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Dialectical Behavior Therapy (DBT) and Substance Abuse Treatment

Author: Alan Downs, Ph.D./Thursday, September 30, 2010/Categories: Chemical Dependency

Dialectical Behavior Therapy — or as it is most commonly known, DBT — has become an acclaimed, evidence-based therapy for individuals struggling with a co-occurring disorders. The evidence to support the use of DBT in substance dependence treatment is growing and recognized by prominent authorities in the field, such as SAMHSA (2008 Science and Service award was given to a DBT program based in Portland, Oregon) and NIDA (published a paper recommending the use of DBT with co-occurring disorders).

The incredible value that DBT brings to the treatment of co-occurring disorders lies primarily within DBT’s emphasis on acquiring skills for emotion regulation. Many alcoholics and addicts use their drug of choice as a primary means of regulating their emotions and improving their mood states. DBT, which was originally created to help individuals with Borderline Personality Disorder — a pervasive disorder of emotion regulation — excels at assisting patients in learning healthy and effective emotional regulation skills. Once the addict and alcoholic surrenders the use of the drug, the patient is left without many useful ways to manage his or her emotions, and it is here that DBT provides needed relief.

To really understand the heart and soul of DBT, we must understand the basic function of our emotional system, something I was reminded of during a recent, unplanned visit to the emergency room. Lying on the floor of the emergency room at Cedars Sinai Hospital in Los Angeles is not a pleasant experience. The day before as I found myself curled up in the worst pain I had ever known, I began to have a backache that grew into what I later learned were the spasms associated with a kidney stone. I was leading a Family Weekend at Michael’s House in Palm Springs, California, during the day, and on the drive back that evening, sitting in the car went from uncomfortable to unbearable. I was rushing back to Los Angeles to make a dinner appointment and had a full day of clients scheduled the next day. The last thing I had time for was to be curled up in pain among the injured masses of a major urban hospital.

The kidney stone was something of a warning signal from my body. I was working long hours under the enormous stress of running an inpatient rehab facility and not drinking enough water to flush my kidneys of the normal deposits. As a result, the stones formed and my body sent a searing message that I needed to stop and do something different. The more I ignored the signal, the stronger it became until ultimately it completely overtook my awareness.

Our emotional system operates very similarly to the pain system within the body. Emotions are designed to primarily warn us of possible danger and to prompt a change in behavior, just like the pain from the kidney stone forced me to stop what I was doing and to ultimately have surgery to remove them. Emotions are intended to organize and focus our behavior in moments when we may need to react quickly, sometimes even before thinking about it.

The science of emotions is complex and growing. Despite a huge number of recent advances, much of which has been fueled by the highly profitable development of antidepressants and other psychotropic medications, some of the basic principles about emotions as described by the legendary psychologist and philosopher, William James, in the late 1800s have held true. James wrote, “My theory … is that the bodily changes follow directly the perception of the exciting fact, and that our feeling of the same changes as they occur is the emotion.”  In short, emotions are changes in bodily states.

While James went on to propose other aspects of emotions that haven’t been confirmed by the last century of research, this point has held up to investigation: When we feel an emotion, it is our brain’s perception of changes in sensations in our body. For example, your brain senses tightness in the chest and rapid heartbeat and interprets this as anger. Similar but subtly different bodily sensations are interpreted as fear. Once the brain interprets these bodily states, it floods our perceptual system with an urge to take action. When we feel anger, we have an urge to strike out. When we feel fear, we have an urge to flee the danger. Likewise, when we feel sadness we have the urge to seek the comfort of the familiar and to “hibernate” within the confines of what we know and what feels safe. Each emotion has its own identifiable bodily state and subsequent action urges.

Think of it this way. An emotion is remarkably like drinking a shot of liquor or taking a drug. Soon after drinking, the alcohol begins to affect your body in very distinctive ways. Your reaction time slows, your muscle coordination diminishes and your ability to maintain focus lessens. Likewise, when you experience an emotion, your body is responding to a unique cocktail of neurotransmitters within your nervous system that affects your entire body. When you feel strong anger, you may have sensations of being stronger than you are, and have moments of narrowed focus on the target of your anger. And just like with liquor, it takes time for the effects of the neurotransmitters to return to normal levels. In essence, you stay drunk on the emotion until these chemicals retreat to baseline, provided that you don’t “re-trigger” the emotion. Just as the alcoholic drinks until he is completely drunk and passes out, if you continually encounter the situation that is triggering an emotion, you remain in an altered state that can become more intense as the emotion is “re-triggered.”

