Radical Acceptance and Your Recovery: DBT for Substance Abuse

Dialectical behavior therapy (DBT) is a broadly used form of psychotherapy. Using DBT for substance abuse treatment has a proven track record.1 This effective form of therapy can be used in many different settings and for multiple needs, including alcoholism therapy.1

In this article:

What Is Dialectical Behavioral Therapy?

Dialectical behavioral therapy (DBT) is a comprehensive behavioral therapy modality, created in the 1970s. DBT is designed to address complex treatment needs, such as personality disorders, suicidal ideation, unprocessed trauma, eating disorders, and addiction, as well as for those whom alternative counseling techniques would not prove beneficial.1

Prior to the development of DBT, cognitive-behavioral therapy (CBT) talk therapy was the primary type of behavioral therapy used. CBT is considered widely effective and is still used to help many individuals, including people with addiction.

However, some people seeking treatment for multifaceted needs experienced the techniques in CBT differently than others, especially in the following areas:1

  • Feeling invalidated and misunderstood by the therapist
  • Finding that the skills training and motivation-building was not taught in the necessary way to be usable in everyday life
  • Having therapy sessions and treatment plans ended before the full benefits and care were offered and improvements were realized

When using CBT for people with more complex needs, the traditional techniques were sometimes experienced as hurtful rather than helpful. Instead of feeling respected, validated, and understood, those who did not respond well to CBT felt unseen and unheard.1

This disconnect created an unhealthy therapeutic environment where the therapist’s attempts to help build skills and motivation while challenging unhealthy behaviors was seen through a lens of mistrust. Many individuals experienced ineffective counseling sessions that ended early, and sometimes the entire course of treatment abruptly finished before any true healing could begin.1

Noting such a difference in response to CBT, therapists came to use DBT for people who needed alternative counseling techniques that could help them feel understood and validated, and begin working on positive skills and motivation while welcoming the counselor’s gentle redirection of harmful habits.1

DBT was created with several of the same tenets of CBT, but with modifications to meet the needs of individuals who were not well served by therapists specializing in CBT.1

These changes include:1

  • Radical acceptance of the person’s needs and capabilities
  • Validation of the person’s emotions and behaviors
  • Skills training
  • Motivation strengthening

What Can I Expect in DBT Treatment?

The process of DBT is slow and delicate, and DBT moves carefully through stages, prioritizing true readiness to move forward. The slow progress made in DBT is different than CBT, but can be ideal for those who did not respond well to CBT or who need supplemental therapy in addition to CBT.1

By moving at a pace dictated by the individual, the therapist safeguards their feelings and needs in the room to promote the most ideal environment and opportunity for positive change.1

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DBT stages are not necessarily chronological and the stage may repeat as the individual’s needs change. Some individuals enter DBT at the ordinary happiness stage, but must undergo a stage of stabilization later when processing a traumatic event in therapy. DBT treatment stages include the following.

Stabilization

DBT is often used for people with high treatment needs. Some individuals start DBT therapy in hospitalization or inpatient settings during a time period while they are experiencing acute and profound symptoms that may present risks to themselves or others.

DBT may also be recommended when individuals who were not previously experiencing symptoms that interfered with their life begin doing trauma work or other intensive therapy that can have mental, emotional, and even physical effects. These effects can include nightmares, panic attacks, flashbacks, nausea, paranoia, and difficulty focusing.

The stabilization phase ensures that everyone is physically and emotionally safe, such as by determining what steps must be taken to mitigate the potential risks of dangerous substance use, self-harm, suicidal ideation, or dissociation.1

The goal of stabilization is to work with your therapist to:2

  • Reduce life-threatening behaviors
  • Reduce therapy-interfering behaviors
  • Reduce problem behaviors
  • Increase skills-based practices

During stabilization, you may need to work with a care team in addition to your therapist. For example, completing medically supervised detox to manage acute alcohol withdrawal symptoms or working with a psychiatrist to start finding the right antianxiety medication for you.

