Dialectical Behavioural Treatment (DBT) for Addiction

The four modules of DBT are:

1. Mindfulness

Linehan created DBT with mindfulness being one of its core elements. It is the first module because it is the foundation on which the other three are built. The principle of mindfulness is one of using various meditative exercises to teach patients to pay close attention to the present – i.e. living in the moment – while fully embracing one’s thoughts and emotions. There are two sets of skills learned in the mindfulness module: what (observing the current environment) and how (maintaining focus even when the current environment is not positive).

2. Distress Tolerance

The second module is known as distress tolerance. It naturally flows from mindfulness in that it uses the what and how skills to teach patients how to deal with stressful situations without falling back on previously negative behaviours. Distress tolerance teaches patients how to work through stressful situations through a variety of strategies to keep the mind focused on the positive.

3. Emotion Regulation

The third module is known as emotion regulation. This should be pretty easy to understand. The skills learned during emotion regulation help patients keep their emotions in check rather than allowing them to dictate the course of action. This is of particular importance to recovering addicts who are prone to temptations by way of their emotions.

4. Interpersonal Effectiveness

The fourth and final module is interpersonal effectiveness. In this module, patients learn skills that will govern their interpersonal relationships. They learn to identify their own needs and ask for help in meeting them. They learn to say no to people, circumstances, and behaviours that would be negative. They learn to positively and effectively handle interpersonal conflicts with others.

DBT is an excellent therapy for addiction recovery for those for whom it is appropriate. UKAT treatment centres now include it among the many options our therapists can choose from. For more information about our treatment centres, our bespoke treatment plans, and all the treatment options available to you or a loved one, please contact UKAT at your convenience.

The Effectiveness of DBT

The effectiveness of DBT as a treatment for substance abuse, addiction, and additional mental disorders lies in two fundamental principles Dr Linehan identified as ‘finding a life worth living’ and ‘radical acceptance’. Within these two principles, the four modules of DBT can be explored and built on.

To illustrate this effectiveness, consider one of the first questions patients are asked at the beginning of DBT: what makes life worth living for you?With the understanding of how thoughts influence behaviour and emotions, patients are immediately encouraged to start directing their thoughts toward positive achievement. They are immediately encouraged to begin framing in their own mind what a life worth living looks like.

In concert with that life worth living, patients are also taught skills that bring them to the place of accepting facts they cannot change. A good example would be the death of a loved one. The recovering substance abuser may be using alcohol or drugs to help deal with sorrow rather than embracing the truth that the facts will not change. Accepting the death of the loved one does not mean the patient loves that person any less, but it does mean the patient is ready to refocus thoughts more constructively.

Combining the desire for a life worth living with radical acceptance of facts that cannot be changed is the core of what makes DBT work. The essence of DBT is very similar to the well-known ‘serenity prayer’ written by Reinhold Niebuhr in the 1930s. The prayer asks for the serenity to accept things that cannot be changed, the courage to change those things that can be changed, and the wisdom to know the difference.

Why is DBT effective for substance abusers?

DBT’s effectiveness for substance abuse and addiction lies in its ability to help patients gain control over their own thought patterns and channel them in positive directions. DBT moves the mind and emotions in a direction opposite from addiction, whereas the patient learns to control them rather than allowing addiction to be the controlling force.

Is DBT ever ineffective?

Every psychotherapy option has both successes and failures. So yes, there are times when DBT proves ineffective for a patient. There can be any number of reasons the therapy does not work, from outside distractions to an inability between therapist and patient to establish the right kind of interpersonal relationship.

The thing to remember about DBT is that it is a team-oriented therapy. Therapists and individual patients are the core of the team while other patients involved in the group portion make up the remainder of that team. It only takes a single team member to make the therapy more challenging for everyone.

DBT may also be ineffective if there are outside circumstances that make it difficult for patients to focus on achieving that life worth living. In other words, DBT often continues long after a patient completes residential treatment. If external circumstances, like finances or family life, inhibit the life worth living a patient is striving to achieve, the effectiveness of DBT may be limited.

Dialectical Behaviour Therapy Versus CBT

The similarity of names sometimes leads to confusion between DBT and cognitive behavioural therapy (CBT). The two are closely related and, in fact, DBT is a specialised form of CBT, but there are noteworthy differences between the two.

CBT is a psychotherapeutic treatment with a primary goal of helping patients understand how their thoughts and emotions are linked. The therapy uses specific goals to lead patients through the process of identifying their thoughts and learning how those thoughts to influence both feelings and behaviours. Upon completion of the therapy, patients have a much better grasp of their own thought patterns and how those patterns affect the rest of their lives. CBT is also a time-limited therapy.

DBT essentially builds on the principles learned in CBT. In other words, once patients understand how thoughts influence behaviours and emotions, they can then begin to restructure their thoughts in such a way as to produce more positive behaviours and emotions. More specifically, they learn how to create constructive thought patterns within interpersonal relationships and in those circumstances that tend to trigger volatile emotional responses.

Practical Implementation of DBT

UKAT utilises dialectical behavioural therapy in conjunction with a comprehensive list of additional therapies to help patients who would benefit from it. Not every patient we treat is a good candidate for the therapy. Therefore, therapists have to evaluate each individual to determine the efficacy of each available treatment.

The practical implementation of DBT really boils down to how patients respond to CBT. Those who do well in understanding how thoughts affect behaviours and emotions are good candidates to continue to DBT. Only once they understand their own thought patterns can they begin the DBT exercises meant to channel those thought patterns in constructive directions.

How long does DBT take?