This is where the emotional regulation skills of DBT are invaluable in teaching us how not to re-trigger the emotion so that we can “sober up” and make decisions that lead to a worthwhile life. It’s not an option for you to “abstain” from feeling (nor is it recommended, as other serious mental health issues arise), so we must learn how to live with our emotions, and more importantly, how to limit the distress that painful emotions bring into our lives.

While DBT isn’t appropriate for every substance abuser, there is emerging evidence to suggest that most components of DBT are efficacious for most alcoholics and addicts, and when the patient struggles with a co-occurring condition, DBT is therapeutic and effective.

For more information on the evidence to support DBT in substance dependence treatment, below is a brief bibliography:

American Psychiatric Association, 1998. Gold Award: Integrating dialectical behavior therapy into a community mental health program. Psychiatric Services 49(10):1338-1340.
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Cacciola, J.S., et al., 1995. Treatment response of antisocial substance abusers. Journal of Nervous and Mental Disease 183(3):166-171.
Cacciola, J.S., et al., 2001. The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients. Drug and Alcohol Dependence 61(3):271-280.
Darke, S., et al., 2004. Borderline personality disorder, antisocial personality disorder and risk-taking among heroin users: Findings from the Australian Treatment Outcome Study (ATOS). Drug and Alcohol Dependence 74(1):77-83.
Dulit, R.A., et al., 1990. Substance use in borderline personality disorder. American Journal of Psychiatry 147(8):1002-1007.
Frances, A.; Fyer, M.R.; and Clarkin, J.F., 1986. Personality and suicide. In: J.J. Mann and M. Stanley (Eds.), Psychobiology of Suicidal Behavior (Vol. 487). New York: Annals of the New York Academy of Sciences, pp. 281-293.
Koons, C.R., et al., 2001. Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy 32(2):371-390.
Kosten, T.A.; Kosten, T.R.; and Rounsaville, B.J., 1989. Personality disorders in opiate addicts show prognostic specificity. Journal of Substance Abuse and Treatment 6(3):163-168.
Linehan, M.M., 1987. Dialectical behavior therapy: A cognitive behavioral approach to parasuicide. Journal of Personality Disorders 1:328-333.
Linehan, M.M., 1993a. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, M.M., 1993b. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.
Linehan, M.M., in press. Skills Training Manual for Disordered Emotion Regulation. New York: Guilford Press.
Linehan, M.M., et al., 1991. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry 48(12):1060-1064. Linehan, M.M., et al., 1999. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addictions 8(4):279-292. Linehan, M.M., et al., 2002. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for border
line personality disorder. Drug and Alcohol Dependence 67(1):13-26. Linehan, M.M., et al., 2006. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality dis
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Linehan, M.M.; Dimeff, L.A.; and Sayrs, J.H.R., in press. Dialectical Behavior Therapy for Substance Use Disorder. New York: Guilford Press.
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apy: A Guide for Practitioners. New York: Oxford University Press, pp. 291-305. Linehan, M.M.; Heard, H.L.; and Armstrong, H.E., 1993. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry
50(12):971-974.
Links, P.S., et al., 1995. Borderline personality disorder and substance abuse: Consequences of comorbidity. Canadian Journal of Psychiatry 40(1):9-14.
Lynch, T.R., et al., 2003. Dialectical behavior therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric Psychiatry 11(1):33-45.
Marlatt, G.A., and Donovan, D.M., 2005. Relapse Prevention: Maintenance Strategies in the Treatment of Relapse Prevention. New York: Guilford Press.
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188(5):287-296.
Nace, E.P.; Davis, C.W.; and Gaspari, J.P., 1991. Axis II comorbidity in substance abusers. American Journal of Psychiatry 148(1):118-120.
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Rutherford, M.J.; Cacciola, J.S.; and Alterman, A.I., 1994. Relationships of personality disorders with problem severity in methadone patients. Drug and Alcohol Dependence 35(1):69-76.
Safer, D.L.; Telch, C.F.; and Agras, W.S., 2001. Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry 158(4):632-634.
Stone, M.H.; Hurt, S.W.; and Stone, D.K., 1987. The PI 500: Long-term follow-up of borderline inpatients meeting DSM-III criteria. I: Global Outcome. Journal of Personality Disorders
1:291-298.
Telch, C.F.; Agras, W.S.; and Linehan, M.M., 2001. Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology 69(6):1061-1065.
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182:135-140.
Zanarini, M.C., et al., 2004. Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. American Journal of Psychiatry 161(11):2108-2114.

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