Treating substance abuse with DBT
Dialectical Behaviour Therapy, or DBT for short, is a well-established and well-researched therapy for people experiencing multiple and severe psychological difficulties.
DBT uses a skills training approach - participants learn skills in regulating emotions, tolerating distress, and behaving effectively in interpersonal situations. DBT differs from other treatments in its use of the notion of the “dialectic”.
What is a "dialectic"?
The term dialectic is one with which many people are unfamiliar. A dialectic is essentially a scale with two opposing poles, which, despite the fact that they are opposing, can in fact co-exist, or be synthesised into a coherent approach that incorporates a synthesis of both poles. In DBT the most significant dialectic is that of
acceptance and change. A DBT therapist encourages clients to change, while at the same time accepting their current struggles and efforts. This dialectic is particularly significant when DBT is used to help with substance abuse difficulties.
Committing to Abstinence
The DBT stance on substance abuse is quite clear - the goal is complete abstinence, which means never again engaging in the substance abuse under any circumstances. This is the change end of the dialectic. The DBT therapist assists the person to make a 100% commitment to abstinence. Anything short of 100% leaves the door open for ideas that undermine the commitment, such as thinking "I can have this drink (or this joint, pill etc) and then "get right back on the wagon". This type of thinking makes it more likely that a person will decide to "fall off the wagon" and slip back into substance abuse. Clients in DBT learn a range of skills to anticipate and manage situations that threaten their commitment to abstinence, and are encouraged to “burn bridges” with their suppliers, any substance abusing friends, their substance abuse equipment and so on.
Dealing with lapses
The acceptance end of the dialectic is demonstrated by the way in which lapses into substance abuse are conceptualised. In DBT, a lapse is seen as a problem to solve rather than as a failure. The focus is on harm minimisation. Taking this approach to lapses avoids the intense negative feelings and thoughts which often occur after a lapse, thoughts and feelings which may otherwise lead to the abandonment of efforts to stop the substance abuse.
In the event of a lapse, the therapist assists the client in making a very detailed behavioural analysis of the events that led to and followed the substance use. The precipitating event is identified and described in detail, along with factors that made the person particularly vulnerable at that time: why did this lapse happen today rather than yesterday? for example.
Next, all the links in the chain from the precipitating event to the occurrence of substance use are uncovered. These links will be a series of events, thoughts, feelings and behaviours. Short and long term consequences are identified. This analysis provides an enormous amount of relevant information, and often reveals features of the progression from precipitating event to substance use, of which the person was previously unaware.
A solution analysis is performed. At each link of the chain, DBT skills are identified that could have been used to avert the substance use, and a prevention strategy is also identified to allow for a different response to the precipitating event if it were to occur again. In this way, a very specific plan of action is developed to assist with avoiding and/or coping with similar future situations.
The DBT model of substance abuse
Going back to the notion of dialectics, this DBT model for substance abuse incorporates a synthesis of focusing on abstinence, even if it is only momentary, and using harm reduction after a slip, even a small one. Marsha Linehan, the clinical psychologist who developed DBT, reminds us "It is possible to do these two seemingly contradictory things - commit to absolute abstinence from addictive behaviour, and accept a lapse should such behaviour occur". It is important to be clear that this acceptance does not mean accepting a lapse before one happens or believing that a lapse is inevitable or likely. The dialectic of change and acceptance is key.
If you or someone close to you struggles with substance abuse I encourage you to make an appointment so that we can discuss whether DBT would be an appropriate treatment option. Please review my other articles on aspects of DBT treatment at Dialectical Behaviour Therapy DBT, including What is Dialectical Behaviour Therapy?, and the articles on DBT skills.