DBT in Addiction Treatment: Acceptance and Change

At its core, DBT is a form of cognitive behavioral therapy that focuses on disrupting negative patterns of thought and behavior to create more positive outcomes through a series of four modules: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness. These modules are built on the belief that destructive thoughts, feelings, and behaviors—such as those that lead to substance abuse—are learned and can be unlearned under the right conditions. However, DBT is unique from what is traditionally thought of as CBT in its emphasis on self-acceptance and validation. It is there that we find the dialectal quality of DBT.

Dr. Linehan’s research revealed that focusing solely on behavioral change did not produce positive outcomes in people suffering from self-destructive impulses:

Many patients were explicitly sensitive to criticism; when prompted to change, they responded by shutting down emotionally or by exhibiting increased, sometimes overwhelming emotional arousal. At the same time, dropping the emphasis on change and instead encouraging patients to accept and tolerate situations that distressed them produced equally negative consequences. In short, patients experienced both promptings for acceptance and promptings for change as invalidating their needs and their experience as a whole, with predictable consequences of emotional and cognitive dysregulation and failure to process new information.

Because neither acceptance nor change alone work to produce positive outcomes, the two must work together in order to create favorable conditions for healing. As Linehan points out:

The simultaneous embrace of acceptance and change in DBT is consistent with the philosophical approach found in Twelve-Step programs, expressed in the Serenity Prayer: ‘God grand me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

As such, DBT is in many ways a formalized therapeutic articulation of Twelve-Step wisdom.

DBT approaches self-destructive behaviors as maladaptive responses to emotional dysregulation. While this is not applicable to all people with substance use disorders, lack of emotional regulation is a central component of many people’s struggle with addiction, particularly if they experience a co-occurring mental health disorder. Jeremy Schwartz, a licensed clinical social worker, explains, “When a person experiences emotions as very intense, and has difficulty tolerating painful feelings, he or she may look to substances or other addictive behaviors as a strategy for coping.” DBT seeks to increase your ability to tolerate painful feelings without resorting to self-destructive behaviors while simultaneously developing healthy coping mechanisms to replace damaging patterns. In doing so, you become more resilient and better able to regulate your own inner state while reducing reliance on drugs or alcohol.

As DBT has become increasingly integrated in substance abuse treatment, Linehan has developed a DBT-driven approach to relapse prevention. As Schwartz notes, “[T]here has long been a divide between those who promote abstinence and those who promote harm reduction. Rather than looking exclusively to either of those options, DBT’s approach is to support ‘dialectical abstinence.’” Dialectical abstinence means that clinicians promote total abstinence upon entering treatment, but recognize that relapse does not indicate treatment failure. Linehan writes:

DBT treats a lapse into substance abuse as a problem to solve, rather than evidence of patient inadequacy or treatment failure. When a patient does slip, the therapist shifts rapidly to helping the patient fail well—that is, the therapist guides the patient in making a behavioral analysis of the events that led to the drug use, and gleaning all that can be learned and applied to future situations.

As such, relapse is re-imagined as an opportunity for learning that can be used to foster recovery rather than as the end of recovery.

However, coping mechanisms are not only implemented upon relapse, but taught immediately to allow people struggling with addiction to “cope ahead.” This includes learning to identify potential future triggers and developing the skills necessary to cope with those triggers before you are exposed to them in order to prevent a return to using. This approach allows DBT to be valuable even to those who do not struggle with general emotional dysregulation, as it targets vulnerabilities common to all addicts.