We'll order now what they ordered then, ‘Cause everything old is new again
“Everything Old Is New Again,” Peter Allen and Carole Bayer Sager
DBT” is a relatively new construct being used as the wrapping for some time-tested techniques now being generously re-gifted to the substance use treatment community. An evidence-based practice, Dialectical Behavior Therapy is helpful with substance abusers who are suicidal or have borderline personality disorder, and includes a lot of what we do already.
Historically, the addiction field has had a dialectical approach. We have combined the seemingly opposite strategies of confrontation and affirmation to help our clients change. DBT offers a similar dialectic that synthesizes two apparently opposite goals: validating clients as they are and challenging them to change.
Developed by Marsha M. Linehan, PhD, DBT evolved from her work to help suicidal clients. She realized that people who wanted to be dead might not have the coping skills necessary to build a happy life. But when these highly sensitive people were challenged to change, they perceived this as hurtful criticism and often fared even worse.1
Linehan's solution was to combine constructive criticism with efforts to promote self-acceptance. This thinking parallels the growth in our field that has resulted in the understanding that improvements in self-esteem make clients more receptive to gentle confrontation (this is described as “developing discrepancy” in Motivational Interviewing literature).
One common dual diagnosis is substance abuse and bipolar disorder. DBT includes specific strategies to improve retention and success rates among this group. The treatment goals include improving client motivation to change, developing client skills, generalizing new behavior, restructuring the environment, and improving counselor skill and motivation.1
When used with people with substance use problems, DBT prioritizes goals on the basis of how big an obstacle each behavior is to the client's quality of life. The first goal is usually to decrease the use of substances, then to alleviate the discomfort clients face in adjusting to withdrawal and not using.
The next step is to address urges and cravings, while avoiding likely relapse cues (drug users, crack houses, bars, etc.). Then there is work on eliminating or reducing behavior patterns that might lead to relapse (acting impulsively, for example). Finally, there is a focus on community reinforcement, the building of healthy behaviors, sober social connections, employment, and other protective factors.
Examples of practices
There are several DBT practices to consider. These can be incorporated into your current work, or you might already be practicing them by another name:
Time-limited abstinence pledges. Clients who aren't ready to commit to abstinence are asked to commit only to a specific length of time. This could be a week or 20 minutes, but the most important thing is for the client to feel confident it is doable. Once this goal is achieved, counselors insist on another time-limited pledge. This is not unlike the “one day at a time” strategy that eventually results in long-term sobriety.
“Coping ahead.” This is the DBT equivalent of relapse prevention. Clients develop strategies for dealing with potential problems.
The other side of the dialectic of insisting on abstinence incorporates the concept of “failing well.” Any actual lapse is treated as a learning opportunity. The counselor supports clients by helping them to avoid the abstinence violation effect, which might result from thinking such as “I'm a screw-up, so I might as well stay stoned.”
DBT also incorporates harm reduction techniques, by first targeting the primary drug of abuse and then other drugs that are associated with the primary drug. There is an emphasis on goals that are attainable.
Body of evidence
Research has shown DBT effective for substance use disorders for suicidal and borderline clients. There is less information on the use of DBT in the treatment of substance abuse alone. But DBT training can help us rethink what we are doing and help us grow professionally. We grow both when we learn a new technique and when we acquire confirmation that what we already are doing is efficacious.
DBT might be most helpful for clients who have the hardest time controlling their emotions and less helpful for those whose emotions have less to do with their ongoing substance use.1 Additional research is being done to determine the exact situations in which DBT can be most helpful.
Linehan has provided a great deal of information on this therapy. The Web site http://faculty.washington.edu/linehan includes her contact information as well as links to a wide range of materials on DBT. Her two books, both published by The Guilford Press in 1993, are Skills Training Manual for Treating Borderline Personality Disorder and Cognitive-Behavioral Treatment of Borderline Personality Disorder. The latter includes a comprehensive explanation of DBT theory and techniques. The former includes extensive handouts and homework sheets to reproduce for DBT skills training.
Nicholas A. Roes, PhD, author of