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*artwork by RR resident, age 17yo; paper by RR founding director Gillian Wood
Dialectical behavior therapy (DBT) has emerged as a gold standard of therapeutic intervention for individuals with borderline personality disorder. The learning and implementation of adaptive skills taught in DBT reduces the need to engage in maladaptive coping behaviors. This reduction in self-harming behaviors has the potential to carry across populations who suffer with similar maladaptive behavioral patterns to meet emotional needs. The psychoeducational modules presented in DBT relate directly to the etiology and function of substance misuse. Thus, DBT has the potential to be an effective therapeutic intervention in substance abuse treatment.
As a young woman with severe emotional disturbances and suicidal thoughts, Marsha Linehan spent two years in a psychiatric hospital where she received psychotropic drugs, electroconvulsive therapy, and seclusion. She made a vow that “if she could get out of the emotional hell, she would help others to get out of hell as well and to build a life worth living” (John, 2020). She subsequently completed college and a doctorate of philosophy in psychology. She spent time deconstructing her personal narrative that led to her symptoms of borderline personality disorder, focusing on family mental health predisposition and a “chronically invalidating family environment” (John, 2020).
In the 1970s, Dr. Marsha Linehan developed dialectical behavior therapy (DBT) to treat women like herself who battle self-harm, suicidal ideations, and suicidal gestures. DBT was developed as an adaptation of cognitive behavior therapy (CBT). While CBT encourages the rejection of distressing thoughts, feelings, and behaviors, DBT encourages accepting them. DBT aims to find balance between acceptance and change, blending the acceptance strategies of mindfulness with the change technologies of CBT. Incorporating an acceptance framework allows problematic thoughts and intense emotions to be normalized and validated, especially in light of traumatic personal narratives, thus enhancing self-trust, self-efficacy, and an internal locus of control.
Linehan focused her research on the development and evaluation of evidence-based treatments for populations with high suicide risk and multiple severe mental disorders. DBT is an evidence-based intervention for the treatment of borderline personality disorder, often diagnosed in women with histories of childhood sexual trauma. DBT has been adapted for specific populations including adolescents and can be modified for diverse cultures. DBT is designed to address maladaptive coping behaviors that are self-injurious including non-suicidal self-harm, eating disorders, and substance use disorders. “The development of DBT has been considered as a major milestone of behavior therapy for people with emotional instability” (John, 2020).
DBT works from the perspective that maladaptive, impulsive behaviors function as misguided attempts to regulate unwanted emotions” (Brown et al., 2020). As such, DBT focuses on developing concrete, skillful behaviors to improve self-regulation through four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Dialectical behavior therapy includes these psychoeducational modules that are taught in a group format in combination with individual therapy.
Mindfulness Module. “Substance use disorders are driven by dysregulation of neural processes underlying reward learning and executive functioning” (Priddy et al., 2018). Substance use disorders manifest in a three-stage cycle of addiction: preoccupation/anticipation, binge/intoxication, and withdrawal/negative affect. This cycle affects neurological reward and stress systems, ultimately leading to “decreased responsiveness to natural rewards, increased sensitivity to stress, and automatic, conditioned responses to drug cues that drive substance use behavior” (Priddy et al., 2018). This disconnection between cognitive control and reward systems contributes to compulsive drug seeking behaviors despite negative consequences. Chronic, prolonged substance use produces maladaptive neuroplasticity that affects individuals even long after they have stopped using. Triggers related to substance use through environmental classical conditioning and negative emotional states are likely to be salient for a long time despite abstinence. Learning to effectively cope with these ongoing substance-related cues will help an individual obtain and sustain recovery.
