History of DBT
In the era of the 1970s and ’80s, therapists struggled to find an effective cure for individuals who repeatedly attempted suicide. The main problem behind this was individuals' low self-confidence or lack of positive thinking patterns. As a result, individuals were constantly attempting suicide. Since a lot of time was utilized to diagnose this situation, it left very little time to concentrate on the issues that could enact real change in the individual’s life. In such moments of difficulty, Dialectical Behavioral Therapy (DBT) was developed by Marsha Linehan in 1993 as a treatment for borderline personality disorders. She initially developed it to treat women only. But as time progressed, the application of Dialectical Behaviour Therapy was expanded to other populations and disorders. When Marsha Linehan started working with clients with Borderline Personality Disorder (BPD), she initially followed an orthodox cognitive-behavioral approach. She started noticing that people with BPD had a strong, negative reaction to the heavy concentration on change. That is inherent in the cognitive-behavioral tradition of recognizing and tangling beliefs, to change distressed behaviors. Linehan identified that people with BPD are really sensitive. They tend to react powerfully to circumstances in which they feel invalidated. They are usually treated harshly in their childhood by caregivers. Such therapy created an environment in which kids' emotions were often invalidated. Invalidation is a result of rejection, punishment, denial, or discrimination by the caregiver.
Linehan proposed that the ‘change emphasis’ of orthodox CBT is profoundly invalidating for patients. This ‘change emphasis’ provokes a sense in these highly sensitive clients that there’s something wrong with them. This situation brought back distress-filled childhood memories of invalidation. They were not properly engaged nor benefitted from therapy because it felt painfully invalidating to them. Linehan proposed a few innovations to her therapeutic approach in response to such a situation. A significant modification was made to the acceptance and validation of the patient’s emotional and behavioral situations. People look for treatment because their life is not running smoothly. They ask for help to make some productive changes. This introduced a therapeutic quandary for Marsha because ‘acceptance and change’ are conflicting agendas. She thought of moving back and forth between change and acceptance during therapy in a dialectical manner as a solution to this dilemma. The term dialectic means to seek a compromise between things that seem incompatible. Sometimes, she’d accept and validate and other times she’d be promoting and rooting for change. She would switch according to her patient’s ability to manage and tackle with emotions that surrounded change requests.
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The primary focus in Dialectical Behaviour Therapy is on reinforcement and integration of ‘acceptance and change’. Instead of having one-dimensional conversations with the patient, she would engage him/her through the use of real-world examples to extract the desired responses. One by one, Linehan, the DBT developer was able to teach her patients how to react with versatility in different situations. A key component is ‘mindfulness’, which has roots in the practices of Buddhism. It emphasizes staying present in the moment and experiencing what’s happening inside and outside without judgment.
DBT for Substance Abusers
Dialectical Behavioural Therapy is an effective and dynamic source for addiction treatment. Such sessions help a person negotiate and overcome harmful substance-abusing behaviors, damage-inflicting emotions, and negative thinking patterns. The therapist provides positive behaviors that build a concrete foundation for recovery success as opposed to the negativity of the current situation. Addiction is a result of dysfunctional emotions and self-harming behaviors. The emotional, physical, and mental distress and instability caused by repetitive drug or alcohol use can intensify these patterns even more. Such damage can take down an individual’s health, tarnish relationships, and may undermine a smoothly progressing career. Sometimes, even after knowing all this, it can be hard for a person to change and adapt to new settings. In addition to this, some people find difficulties in accepting the current situation which can also be a stumbling block to recovery. Dialectical Behaviour Therapy promotes an equilibrium between change and acceptance so that an individual is emancipated to take steps toward a life free from drug use. An individual learns how to manage urges, and healthy emotions, set positive and affirming goals, and develop relapse prevention skills. These changes create fine mind-body-spirit balance and develop sobriety.
Dialectical Behavioural Therapy was introduced by Dr Marsha Linehan to cure borderline personality disorders. However, it has been utilized as a cure for substance abuse disorders and different forms of mental illness. Therapy can take place in an outpatient or inpatient setting depending upon the circumstances. An inpatient drug treatment generally offers more intensive therapies and opportunities for rehabbing and healing than does outpatient care. Cooperation and bond between therapist and patient must be aesthetic. It’s generally difficult to form such a partnership at the initial stages of dialectical behavioral therapy. As soon as rehab begins, dialectical behavioral therapy encourages complete temperance. It is a very intimidating prospect for a newcomer in recovery. DBT segregates long-term sobriety into smaller and more easily achieved goals. Therapists often suggest an individual set a small goal such as being nice and sophisticated with the tone for an hour, day, or a week. Once the person has successfully achieved a particular goal, the therapist renews it and begins again. He/she keeps gaining stability and moves closer to long-term temperance as time passes.
