Dialectical Behavior Therapy

One of the most interesting and illuminating aspects of Dialectical Behavior Therapy (DBT) is its history. This therapy, which is considered to be a version of Cognitive Behavioral Therapy, was developed specifically for people with borderline personality disorder (usually including suicidal thoughts and prior attempts as main symptoms). Dr. Marsha Linehan, the therapist who developed DBT, was treating patients with borderline personality disorder, it was in vogue to use behavioral therapy. However, Dr. Linehan repeatedly found that her patients did not respond well to behavioral therapy and would often end treatment, with little to no improvements being made. Dr. Linehan observed that her patients did not want to change. That insight led her to develop DBT.

Dr. Linehan’s patients most often had severe symptoms and were difficult to treat. Therapist burnout can happen vis-à-vis clients with borderline personality disorder, but Dr. Linehan was determined to find a way to help her patients. Dr. Linehan recognized that she needed to accept her patients’ thoughts, behaviors, and emotions even more fully. Similarly, Dr. Linehan realized that her patients needed to accept themselves and their circumstances. Dr. Linehan’s main goal was to provide her clients with immediate relief from their symptoms. Due to the nature of borderline personality disorder, and the risks patients face when they are experiencing suicidal thoughts, Dr. Linehan found herself having to be practical. Her main goal was as basic as trying to keep her patients alive and help them regain control of their circumstances.

Attempting to create a therapy built around acceptance and change, in 1980, Dr. Linehan sought and received funding to develop her DBT method. Dr. Linehan found that her patients’ symptoms improved with DBT treatment, and the method was expanded to treat a host of other mental health disorders. Today, DBT is a research-based therapy for the treatment of drug abuse. This article illuminates the main features of DBT by discussing its overarching principles and then describing four DBT modules as they apply to the treatment of substance abuse.

Acceptance and Change in DBT

As an article published by The Fix explains, radical acceptance is a key component of DBT. It may be obvious, but Dr. Linehan found that acceptance can serve as a precursor to change. On the one hand, DBT clients need to accept themselves. On the other hand, because of the state of their health (such as being engaged in drug abuse), clients want to change themselves. It may seem like DBT asks people to engage in opposite actions — accept yourself and then change yourself — but the method has been shown to be effective. Since these two opposite tendencies are blended, the term dialectic is fitting, and that’s why the method is called Dialectic Behavior Therapy. This form of therapy can help a client get to a point of acceptance and then change. It also provides clients with numerous tools to sustain the changes made. As a result, DBT is considered a comprehensive therapy.

The concept of dialectics necessitates further discussion since it is not an everyday concept, and it is a cornerstone of DBT. Dialectics is based on a philosophy that looks at multiple approaches to find the truth. However, this approach does not posit that there is one truth, nor would a DBT therapist state that there is a right or wrong in any given situation. Rather, this approach discusses thoughts, behaviors, and emotions in terms of whether they are effective or ineffective in any given situation. A core assumption here is that people’s behaviors make sense to them. As applied to drug abuse, for example, if a person feels extremely insecure and emotionally traumatized, it does make sense to that person to use drugs to cope with the pain. A DBT therapist understands that a person in recovery does not benefit from being judged or punished. In fact, stigmatizing comments or attitudes will likely cripple the recovery process for individuals in recovery and disrupt their ability to accept themselves. In short, it can be easier to accept oneself when another person, such as a therapist, has an attitude of acceptance.

4 Modules of DBT

Dr. Ashley Chin, a psychologist, uses DBT to treat clients who are experiencing substance abuse. As Dr. Chin explains, there are four main modules within DBT. This discussion identifies and explains each module in order to highlight how DBT works and how it can benefit a person who is seeking to recover from drug abuse or addiction. The four modules of DBT are as follows: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. The discussion of these modules is adapted to the drug abuse treatment context in specific.

The mindfulness approach borrows from Buddhism. Stated most simply, mindfulness is about being aware of the present moment without judging thoughts, emotions, or behaviors. Dr. Chin explains that she teaches her clients to think about their minds as having three potential states: (1) emotion mind, (2) reasonable mind, and (3) wise mind. It is important to understand that no mind state is better than the other. A person is thought to be in an emotion mind when they are in an emotionally charged situation, such as visiting a loved one in a hospital. A person is in an emotion mind when using drugs, as this behavior is not usually based on a rational decision and runs counter to the survival drive. When individuals are in reasonable mind, they are dealing with facts and evidence. A person who is studying for an exam would be in the reasonable mind.

The wise mind is able to synthesize the emotions and facts from the emotion mind and rational mind. To help clients get into the wise mind, a DBT counselor can use different techniques, including helping a client use “and” instead of “but” to join two statements. For example, a client may say, “I was depressed and using drugs but now I’m in recovery.” By guiding the client to change the statement to something like, “I was depressed and using drugs, and now I’m in recovery,” the former statement has less weight. The highlight of the sentence is that the person is in recovery. Changing the way one speaks can change thoughts, and changing thoughts can change the way one speaks. Mindfulness is a method to bring such changes about.