Mindfulness is the practice and state of purposefully engaging with the present moment, turning the mind from rumination on the past or anxiety about the future. “The state of mindfulness is cultivated during mindfulness practice and is characterized by a non-judgmental, non-reactive, present-centered attention and metacognitive awareness of cognition, emotion, sensation, and perception” (Priddy et al., 2018). One primary mindfulness practice includes specific attention which involves attending to an object of focus such as the breath, sensations in the body, natural rhythms like walking, or visual stimuli. This specific attention is maintained while simultaneously acknowledging yet avoiding distractions. Another primary mindfulness practice includes open monitoring which involves remaining cognizant of the flux of internal and external sensations, thoughts, urges, and feelings while refraining from fixating on any specific object of attention. This is analogous to sitting on a riverbank and watching broken branches float downstream, acknowledging their presence on the river but then letting them continue downstream without further thought or judgment. Regarding internal awareness, mindfulness enhances the ability to acknowledge thoughts and feelings without suppressing them or clinging to them, simply allowing them to exist as they are without judgment or expectation. Repeated mindfulness practice evokes the state of mindfulness, and over time this develops into trait mindfulness (Priddy et al., 2018). Trait mindfulness becomes a more habitual baseline state of functioning wherein there is increased mindfulness in daily life and decreased reactivity to distressing thoughts, emotions, and situations. Thus, beyond acute mindfulness states, acquired trait mindfulness is associated with heightened executive functioning and decreased emotional reactivity to stressful triggers.
Neuroscience has measured the ability of mindfulness practice to change white matter in the brain. The hypothesis then becomes that if mindfulness can physiologically alter the limbic system response in the brain, it can enhance the ability to regulate emotions, thereby affecting the neuroanatomy of drug craving. “Mindful traits may decrease cognitive, emotional, and behavioral tendencies that help sustain substance misuse” (Priddy et al., 2018). Mindfulness practices enhance the ability to mindfully observe internal sensations and urges related to triggers around substance use. This self-awareness can empower an individual in recovery to recognize psychosocial triggers, emotional vulnerability and vacillation, and impulsive urges. This grounded awareness provides an opportunity for the application of other more adaptive coping skills, enabling an individual to feel feelings instead of reacting to them.
Distress Tolerance Module. Challenging emotions often seem overwhelming, intolerable, and unbearable. It is unsurprising that individuals may attempt to avoid, suppress, or seek urgent relief from such emotions at all costs, resulting in maladaptive coping behaviors including substance misuse. Individuals with substance use disorders have a higher historical prevalence of adverse childhood experiences (ACEs), traumatic events or assaults, systemic discrimination and oppression related to marginalized identities, etcetera. Maladaptive coping tools like substance misuse become legitimate tools of self-preservation and survival. When facing an emotion seems daunting and unbearable, the perception could amount to further harm, real or imagined. Thus, feeling the emotion is inhibited, and an illusion of control becomes a life-vest in an overwhelming sea of risk. The irony is that emotions have evolutionary purpose and an inherent nature to seek completion through expression. So, the greater the attempt at controlling an emotion through avoidance and suppression, the greater control the emotion itself has over one’s sense of self and basic functioning. Life becomes about escaping the emotion instead of leaning into it and moving through it, liberating focus and energy to living life outside the emotion. Sobriety unleashes emotional vulnerability and novelty. Sitting safely with challenging emotions and tolerating distress becomes a vital skill set to obtaining and maintaining sobriety.
Distress tolerance is the ability to tolerate painful emotions and situations without engaging in behaviors that could make things worse. Dialectical behavior therapy offers tangible skills to tolerate distress healthily and effectively, utilizing a harm reduction approach in order to survive an emotional crisis by building mastery. Some techniques include distraction, self-soothing, physiological regulation, and improving the moment. Distraction helps to disperse the emotion over time, taking away its overwhelming power, allowing for emotional respite through compartmentalization. Self-soothing helps to nurture the primal needs that may have been neglected, abused, or overlooked, and provides the opportunity for reintegration of self-worth and self-care. Physiological regulation helps to activate the parasympathetic nervous system by deliberately adjusting body temperature and rhythms through movement, exercise, and water exposure. Improving the movement gives tools to alter perception of the precipitating event, returning the locus of control to the individual over the environment. Such skills empower an individual in emotional crisis to tolerate and lean into painful emotions without resorting to maladaptive behaviors in attempts to avoid them.
