The debate over what causes addiction never seems to end. Is it nature or nurture? Is it a disease, or is it a choice? What makes it worse: drug availability or social isolation? While determining the cause of an addiction can be helpful, in truth it is an incredibly complex syndrome that arises from a web of factors, and addressing a single cause often does little. If we learn someone has a genetic predisposition for alcohol addiction and prescribe them Antabuse, a medication that induces nausea after a single sip, their cravings for alcohol might go away but they may still struggle with the lived experience of the disorder. That’s where good treatment comes in. Interestingly, a relatively new form of therapy—originally not even created for addiction—may be particularly helpful in treating it.
Dialectical Behavior Therapy (DBT) was created in the 1980s for the treatment of Borderline Personality Disorder (BPD). BPD is characterized by extreme mood swings that lead to unstable emotions, relationships, and sense of self. DBT views the disorder through a biosocial lens: it holds that BPD clients are not only biologically predisposed to emotional volatility, but also that their environment may exacerbate this emotional experience by trivializing or stigmatizing it. For example, if someone with BPD is seen as “bonkers” by their family members, this label will in turn make the individual even more volatile and prone to outbursts. This can take a tragic turn, as BPD patients are at an increased risk for hospitalization and suicide. Accordingly, the main goal of DBT is to improve emotional regulation so that the individual can better weather the storm of volatile emotions.
There are four components and four skills essential to DBT as a treatment.
First, to the four components:
- Psychotherapy: weekly one-hour individual sessions
- Phone Calls: clients have to option to hold brief phone calls with the clinician in between individual sessions
- Skills Training: weekly two-hour small group sessions led by two facilitators that focus on building particular skills
- Consultations: weekly two-hour meetings between therapists and skills training facilitators to discuss progress of clients
Next, the four skills that serve as the basis of the Skills Training:
- Mindfulness: The sense of nonjudgmental awareness in which one’s present moment experience is dispassionately observed
- Distress Tolerance: Techniques to endure an unpleasant emotional experience without reacting in a negative way
- Emotional Regulation: The capacity to recognize detrimental emotions as they arise and take actions to offset them
- Interpersonal Effectiveness: Strategies for better navigating social situations to reduce the compounding effect that environment has on emotional experience
These are the four components and four skills that constitute DBT, which, over time, has amassed a strong evidence base as a treatment for BPD. The question remains: could it be an effective addiction treatment as well? The four skills at the heart of DBT, particularly those regarding Mindfulness and Distress Tolerance suggest it may be especially helpful when working with addiction.
Inspired by Buddhism’s 2,500 year-old tradition of meditation, mindfulness is the practice of bringing awareness to one’s present moment experience, such as thoughts, emotions, and sensations, without judgment. While there are many iterations of mindfulness practice, DBT’s focuses on a few key strategies. For example, clients are taught to cultivate a “wise mind,” that develops both emotional and rational thought patterns. Consequently, clients gain a sense of non-attachment from emotions and thoughts: an “angry person” is reframed as a “person briefly experiencing anger.” This would be especially helpful for someone with addiction, who may have long thought of themselves as an “addict,” but can now step back and see themselves as a “person experiencing addiction.” Another helpful strategy is “urge surfing,” in which clients are taught to bring awareness to their urges—acknowledging that like any other sensation, they will pass—without acting on them. This may also be helpful in working with addiction since cravings are often quickly acted on without any investigation.
DBT holds that distressing situations can elicit harmful responses. For example, a bout of anger could lead someone to hurt themselves. With this skillset, clients are taught strategies to help them better deal with negative emotions. Two may be particularly helpful for addiction. Firstly, with the strategy of “adaptive denial,” clients are taught to reframe cravings for their drug of choice as a craving for something else. For example, a craving for the “high” of marijuana could be reattributed to craving for a natural “high,” achieved by taking a hike or going for a long run. Secondly, the skill of “burning bridges” asks that clients cut themselves off from any associations with drug use, such as friends that encourage use or establishments that foster it. This may be easier said than done and the client might need support from the therapist to fully break away.
Lots of Potential, Little Research
While the philosophy of DBT’s Skills Training would suggest that the modality could be helpful with addiction, at this point in time no studies have been conducted on its efficacy in treating addiction alone. Most studies involve patients with co-occurring BPD and addictive disorders. A 1999 study of this population found that, in addition to producing better treatment completion rates, DBT helped patients achieve a higher proportion of days abstinent from drugs and alcohol compared to treatment-as-usual. However, there were inconsistencies across the treatment structures. A 2002 study compared the use of DBT to Comprehensive Validation Therapy (CVT) with clients with co-occurring BPD and opioid addiction. While DBT fared better in reducing drug use, CVT had better treatment completion rates, so it was not clear that one was better than the other. Dr. Marsha Linehan, the creator of DBT and leader of the two previously mentioned studies, and Dr. Linda Dimeff have suggested that while DBT may be effective in treating addiction, it may also be too extensive for some people. With so much focus on teaching emotional regulation, DBT may be best for clients whose addictions are mostly a result of dysregulation. Furthermore, DBT normally only gives clients the option of abstinence as a treatment goal. While this may be wise for someone with co-occurring BPD, it may be too restrictive for someone with an addiction but who is more interested in moderation-based treatment.
Despite DBT’s potential in treating addiction, issues regarding insurance coverage may be an obstacle. Since the Skills Training component requires two facilitators and is limited to ten clients, it is not well-reimbursed for by insurance. Also, in some cases, the Phone Calls and Consultations are not covered at all. On the bright side, if DBT gradually gathers an evidence base as an effective treatment for addiction it will likely be covered better by insurance. When that happens, more people will get the help that works for them.
My own Approach
When I work with clients, I always incorporate the best of cutting-edge treatment. While I don’t offer a full-fledged DBT program my work does contain the two elements with the most potential for treating addiction issues. Incorporating Mindfulness, CBT, and Neurofeedback helps my clients learn to attend to their state of being, reframe distressing situations, and reduce anxiety while improving emotional regulation. All combined this leaves clients with less distress and a better ability to regulate their behavior.
It’s a beautiful thing.
- Chapman, A. L. (2006). Dialectical Behavior Therapy: Current Indications and Unique Elements. Psychiatry (Edgmont), 3(9), 62–68.
- 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 borderline personality disorder. Drug and Alcohol Dependence 67(1):13-26.
- Dimeff, L. (2008). Dialectical Behavior Therapy for Substance Abusers. Addiction Science & Clinical Practice, 4(2), 39-47.
- Koons, C. R., O’Rourke, B., Carter, B., & Erhardt, E. B. (2013). Negotiating for Improved Reimbursement for Dialectical Behavior Therapy: A Successful Project. Cognitive and Behavioral Practice, 20(3), 314-324.