Ordinary Happiness

The second stage of treatment is used to begin reducing ongoing symptoms and to address gaps in life skills that affect how you live. If you have not previously been evaluated for mental health conditions other than substance use disorder, your therapist may evaluate you for conditions like post-traumatic stress disorder (PTSD) based on your symptoms, behaviors, or experiences. 2

Not everyone in DBT has a secondary diagnosis, like PTSD, but many have had invalidating or emotionally traumatic experiences that have never been addressed in previous therapy.2 In this stage, you and your therapist will process your childhood experiences, your family dynamics, the roots of the behaviors that you have stabilized, and your romantic relationships. This processing is done to determine what in your life might be making it difficult for you to feel everyday happiness and that your life is purposeful.2

This stage is focused on achieving ordinary happiness, where you can put aside overtly unhealthy thoughts and actions to develop a stable lifestyle by building living skills, committing to abstaining from life-threatening behaviors, and continuing to reduce the frequency and intensity of behaviors that interfere with therapy and your quality of life.1,2

Completeness

The third stage starts to focus on mindset, where you are challenged to overcome and alter your negative thought patterns that may have contributed to a sense of incompleteness or unworthiness in life.1

During this stage, you work on learning to trust yourself and on achieving progressively bigger and more meaningful personal goals.2 You may begin to need fewer sessions and begin to utilize peer and community supports, such as Alcoholics Anonymous (AA), meetings in this stage as your progress becomes slightly more self-directed.

Finding Joy

The final stage brings together all stages and achieves an overall sense of joy as you witness a change in your quality of life and way of thinking, consistently abstain from unwanted behaviors, and see yourself as worthy of happiness and love.1

Clinicians may define this stage as obtaining “deeper meaning through spiritual existence.”2 This reference to spirituality is not based on a certain belief system, but rather on a feeling of connectedness, hope, and joy in your life.

How Is DBT Used in Alcoholism Therapy?

Because DBT was initially created for people with higher treatment needs, the authors developed a form of DBT specific to substance misuse and addiction with the ultimate goal of building a sober lifestyle and a purposeful life.3

With addiction, it is not uncommon for people to experience multiple conditions at once, making their treatment needs more complex. This fits perfectly into the treatment abilities of DBT, where higher needs and multiple conditions can be treated at the same time with the same therapeutic modality.3

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When using DBT for substance abuse, addiction or alcoholism is the primary focus for your treatment. Promoting abstinence and reducing the frequency, length, and adverse impact of relapses are the goals of treatment.3

When starting behavioral modification in alcoholism therapy, a comprehensive plan to modify behavior includes:3

  • Showing a marked decrease in the amount of substances misused. This should include illegal drugs, as well as legally obtained drugs, such as alcohol and prescription medication that has been misused.
  • Coping, in a healthy way, with physical discomfort from alcohol or drug abstinence and seeing an eventual end to the withdrawal process and any discomfort experienced.
  • Actively seeking healthy activities to overcome cravings, as well as intentionally avoiding opportunities that previously led to alcohol misuse and unhealthy behaviors.
  • Working to reduce any unhealthy behaviors that may have contributed to alcohol misuse.
  • Increasing healthy supports within the community and family, to help foster and grow in long-term sobriety.

Working to overcome alcohol addiction is accomplished by promoting abstinence or sobriety from alcohol use and building the motivation and skills necessary to avoid relapse. The expectation for sobriety is communicated in the first session and may feel daunting. Yet, DBT for alcoholism is an affirming technique, where the therapist will reassure you that sobriety is possible and relapse does not mean failure.2

Treatment involves coaching into sobriety through thought and behavior modification, all while maintaining a nonjudgmental, problem-solving response to relapse. During a relapse, the therapist offers techniques to reduce the dangers of overdose, infection, and other adverse consequences.2

If relapse does occur, DBT works to build your resilience, so the relapse is not as long or severe as before treatment. This will then establish internal motivation to regain your sobriety despite your relapse and return to your recovery mindset and lifestyle.2

How Is Other Alcoholism Therapy Used With DBT?