Research has examined distress tolerance levels in substance dependent individuals and found that distress tolerance levels are very low in comparison to controls without substance dependence (Özdel & Ekinci, 2014). Results did not demonstrate any significant correlations between singular or polysubstance use, duration of substance use, or age of first substance use (Özdel & Ekinci, 2014). This research suggests that regardless of the characteristics of the substance use, developing skills around distress tolerance is a therapeutic target factor that will likely enhance the outcomes for individuals in substance use treatment. Among individuals with alcohol use disorder, dialectical behavior therapy produced improvements in emotional avoidance, enhancing efficacy and mastery around willingness and ability to face difficult feelings (Cavicchioli et al., 2020). These individuals were able to articulate the connection between difficulties with emotion regulation and their maladaptive behaviors. This self-awareness combined with learned distress tolerance skills resulted in reductions in maladaptive behaviors like substance use (Cavicchioli et al., 2020). Distress tolerance is psychologically comparable to medically-assisted treatment (MAT) in that it enables sufficient crisis stabilization to make way for more advanced and prolonged therapeutic intervention.
Emotion Regulation Module. As aforementioned, when challenging emotions seem overwhelming, intolerable, and unbearable, individuals may attempt to avoid, suppress, or seek urgent relief from such emotions at all costs, resulting in maladaptive coping behaviors including substance misuse. When prolonged substance use has masked authentic emotions, identifying emotions may present as a challenge. In his memoir Dry (2003), Augusten Burroughs writes, “I feel edgy and worried and frustrated and angry and sad and confused and relieved and every other emotion on that damn rehab feeling chart. Sometimes, a few feelings collect and have a sort of party in my head. Then it seems they all leave and I have no feelings at all” (p. 245). The inability to isolate and identify an emotion can lead to overwhelm, emotional dysregulation, and an inability to problem solve in a manner consistent with the emotional state. When prolonged substance use has masked authentic emotions, regulating the intensity of emotions may also present as a challenge. “I feel as if something essential is rushing out of me and there is nothing I can do to stop it. I cannot find the valve. I’m bleeding out, deflating. There is the sensation of speed. Spiraling. Of falling” (Burroughs, p. 241). While the emotion may be congruent with the situation, the inability to regulate the intensity of the emotion can lead to overwhelm, catastrophic thinking, and unnecessary suffering. When prolonged substance use has masked authentic emotions, understanding what emotions are trying to communicate may also present as a challenge. “Ever since I stopped drinking, my brain sometimes hands me these memories to deal with. It’s like my fucked-up inner child wants attention, wants me to know he’s still in there” (Burroughs, p. 154). Emotions have evolutionary purpose and drive humans to action. The inability to interpret internal emotional communication can result in stunted development and stagnant functioning.
Whereas DBT’s distress tolerance module builds skills around crisis survival, DBT’s emotion regulation module builds skills around decreasing the intensity of emotions and changing unwanted emotions. Emotion regulation skills help individuals mindfully recognize and correctly label emotions through unique psychosomatic indicators, understand the meaning behind individualized emotions both historically and presently, dismantle myths about emotions acquired through social construction, decrease emotional vulnerability and increase resilience, and utilize adaptive coping skills to alter perceptions and regulate emotions, subsequently alleviating psychological suffering. Regarding emotions, there are always four choices: do nothing and stay miserable, change the situation when possible, change the emotional response to an unchangeable situation, or radically accept both the situation and the correlated emotion in order to reduce suffering. DBT’s emotion regulation skills provide the tools to recognize when the latter three scenarios are useful and strategies for effective intervention. Checking the facts is a skill that helps to determine whether the emotion itself or the emotional intensity fits the facts of the situation. When the emotion and situation are incongruent, the aim is to change the perception. Opposite action is a skill that helps to mitigate or change an unwanted emotion. Problem solving involves changing the situation in order to reduce correlated negative emotions.
When emotions can be regulated and modified in adaptive manners, the need to use substances for emotion regulation decreases. Neuroscience research has found that DBT reduces activity in the amygdala, which enables the prefrontal cortex to engage, subsequently improving overall emotional and behavioral functioning and health (Gonzales, 2022). Research has assessed the relationship between improvements in emotion regulation skills and substance use problems following DBT treatment. Results indicate that DBT improves emotion regulation, and that this emotion regulation explains the variance of decreased substance use frequency (Axelrod et al., 2011). This research demonstrates the increased behavioral control in patients receiving DBT.
