Therapists who treat individuals with complicated emotional and psychological problems who are also resistant to change face a difficult challenge. Attempting to apply aspects of psychological theories in therapy is not an easy task even with individuals who want to change their behavior. Moreover, people who display certain types of problems, such as substance abuse, certain personality disorders, disorders that result from trauma, etc., have built-in resistance to change that includes a fear of change itself and the fear of failure regarding their ability to change their behavior.
One particularly difficult type of client that presents problems in therapy is the chronically suicidal or self-harming individual. These individuals are often resistant to changing the aspects of their beliefs that contribute to their tendencies to want to engage in self-harm, and they are also resistant to accepting aspects of the world that they cannot change. Thus, these clients are resistant to both making changes and to accepting reality. It became clear to a number of therapists that a specialized approach to deal with this therapeutic dilemma needed to be developed. Several different therapeutic paradigms have addressed this double-barreled problem.
One of the most severe personality disorders is borderline personality disorder (BPD). Individuals diagnosed with BPD are often prone to self-harm and gestures of suicide, and may even commit numerous attempts at suicide. Individuals with BPD in therapy are often resistant to notions that they need to change certain aspects of their own beliefs about themselves and at the same time are resistant to accepting the reality that the world does not revolve around their needs or desires. People diagnosed with BPD are notoriously difficult to treat and many therapists steer clear of them.
Dialectical Behavior Therapy (DBT) is a specialized form of Cognitive Behavioral Therapy that was initially developed to address these types of issues, and it originally found its validation in treating individuals with BPD. DBT techniques have been refined to the point where this technique is now recognized as the gold-standard therapy for treating individuals who have borderline personality disorder. In addition, DBT has also been modified to treat individuals who have issues with substance abuse (who often present with the same double-barreled attitudes regarding changing themselves and accepting reality), other personality disorders, and other difficult-to-treat psychological issues.
Standard Components of DBT
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.
Additional Techniques Developed for Assisting Change and Acceptance
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.
The primary therapeutic paradigm or school of thought that DBT originates from is known as the cognitive behavioral paradigm. The cognitive behavioral paradigm combines two primary psychological schools of thought: the cognitive paradigm and the behavioral paradigm.
- The cognitive paradigm addresses the internal mental processes that are related to how a person feels and acts. This paradigm assumes that behavior is a function of a person’s thoughts, feelings, and perceptions. When these are irrational or dysfunctional, the person’s behavior becomes dysfunctional.
- The behavioral paradigm was designed to specifically look at changing behavior. By understanding the actions that trigger a behavior (the antecedents of the behavior) and the consequences of the behavior, a therapist who employs strictly behavioral therapy practices can change how a person acts. Typically, this involves either changing the triggers, changing the consequences of one’s actions, or both.
- Cognitive Behavioral Therapy combines these two paradigms in order to understand both the triggers (antecedents, which include the person’s feelings and thoughts), the behavior itself, and the consequences of the behavior (including the internal states or feelings one has after acting and how one’s actions affect others).
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.
How Sessions Work
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.
Does DBT Work in the Treatment of Substance Abuse or Addiction?
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.
Who Can Perform DBT?
DBT is an intensive and specialized form of therapy. It should only be practiced by professionals who have been specifically trained in the principles of DBT and who continue to receive upgraded training. DBT cannot be learned from a book or an article, even by professional therapists. Only licensed, professional therapists who are trained in DBT should be considered competent in the delivery of the entire DBT package. The Linehan Institute, named after the founder of DBT Dr. Marsha Linehan, offers a clinical resource directory service to allow people to find certified DBT therapists in their area.