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Using Dialectical Behavioral Therapy in the Treatment of Addiction

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Amy Litteral – Licensed Marriage and Family Therapist

Dialectical behavior therapy (DBT) is a therapy designed to help people change patterns of behavior that are not helpful, such as self-harm, suicidal thinking, and substance abuse.

Substance abuse can also be considered a self-harming behavior. Negative consequences from substance abuse often brings numerous adverse consequences for Addicts. ie (health problems, relationship and job losses, legal problems, and economic issues to name a few) Yet despite the negative consequences, many will continue to use to experience even a short reprieve from discomfort or pain.

DBT allows for people struggling with substance abuse problems, a way to achieve self-acceptance while simultaneously accepting the need for change in their lives. DBT has 4 main sections with coping skills embedded in each: Mindfulness, Interpersonal Effectiveness, Emotion Regulation, and Distress Tolerance.

Mindfulness is an idea originally borrowed from Zen Buddhism. Mindfulness teaches people how to focus on the present moment as opposed to the past or future and to be aware and accepting of what is happening both within and outside without making judgments about the experience. This can also be described as acceptance of the self and of one’s circumstances.

Interpersonal Effectiveness teaches how to set limits/boundaries in relationships. Namely, it aims at increasing one’s ability to ask for what they need and say no to unwanted requests in a way that allows for respect for self and others. Many times, the behaviors associated with substance abuse cause havoc in relationships and trust needs to be rebuilt.

The Emotion Regulation section of DBT teaches how to identify, regulate and experience emotions without becoming overwhelmed and acting on impulse. The skills aim to reduce vulnerability and increase positive experiences. Emotion Regulations skills can assist the addict in recognizing emotions and/or cravings so that they can apply a coping skill before acting on the impulse to obtain drugs/alcohol.

The fourth area of DBT is Distress Tolerance. This area is focused on the development of skills to cope with crises when emotions/cravings become overwhelming and the individual is unable to immediately solve the problem (a death, sickness, loss of job, a break up, an argument etc.) but needs to persevere and live through the crisis without making it worse by impulsive actions (for example, getting high or drunk).

In the quest for abstinence, DBT pushes for immediate and permanent cessation of drug abuse (change) while also offering the idea that a relapse, should it occur, does not mean that the individual cannot achieve the desired result (acceptance). The dialectical approach therefore joins unrelenting insistence on total abstinence with nonjudgmental, problem-solving responses to relapse, which include techniques to reduce the dangers of overdose, infection, and other adverse consequences.

DBT treats a lapse into substance abuse as a problem to solve, rather than as evidence of patient inadequacy or treatment failure. When a patient does slip, the therapist shifts rapidly to helping guides the client in making a behavioral analysis of the events that led to and followed drug use, and gleaning all that can be learned and applied to future situations. The therapist also helps the client make a quick recovery from the lapse. This approach may lessen the intense negative emotions and thoughts that many people feel after a lapse and that can hinder reestablishing abstinence. (“What’s the point? I’m a failure. I can’t do this. I give up. I might as well keep using.”)

The idea of the lapse also involves repairing the harm done to oneself and others during the lapse. This concept is similar to making amends in steps eight and nine of the 12 steps of Alcoholics Anonymous, and serves two functions. It increases the awareness and memory of the negative consequences of using drugs while also directly dealing with the adverse effects of using specifically, “justified guilt” that is, being able to accept that it’s appropriate to feel guilt, regret, and a desire to change, as a result of negative acts. (For example, stealing money to buy drugs.)

In DBT with substance abusers, the clinician enters into an agreement (“abstinence pledge”) with the patient that he/she will remain abstinent for a specific amount of time. Since many substance abusers would find a lifetime of abstinence overwhelming, the “contract” is for a set period of time and renewed when the time period ends. The rationale behind this is that the goal needs to feel “achievable” so the amount of time is negotiable between the therapist and client. In some ways, this mirrors the “one day at a time” philosophy found in 12-step programs.
Clients are then taught strategies for dealing with potential problems including “triggers” to use drugs and/or alcohol. This “coping ahead” skill is the DBT equivalent of relapse prevention. It acknowledges that an addict’s fallback coping mechanism in many situations is to use and it is essential that the individual identify other tools for addressing difficult situations ahead of time.

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