DBT targets a few behaviors that can significantly improve a person's chance of recovery as the therapy progresses.
- Reducing withdrawal symptoms
- Reducing temptations and cravings for relapse
- Removing people, places, or events that trigger drug abusement
- Overcoming thinking patterns that encourage drug abuse
- Reinforcing and reintegrating healthy relationships, environment, and behaviors that encourage sobriety
The primary goal of DBT is to assist a person in developing a “clear mind”. In such circumstances, an individual stays concentrated on their recovery goals while also poking an eye for potential threats to their sobriety. Dialectical Behaviour Therapy deteriorates long-term sobriety into smaller, more easily obtained goals. Addiction can make it complex for an individual to take care of themselves. Maintaining quality behaviors and making healthy choices can be difficult for a person who is addicted to alcohol or drugs. Many drug or alcohol abusers find out the need to have a certain life skill, which they may not have or may need improvement, at the time of arriving for therapy. A therapist of Dialectical Behaviour Therapy assists a patient in recognizing what’s missing in their life or on what areas of life they need to work. After the recognition of loophole areas, they work together as a team to develop an arsenal of life skills that helps to cope with and manage negative thinking patterns. Sometimes, the way a person especially a drug abuser reacts to a situation can make it worse. It becomes evident when an individual’s patterns of thinking and judging are clouded by the influence of alcohol or drugs. Such instances are tackled by personalized skills which helps a patient in managing negativity.
While dialectical behavior therapy treats borderline personality disorders, it has shown significant promise in treating:
- Substance abuse (drugs or alcohol)
- Attention-deficit hyperactivity disorder (ADHD)
- Bipolar disorder
- Bulimia
- Binge-eating disorder
- Depression
- Post-traumatic disorder
In DBT, the therapist of the patient is the primary therapy provider. The therapist is responsible for furnishing and smoothly running the treatment plan for the concerned individual. The plan usually consists of five important functions:
- Improving an individual’s instincts to change
- Increasing an individual’s capabilities
- Generalizing latest behaviours
- Environment structuring
- Increasing therapist motivation and capability
These functions are delivered through four different modes of outpatient therapy: group skills training, individual therapy, telephonic therapy, and therapy for the therapist.
It’s difficult to draw drug-abusing individuals into treatment. Although few easily get tangled in treatment, others behave like butterflies, flying frequently up and down the therapist’s grip. Typical butterfly problems are epidemic involvement in therapy, failure to participate in the session, and eventually early termination from therapy. The DBT takes the form of thrust for instant termination of drug abuse (change) while also inculcating the fact that if a relapse occurs, it does not mean the failure of therapy on behalf of the patient or therapist (acceptance). The dialectical behavior therapy approach, therefore, goes for the elimination of abstinence with problem-solving and nonjudgmental responses to relapse which include techniques for diminishing the dangers of infection and overdose. DBT cures an inclination towards substance abuse as a problem to solve, rather than thinking of it as a sick person's inadequacy or therapy failure. When a person relapses into drug use, the therapist guides them to do a behavioral analysis of the circumstances, events, or people that led to substance abuse and note down everything that may prove useful in such future situations. There’s a common misunderstanding regarding the scope of abstinence required in DBT. In DBT, the therapist studies the scope of abstinence appropriate for every single patient based on a detailed assessment and 3 ruling principles:
- Focusing on the primary drug(s) of abuse, which is those that are inflicting major self-harm on a patient according to the individual’s history of abuse and behavioral analysis.
- Focus on other drugs that look to reliably rash the use of the primary drug of abuse.
- Certainty about life goals attainability.
Patients with drug abuse disorder and BPD generally have myriad problem behaviors including self-harm and suicide inclination behaviors in addition to those linked with drug abuse. Patients with SUD usually commence DBT in a behavioral state called ‘addict mind’. They are practically and emotionally controlled by drugs. After going through the initial stages of DBT, they get a state termed a” clean mind”. They are free from drugs but immunity for future relapses stays active depending upon circumstances. After getting through this stage, an individual finds a third state called “clear mind”. The patient enjoys life free from drugs while staying fully aware and vigilant about the situation that may lead to drug use.
The phenomenon of substance dependence in individuals with personality disorder poses risks and challenges for both parties, patients and therapists. Dr Marsha Linehan developed Dialectical Behaviour Therapy for chronically parasuicidal individuals with BPD. Certain interventions are adapted including drug-specified behavioral targets for curing drug use problems, dialectical abstinence, and a set of attachment strategies for developing a powerful therapeutic relationship. Dialectical Behaviour Therapy may also be effective for drug disorder patients with complex problems attached to emotional dysregulation who haven’t responded to other evidence-based approaches.
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