The two biggest differences between CBT and DBT relate to group therapy and time commitment. In terms of the former, CBT offers no group therapy component in that it is designed to be a one-on-one therapy only. DBT utilises both one-on-one and group therapy. The group therapy allows patients to work on their interpersonal relationships, which is a vital component of the DBT modality.

Where time commitments are concerned, CBT is typically time-limited. The average patient can complete CBT in a total of 12 to 15 sessions over several weeks. DBT is more open-ended. Therapists and patients agree to a target completion date, say three or six months down the road, but that completion date will constantly be re-evaluated depending on the patient’s progress. Some patients complete DBT in a few months while others could continue for a year or longer.

Why do therapists choose DBT?

Like any other therapy, DBT is not right for everyone. Therapists use it for patients whose emotional arousal levels increase or decrease more rapidly than what is considered normal for the average person. DBT is helpful in this regard because learning to redirect one’s thoughts can help control the extreme emotional swings that DBT patients routinely experience.

When therapists create a treatment plan for patients, they look for certain signals that would indicate whether DBT would be effective or not. For example, they may ask a series of questions designed to measure how quickly a person’s state of emotional arousal increases and, once peaked, how long the patient remains in that heightened state of arousal.

A patient who reaches a heightened state of emotional arousal more quickly than average is generally a good candidate for DBT. Therapists also look for other signals including an inability to maintain interpersonal relationships and unrealistic perceptions of known facts.

Who and what is DBT good for?

Dialectical behavioural therapy is an excellent choice for individuals who do not understand how to direct their thoughts and emotions to the extent that they allow their emotions to control most of their behaviours. People who benefit from DBT tend to be those with problems related to substance abuse, borderline personality disorder, and mental illnesses like depression and anxiety.

The therapy is helpful for patients who are able to make that connection between thoughts and emotions. Why? Because it bridges the gap between thoughts and emotions and then teaches patients how to control both. It is an excellent therapy for re-establishing acceptable forms of behaviour based on a desire to create a life worth living in the midst of accepting facts that cannot be changed.

How does DBT actually work?

Patients enrolled in a DBT therapy programme undergo two different kinds of therapy sessions in which certain skills are worked on. First, individual psychotherapy sessions are conducted on a weekly basis. Therapists and patients work on problem-solving behaviours directly related to things that happened since the previous session.

In these sessions, therapists prioritise certain kinds of problems. For example, instances of self-injury or suicidal thoughts take precedent over everything else. Therapists also prioritise quality of life issues, heightened emotional responses, and other behaviours that might interfere with therapy moving forward.

Weekly group therapy sessions are offered separately from one-on-one sessions. Group therapy can take several hours and is conducted by a trained therapist able to facilitate group members learning from one another and building off each other’s learned skills. The point of group therapy is to work on the four modules of DBT.

Both individual and group therapy sessions are governed by something known as the DBT Ways of Coping Checklist (WCCL). This checklist measures the rate at which skills are being learned and mastered, along with how those skills are being applied to interpersonal relationships. The goal of the checklist is to give patients and their therapists a guide they can follow as they move through therapy. The WCCL is a more defined checklist based on its predecessor, the Revised Coping Checklist developed in the mid-1980s.

Is DBT integrated with 12-step work?

The core principles of DBT intersect with the main philosophies of 12-step work in many ways. As a result, it is not unusual for therapists to integrate the two in a formal treatment programme. The implementation of the mindfulness module is a very good example.

Mindfulness is often viewed as the basis of DBT because the remaining three modules are built on it. Mindfulness is sometimes described as ‘moment to moment awareness of one’s current state of mind’. Similarly, the 12-step philosophy includes three states of mind that are developed as a patient goes through the steps. It encourages the patient to take an active role in always being mindful of his or her own state of mind.

It should be noted that DBT and 12-step work tend to continue after residential treatment is concluded. As such, they continue to intersect during the patient’s aftercare period.

Common Uses for Dialectical Behaviour Therapy

UKAT’s implementation of DBT generally relates to substance abuse and addiction. Our therapists use it to help substance abusers and addicts understand the relationship between addictive behaviour and their thoughts and emotions. When thoughts can be redirected and emotional responses controlled, addictive behaviour can be avoided.

Beyond substance abuse and addiction, DBT is a therapy with many other practical applications. Below are just a few examples of other disorders DBT is used to treat.

DBT for Eating Disorders

DBT has been adapted to treat some kinds of eating disorders by helping patients be more mindful of what they think about eating. When DBT is recommended as an eating disorder treatment, it is often because patients suffer from more than just one disorder.

DBT for Borderline Personality Disorder

Since DBT was developed specifically as a treatment for borderline personality disorder, we would expect that therapy is still used for that purpose today. It is. Moreover, BPD continues to be the most often diagnosed disorder for which DBT is used.

DBT for Obsessive-Compulsive Disorder

OCD is another disorder for which DBT has proven effective. For this sort of treatment, thoughts are not considered either good or bad; they are just thoughts. The goal is to channel thoughts toward certain kinds of behaviour that address the symptoms of OCD.

DBT for Depression and Anxiety

Depression and anxiety are two mental disorders on opposite ends of the emotional response scale. DBT can be an effective treatment when it is used to teach patients how to better control thought patterns. And because depression and anxiety are sometimes linked to substance abuse and addiction, it is not uncommon for DBT to address both aspects.

Dialectical behavioural therapy is an effective therapy with plenty of research behind it. When it is recommended for UKAT patients, it is provided by experienced, trained therapists whose goals include helping patients create a life worth living. Finding and living that life is ultimately what leads to long-term recovery.