Harkening back to how DBT was started, Dr. Linehan needed to help clients control their emotions. For this reason, emotion regulation became a main module within DBT. A DBT therapist can help a client to develop emotion regulation skills in order to accept and change ineffective emotions. To help a client understand and apply emotion regulation techniques in daily life, a DBT therapist may explain that emotions have a valid evolutionary purpose. For example, fear is great if a bear is charging at people, because it will motivate them to run and save their lives. But fear can also be an ineffective emotion, such as when it motivates a person to abuse drugs. A DBT therapist can help a client to accept their ineffective emotions and make a decision to change them to effective ones. People can control their emotions, but it’s not always an obvious process. DBT can help.

DBT focuses on how people are doing in the present moment and aims to help them lower any distress they are experiencing. Known as distress tolerance, DBT can train recovering clients on how to decrease distress in any given situation. In this way, DBT can help clients to avoid drug use cues. For example, if the holidays with family are distressing, that may be an old drug use cue (i.e., doing drugs to cope with the emotional pain that comes up). DBT can help a recovering person to think about how to respond to distressing situations. There are at least four possible ways of reacting in the face of a stressor:

• Do nothing
• Change one’s behavior
• Change one’s interpretation of the situation, or
• Radically accept what is happening.

It may be surprising that DBT recognizes that a person may do nothing when in a stressful situation, but again, DBT is nonjudgmental. When a person sees that there are ways to lessen stress, the person may opt to do what’s necessary in order to feel greater peace. Running through the possibilities, in the family holiday scenario, that could mean:

• Doing nothing different
• Going for a walk instead of engaging in a triggering situation, such as an argument
• Seeing a family member differently, such as having compassion for how that person is suffering
• Using all of one’s being to take in the situation and not react in an unhealthy way.

The last approach can help a person develop equanimity. In Buddhism, equanimity is a sort of neutrality – a person can be in a situation without holding it inside and reacting in an ineffective way. These techniques take time to develop, but even the slightest practice of them in a moment of distress can lead to insights that help to lower one’s stress.

DBT aims to help recovering individuals to strengthen their interpersonal effectiveness. Doing so can help a person improve their communications with others and, in this way, develop a stronger bond of trust and respect with others (provided the other person is not using an ineffective communication style or at least trying to change it if they are). As Dr. Chin explains, there are three key areas within the interpersonal effectiveness module.

First, a person should learn to be assertive without being aggressive. Some individuals may have such a difficult time saying “no,” in general, that they end up doing things they don’t want to do and then feeling undervalued (which, for a person facing insecurities, can seem like a confirmation). By letting others know what one wants, one can strengthen their interpersonal effectiveness skills. Second, a person can work toward maintaining healthy relationships. Friendships, indeed all relationships, need to be honored, tended to, and given adequate attention. They also prove a great way for people to test out effective communication styles. It’s usually very clear when a person is using an ineffective communication method because the relationship breaks down and people are often hurt. Third, DBT can help a recovering person to preserve their self-respect while respecting others (indeed, the two are interconnected). Having compassion for others can help individuals to have compassion for themselves, and vice versa. Since acceptance is at the heart of DBT, it makes sense that the more individuals grow in self-acceptance, the more they can accept others and grow their interpersonal bond with them.

Reflections on DBT in Drug Treatment

In view of the highlights of DBT, it is evident that this therapy approach is well tailored to the addiction treatment context. A person who is experiencing substance abuse, like a person who has severe symptoms of DBT, needs immediate help to remove the threat of grave self-harm or fatality. DBT can help a person manage their thoughts, behaviors, and emotions in the moment when they can be most out of control and at risk of harm. Due to the brain’s neuroplasticity, therapy can actually help a person rewire (so to speak) the pathways in the brain that are in charge of thoughts, behaviors, and emotions.

The changes DBT can bring about, both psychologically and neurologically, can be thought of as improving a person’s stop-go system (borrowing from a therapist’s visual characterization here). When a person is compulsively abusing drugs, the green light is steadily on. However, when a person decides to stop the drug abuse and get help, therapy can help the recovering person reinstall the yellow and red light system. When a recovering person (irrespective of how long they have been abstinent) experiences a stressor or drug use cue but stops to think about it and uses the mindfulness technique to observe the thoughts, the yellow light is activated. When the person, after using techniques such as emotion regulation and distress tolerance, decides not to use drugs and opts for a healthy alternative (such as watching a television program, calling a sponsor, or going for a walk) then the red light is activated. Although drug abuse has the effect of taking away a person’s control, therapy approaches such as DBT can restore self-control, bringing extensive benefits.