
You Struggle With Suicidal Thoughts and Feelings.
Even if you don’t struggle with BPD, you may experience suicidal thoughts and feelings. Substance use and suicide have a highly interlinked relationship, and almost all types of substance use disorders lead to a higher risk of suicide. If you’ve found yourself feeling hopeless and suicidal, then DBT may help you to work through those feelings.
You Want to Stop Your Self-Destructive Behavior.
If you aren’t willing to give up self-destructive behavior, including suicidal behaviors and drug and alcohol use, then DBT isn’t likely to work for you. On top of that, if you don’t want to be in DBT but a family member is “forcing” you, then DBT is unlikely to be effective. If you are committed to making an attempt toward recovery, however, then DBT can teach you the skills you need to be successful.
Limitations of DBT
Although DBT has been found to be incredibly helpful, especially for decreasing suicidal thoughts and behaviors, it’s not for everyone. DBT might not be for you if you:
- Don’t have the time to commit to DBT: Many DBT programs have a strict attendance policy, and will expel you from the program if you miss too many sessions. On top of that, DBT requires many hours of skills practice in between sessions.
- Want to keep seeing your current therapist: Since DBT is so structured and uses a specific philosophy, most DBT programs require you to take a break from seeing your usual individual therapist during the time you’re in DBT. You’ll be able to see your psychiatrist for medication, however.
- Don’t want to go to DBT: DBT isn’t an intervention that’s designed to increase your motivation to change. If you don’t want to be there, then DBT sessions are unlikely to help you.
Despite these limitations, DBT isn’t likely to have any negative effects, and it’s worth trying, especially if you’ve already gone through other addiction treatments before.
Next Steps: How to Get Started with Dialectical Behavior Therapy
If you’re interested in going through DBT for substance use disorder, then you should search specifically for a DBT program. Many rehab facilities employ therapists who are trained in DBT. Keep in mind that only Masters- and Doctorate-level therapists can be trained in DBT; certified substance abuse counselors are not able to deliver DBT. You’re more likely to find a trained DBT therapist in rehab facilities that focus on dual diagnosis conditions.
To begin looking for a rehab facility near you, use the RehabAid search function. We care about your well-being and have put time and effort into reviewing reputable rehab centers in every city. With the right treatment, addiction recovery is within your reach.
At RehabAid.com, we are dedicated to helping people recover from problematic substance use and associated mental health disorders. If you or a loved one are struggling with addiction to drugs or alcohol, you are not alone. Information on treatment and support options is readily available through the National Helpline of the Substance Abuse and Mental Health Services Administration (SAMHSA) at 1-800-662-4357. To further assist you along the path to recovery, the treatment center locator on our website allows you to easily find rehabilitation programs and services in your local area.
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