Interpersonal Effectiveness Module. Substance misuse is often embedded in chaotic interpersonal relationships, whether the unhealthy relationships cause the substance use or the substance misuse causes the unhealthy relationships. In fact, one of the diagnostic criteria for substance use disorders specifically identifies social or interpersonal problems related to use wherein the substance use has caused relationship problems or conflicts with others. Additional diagnostic criteria could also negatively impact social relationships. The criteria of neglecting major roles because of use could impact work responsibilities by overburdening colleagues and could also impact parental responsibilities in regards to safe and effective parenting. The criteria of spending much time using could also impact parenting roles in terms of being physically and mindfully present for children. The criteria of giving up activities to use could impact time previously spent engaging thoughtfully and joyfully with children. Substance misuse increases the prevalence of both perpetration and victimization of assault, gender-based violence, and child abuse and neglect. Substance misuse also involves complex interpersonal dynamics such as enabling and codependency, strained workplace relationships, and high conflict custody cases. Given the high correlation between substance misuse and a history of adverse childhood experiences, it is common that generational cycles of maladaptive coping repeat through social norms, modeling, and reinforcement. This makes it all the more necessary for an effective intervention for substance use disorders to teach and model interpersonal effectiveness skills.
Interpersonal effectiveness involves communicating with others in effective ways while simultaneously maintaining healthy boundaries and self-respect. Dialectical behavior therapy teaches interpersonal effectiveness skills according to the prioritization of three different aims: obtaining the objective, maintaining the relationship, and maintaining self-respect. Some of the goals of interpersonal effectiveness include being skillful in getting wants and needs met from others, saying no to unwanted requests and setting boundaries, being proactive instead of reactive and resolving conflicts before they become overwhelming, repairing relationships when needed, recognizing and ending toxic or abusive relationships, building new relationships, and creating a balance between the needs of self and others.
Interpersonal effectiveness skills provide the tools to maintain and repair existing relationships, build new relationships, and end unhealthy or unsafe relationships. People in treatment for substance use disorders will likely need to apply skills to all of these. Dr. Dawn-Elise Snipes, therapist and educator, speaks to the importance of enhancing social supports as an element of recovery. She highlights the need for psycho-education around healthy, sober relationships. And she emphasizes the value in using group settings to practice and reinforce communication skills. DBT groups develop the knowledge, skills, and abilities around these social deficits.
Dialectical behavior therapy for substance use disorders (DBT-SUD) is a modified version of DBT that incorporates substance abuse prevention strategies and skills to help individuals overcome addiction and maintain recovery. Dialectical abstinence is the synthesis of absolute abstinence and harm reduction; there are skills to plan for both. When the crisis is addiction, dialectical abstinence resembles relapse prevention planning. Skills are related to recognizing triggers, managing urges, coping ahead, and problem solving. The skill of community reinforcement involves restructuring the environment so it will reinforce abstinence instead of addiction. The skill of burning bridges involves actively eliminating connections to potential triggers for addictive behaviors. The skill of building new bridges involves creating new visual and olfactory mental stimuli to compete with addiction urges. The ultimate aim of DBT-SUD is to provide tools to function and operate from a place of clear mind. The addict mind is governed by addiction, and the clean mind thinks that problems are overcome and exist only in the past. Clear mind, however, involves not engaging in addictive behavior while remaining ever-vigilant of the temptation to do so.
“DBT has been conceptualized as a transdiagnostic psychotherapy due to its similar positive impacts across diverse settings and diagnostic groups, including people with SUD” (Marceau et al., 2021). DBT has demonstrated effectiveness in curbing maladaptive behaviors across a variety of populations with mental health issues. DBT shows promise as an integrated intervention for dual diagnosis patients because it can be utilized as a single treatment method yet address symptomatology of multiple diagnoses including borderline personality disorder, substance use disorders, eating disorders, post traumatic stress disorder, bipolar disorder, and depression. DBT can be modified for accessibility by differing ages, cultures, faiths, and abilities, and it can be modified for therapeutic interventions targeting specific behaviors like substance use or specific etiologies like trauma. DBT is a treatment modality that can help individuals survive the darkness as they gain tools to grow into the light. “Through her personal and therapeutic experiences, Linehan reiterates the importance of building a worthy life while being in the middle of emotional stress, difficulties, and myriad weaknesses. It is about accepting both the thorns and the roses and trying to build a healthy life from whatever circumstances available” (John, 2020).
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*Submitted by Gillian Wood in February, 2022 for partial fulfillment of alcohol and drug counseling certification through the University of California San Diego Division of Extended Studies