People who enter a substance abuse rehabilitation program need to make changes in their lives. That much is obvious. Living with an addiction can take a serious toll on the person’s health, finances and relationships. But while the person might know that change is necessary, and the person might even want to change, making adjustments that will stick, day in and day out, can be difficult. Sometimes, the way a person thinks, and the way a person reacts to the world outside, can create a major stumbling block on the road to recovery. Dialectical Behavior Therapy (DBT) is designed to help people understand and adjust their thoughts and emotional responses.
The History of DBT
Traditional forms of therapy encourage people to look closely at their lives, see the areas in which they should make changes, and then figure out how to make those changes. While some forms of therapy can be supportive, many types of therapy tend to be confrontational, forcing people to look at the stark reality of their lives and see why change is so important. In the late 1980s and early 1990s, a therapist working with patients in Washington State determined that confrontational tactics like this were not working with her patients. Many of these patients had borderline personality disorders, and when they were confronted in this way, they responded with anger or distress. They would drop out of the program, or they would shut down in the therapy session and no progress would be made. In order to reach these patients and come up with a program that could help them to truly change their lives, this researcher, named Marsha Linehan, developed DBT and worked with colleagues to create a manual that other therapists could use if they wanted to apply the therapy and use it with their own patients.
While DBT was originally created for borderline personality disorders, it’s been modified for use in the treatment of a wide variety of other mental health issues, according to the magazine Social Work Today. DBT is now used to treat:
- Substance abuse issues
- Eating disorders
- Post-traumatic stress disorder
- Obsessive-compulsive disorder
Understanding the Power of Thought
A pot of cool water sitting on a burner needs a specific amount of heat to transform into steam. Turn off the flow of heat, and the steam returns to water once more. Emotional responses are much like water, and stress is a lot like heat. For many people, a huge emotional response only comes about after a long period of stress, and when that stress is removed, the person returns to a calm state relatively quickly. By contrast, there are some people who only need a tiny bit of heat to explode, and they may stay in this heightened state for an incredibly long period of time. To return to the analogy, these people would boil mere seconds after being exposed to heat, and they would continue to boil for hours.
Living like this can take an extreme toll on a person’s relationships. Some people find that they become extremely upset at even the slightest bit of inattention or disapproval from others, and they may yell and scream at the slightest provocation. They may swing from one emotion to another, and always feel isolated and misunderstood. It’s easy to see why this could lead to substance abuse issues. People who feel constantly upset or aroused, and who feel consistently alone, may feel as though drugs and alcohol provide the only reasonable means of comfort. DBT strives to help people change their thoughts, so they don’t have to numb those thoughts with substance abuse.
Early Stages of DBT
According to an article written by Marsha Linehan in the Journal of the California Alliance for the Mentally Ill, DBT relies on the ability of the therapist to accurately listen and support the person in therapy, without indicating that the person does not need to change. She writes, “…treatment requires confrontation, commitment and patient responsibility, on the one hand, and on the other, focuses considerable therapeutic energy on accepting and validating the patient’s current condition.” This can be a bit of a balancing act, as the therapist tries to support the person in therapy and help that person feel accepted, while at the same time pointing out why change is necessary. Since this relationship between the therapist and the person in therapy is so important, early stages of DBT often involve very long, intense conversations between the therapist and the patient. These sessions, which might last for two hours or more, allow the two to build up a relationship and understand one another.
As the therapy progresses, the therapist begins to provide instruction on mindfulness techniques. This is a concept pulled from
Eastern religions and it can be quite powerful. The therapist encourages the patient to identify when thoughts are coming from the emotional part of the brain. When those emotional thoughts are identified, the person is then asked to take a step back and observe the situation with logic and objectivity before choosing to react. For some people, this means learning how to simply accept a situation without approving of it. In other words, some people learn how to move beyond things they cannot control. No judgments are needed, and no intercessions are required. The person can just move past the moment.
Some therapists ask people to separate thoughts from facts. If a person feels unintelligent or unloved, it might not mean that the person actually is unintelligent or unloved. The basic thought is faulty, while the emotions that generate that thought may be very real. Teasing out the separation between thoughts and emotions can allow people to stop behaving in a negative manner due to overwhelming emotions.
Middle and Late States of DBT
Therapy sessions may be incredibly helpful, but they may not allow the person to truly practice the lessons and apply them in real time. Group sessions can help to fill this gap. Group sessions in DBT tend to begin weeks after the person has started to work with a therapist, and that therapist remains in charge of the group sessions. These meetings are not similar to addiction support group meetings such as Alcoholics Anonymous. Instead, DBT meetings are tightly structured and controlled by the therapist, and they’re designed to allow people to interact in a safe environment, practicing their skills. The therapist might ask people to role-play or talk about their experiences and get advice from others. Typically, the group works on one of four areas in each group session:
- Interpersonal relationships
- Tolerating and accepting reality and dealing with distress
- Regulating emotions
In addition to these group sessions, people in DBT are often provided with lengthy homework assignments. They may be asked to read articles and write about them, or they might be asked to use a specific technique in a stressful situation coming up that week, and then describe how that technique either worked or did not work.
Supporting Lasting Changes
While therapy might allow a person to make significant changes in the way he/she thinks and responds to the world, those changes may not truly stick when therapy ends unless the environment around the person changes as well. For this reason, DBT also includes a significant amount of family therapy, allowing the group to come together and work through their past trauma. While family therapy is used in many different models of treatment for addiction, family therapy in DBT has one important twist. According to the article by Marsha Linehan, family therapy sessions in DBT always include the patient. While other forms of addiction family therapy may allow members of the family to meet in their own private sessions with the therapist, this might be seen as a violation of trust for some patients. They may worry that the therapist and the family are bashing them somehow, or exchanging private stories. By allowing the person to be in all family therapy sessions, the trust between the therapist and the patient stays intact.
Some therapists using DBT also help people find new places to live, connecting them with community resources for low-income housing or helping them to build up the skills they’ll need to get better jobs, so they can afford new and better places to live. Again, these sorts of changes can help to support long-term improvement, as the person won’t be returning to the life of dysfunction that supported the original addiction.
Effectiveness of Dialectical Behavior Therapy
Many studies have focused on the ability of DBT to help people resist the urge to harm themselves or commit suicide. The therapy has been proven remarkably effective in this respect. For example, according to a study published in the journal Archives of General Psychiatry, people who received DBT were half as likely to attempt suicide as compared to people who received other types of therapy. The skills the people learned in therapy seemed to allow them to keep these destructive ideas at bay.
Similarly, the therapy has been proven effective in helping people who have a Dual Diagnosis, or a substance abuse problem in addition to a mental health problem. A study in the American Journal on Addictions found that women with addictions and borderline personality disorder who were given DBT had large reductions in their drug abuse, and those reductions were greater than the reductions seen in people who were assigned to other forms of treatment. The results for people who have only a substance abuse issue without an underlying mental health issue seem a bit less clear. According to the Substance Abuse and Mental Health Services Administration, some studies have found that DBT is effective in reducing drug use, as compared to other treatments, but other studies have found that people given DBT returned to drug use within the following year. It’s unclear why this would be the case, but it’s almost certain that researchers will be examining this issue closely.
At Michael’s House, we’ve used DBT techniques with our residents, and we’ve found the therapy to be remarkably effective. If you’d like to learn more about how we integrate this therapy into our programs, please contact us.