Dialectical behavior therapy for substance use

Dialectical behavior therapy (DBT) did not begin in the substance use field. Psychologist Marsha Linehan developed it as an application of the behavioral therapy of the 1970s for chronically suicidal people, and it later became a well-studied treatment for borderline personality disorder (BPD), a diagnosis involving intense emotions that are hard to manage. A version for substance use followed.

What DBT is

The word "dialectic" refers to bringing two opposites together. According to Dimeff and Linehan, writing in Addiction Science and Clinical Practice, the central opposites in DBT are change and acceptance. The developers found that pushing only for change left many people feeling criticized and shut down, while offering only acceptance left them feeling their suffering was ignored. DBT keeps both in play: the therapist works toward change while validating how hard things are. The stated goal is broader than reducing a symptom. It is to help a person build "a life worth living."

How DBT works in outline

Standard DBT has four parts, according to a 2016 review in Frontiers in Psychology: a weekly skills training group, individual psychotherapy, telephone coaching, and a consultation team for the therapists. The skills group teaches four sets of skills:

• Mindfulness: paying attention to the present moment, including emotions, thoughts and body sensations, without judging or reacting to them.
• Emotion regulation: learning about emotions, problem solving, checking whether a reaction fits the facts, and acting opposite to an unhelpful urge.
• Interpersonal effectiveness: obtaining goals skillfully while keeping the relationship and self-respect in view.
• Distress tolerance: crisis survival skills, including self-soothing and acceptance of situations that cannot be changed at that moment.

DBT adapted for substance use

Many people with BPD also have a substance use disorder, so Dimeff and Linehan describe an adaptation for people with both. It adds several features:

• Dialectical abstinence. The therapist asks for a commitment to stop using, but only for a length of time the person is sure about, which might be a day, a month, or even five minutes. The commitment is renewed at the end of each period. A lapse is treated as a problem to analyze, not as proof of failure.
• Attachment strategies. Because some people drift in and out of treatment, therapists plan for lost contact, make check-in calls, and may actively try to re-engage someone who stops attending.
• Substance-specific targets. These include reducing use, easing urges, avoiding cues, and building friendships and activities that support recovery.

The authors also state that treatment benefits, such as prescribed medications for cravings, should not depend on abstinence. For more on those, see medications used in treatment.

What sessions can look like

A person in comprehensive DBT has individual sessions and a weekly skills group, and can contact the therapist between sessions for coaching. In individual sessions, the therapist and patient review the past week, giving priority to the most serious problem behavior. After a lapse, they work through what led up to it and what followed, repair any harm done, and plan ahead. The group is closer to a class, usually about eight patients and two trainers, with homework each session.

What the research says

The strongest evidence concerns people who have both a substance use disorder and BPD. Dimeff and Linehan report nine randomized trials of DBT for various problems by 2008, two aimed at substance use with BPD. In the first, DBT (12 women) was compared with treatment as usual (16 women). Those in DBT were more likely to stay in treatment (64 versus 27 percent) and showed greater reductions in drug use. These were small trials run by DBT's developer, which is a reason for care.

Later work points the same way. A 2020 handbook chapter by Salsman, as summarized by APA PsycNet, reviews 8 randomized trials and 12 uncontrolled or quasi-experimental trials and says its evidence appears to meet the usual threshold for a well-established treatment. A meta-analysis of six studies in Research on Education and Psychology found DBT groups did better than alternative treatment or waitlist groups on remission or abstinence. Its authors list limits: few studies, small samples, results that may not apply to men or to people outside the United States, and no separation of people with BPD from those without.

For substance use without BPD, the evidence is thinner. Dimeff and Linehan suggest considering a simpler treatment first, such as cognitive behavioral therapy, and say DBT may fit best when emotional dysregulation drives the use or when other evidence-based treatments have failed.

Limits and who it may not suit

• DBT is intensive, with several weekly components, so it asks for a lot of time and may not be offered everywhere.
• Dimeff and Linehan caution that skills groups alone, separated from the full program, did not help people with chronic suicidal behavior and BPD in one trial, and that nobody knows whether a lighter version would help.
• They also say DBT may be ineffective for people whose emotions play little part in continued use.
• Its skills overlap with mindfulness-based approaches and acceptance and commitment therapy.

DBT is often discussed alongside co-occurring mental health conditions and relapse prevention. A qualified clinician decides what fits a particular person.

Questions to ask a clinician

• Is the program comprehensive DBT with all four parts, or only a skills group?
• Does the evidence for DBT apply to my situation, for example if I do not have BPD?
• How does the program handle a lapse, and does my access to care or medication depend on abstinence?
• How many hours a week does it take, and for how long?