DBT for alcoholism adds an element of creating a “clear mind” and building attachment strategies to counseling and sober support communities.2

Building attachments is a crucial element to addiction recovery success, as so often relationships are damaged during addiction, and you begin to feel unworthy or unable to sustain healthy and loving relationships.2

DBT takes the concepts of overcoming a sense of incompleteness and finding joy while building secure and healthy attachments to better ensure you have a strong foundation for long-term sobriety and recovery.2

DBT for alcoholism may also be combined with other treatment methods to better prepare you for long-term sobriety, including cognitive-behavioral therapy (CBT), interpersonal psychotherapy, somatic experiencing therapy, family therapy, and group therapy. Family and group counseling provide an opportunity to improve negative thinking about worthiness in relationships. With family therapy, you have a direct opportunity to resolve any past damage to relationships and begin healing.

When DBT is offered in family therapy, other members of the family unit will also be taught DBT skills and ways to best support you, or a loved one working to overcome addiction.3

DBT exercises may be brought into sessions using a different primary type of therapy. Two common examples of DBT exercises that may be taught in any type of alcoholism therapy are:5

  1. Dialectical Thinking—Dialecticals are two opposite, yet true, ideas. Part of DBT is learning to “hold” two dialecticals in the mind simultaneously and accept them, determining how that acceptance allows you to change, grow, and move forward. For example, in a family therapy session, you may be asked to hold the ideas that despite loving and wanting the best for a family member, your alcohol misuse has actively and directly hurt them.
  2. Opposite Action—Taking an opposite action is a type of emotional regulation taught in DBT where you determine the urges you experience due to a specific emotion and repeat actions that are in direct opposition to those urges until the emotion changes. Taking an opposite action is often taught as one way to “ride the wave” of an emotion to avoid relapse related to emotions like anger.

DBT is often part of programming offered in inpatient and outpatient alcohol addiction treatment programs.

How Effective Is DBT for Substance Abuse Treatment?

DBT is an effective treatment method, but one that takes time and commitment from both you and your therapist. Yet, if commitment is shown and all four stages completed, DBT has a high success rate for people in achieving lower rates of unwanted behaviors and a better perception of their quality of life.1

Several studies show that DBT for substance abuse treatment is associated with decreased substance misuse among people with borderline personality disorder and other co-occurring disorders. Participants in the studies had not responded positively to previous treatment approaches, but were able to access harm reduction while in DBT.1

People who receive DBT show marked improvement in problem-solving and learn to better envision, articulate, pursue, and sustain goals.2

DBT treatment helps people learn to successfully navigate life’s difficulties without relying on unwanted thoughts and behaviors by using healthy coping skills, positive social supports, and a resilient mindset.2

To learn more about alcohol addiction treatment facilities that provide DBT and other evidence-based alcoholism therapy, call 800-839-1686Who Answers? at any time.

Resources

  1. Dimeff, L., & Linehan, M. M. (2001). Dialectical behavior therapy in a nutshell. The California Psychologist, 34(3), 10-13.
  2. Vaughn, S. (2020, March 31). The 4 Stages and Targets of DBT. DBT in Practice: Mastering the Essentials. Psychotherapy Academy.
  3. Dimeff, L. A., & Linehan, M. M. (2008). Dialectical behavior therapy for substance abusers. Addiction Science & Clinical Practice, 4(2), 39–47.
  4. Fruzzetti, A. E., Santisteban, D. A., & Hoffman, P. D. (2007). Dialectical behavior therapy with families. Dialectical behavior therapy in clinical practice: Applications across disorders and settings, 222–244. Guilford Press.
  5. Lee, S., & Mason, M. (2019) Effectiveness of brief DBT-informed group therapy on psychological resilience: a preliminary naturalistic study. Journal of College Student Psychotherapy, 33(1), 25-37.
  6. Chapman, A.L. (2006). Dialectical Behavior Therapy: Current Indications and Unique Elements. Psychiatry (Edgmont), 3(9), 62-68.

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