DBT Treatment for Addiction and Mental Health Disorders
DBT, or Dialectical Behavior Therapy, has been an interesting treatment choice for individuals who suffer from addiction and mental health disorders. Marsha Linehan developed DBT primarily to treat Borderline Personality Disorder. However, using DBT to treat a wide range of disorders, including mental health disorders and addiction, has gained immense popularity within the treatment realm. This popularity is due to overwhelming evidence that DBT helps treat mood disorders, anxiety disorders, PTSD, bipolar disorder, and substance use disorders. This has led several mental health professionals in the field to use this form of treatment to reach their clients, particularly those that struggle with a combination of many issues, as the evidence upholds its effectiveness. This has also left many mental health professionals debating how to implement DBT into a traditional treatment setting, with questions such as, should it be taught in groups? Individuals? Should the information be modified to adapt to this population, or should the traditional methods outlined by Dr. Linehan be upheld? After many years of training, trial and error, and ultimately putting into practice with clients, I am prepared to break down what I believe to be the most effective way to treat clients in a residential treatment setting using DBT as a modality.
DBT is highly expansive and is broken down into four major domains: Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effectiveness. Traditionally, DBT skills are taught in group settings with two facilitators; one facilitator is responsible for providing education on skills, and the other acts as a moderator for client behavior. Clients learn new skills weekly and are given homework assignments to utilize these skills over the next coming week. Each week, clients take turns processing their use of the skills, including triumphs and struggles, followed by education on a new gift, and thus the cycle continues. This deviates from the traditional “emotional processing” group typically featured in the treatment setting. In contrast, DBT groups primarily focus on the practical implementation of skills, followed by discussing each client’s experience using the skills.
As mentioned, DBT is expansive and would be challenging to teach in its entirety in an average thirty-to-ninety-day treatment episode. DBT is far too beneficial to abandon as a treatment modality simply because it is lengthy. As a result, a mental health professional must analyze the material carefully to extract the information and skills that would best fit the needs of the receiving population. Through my practice, I have broken this down to an eight-week curriculum to educate and implement skills related to the first three modules: Mindfulness, Distress Tolerance, and Emotion Regulation. While Interpersonal Effectiveness skills are extremely valuable, I have opted to leave out this portion when running DBT skills group sessions in a residential setting. I have found that most clients must first learn how to manage their emotions, which tend to fluctuate very rapidly in early sobriety or recovery from mental health disorders, before improving their communication and relationships with others.
Additionally, in this eight-week model, a client need not enter at week one to fully grasp the skills that are being taught. Practically, a client may join at any point during the curriculum and still benefit from the material being presented. The group operates in an open and revolving way. However, if a client opts to pursue DBT groups to gain skills, a client would be encouraged to attend this group consistently on a week-to-week basis to receive the full benefit of the material being provided.
A typical group session is held for two hours and run by one to two facilitators. When two facilitators are present, the second facilitator will act as an assistant or behavior moderator. Clients are encouraged to remain throughout the group with no interruptions. Typically, a fifteen-minute break is provided at the halfway point. Clients are informed that a typical group format consists of one hour of education followed by one hour of skills practice. Varying avenues of education are used, including handouts, videos, and psychoeducation. A majority of the educational material and handouts are obtained through DBT Skills Training Manual and DBT Skills Training Handouts and Worksheets (Marsha M. Linehan, 2015). Clients are encouraged to engage in the educational portion by reading the material aloud with the rest of the group. While the function of this group is skills education and training, if a client is in emotional crisis, they are provided with the opportunity to process this with the rest of the group to seek support. This would traditionally happen at the start of the group.
Week one begins with an overview of DBT and the elements of its formation. Clients are introduced to the definition of mindfulness, which answers what mindfulness is, what mindfulness skills are, and what mindfulness practice looks like. Additionally, the concept of emotion mind, wise mind, and reasonable mind are introduced and frequently referenced in subsequent weeks of this group. When the group’s population consists of those struggling with addiction, the concept of addict mind, clean mind, and clear mind are introduced. This provides valuable information to a client, allowing them to recognize that despite ceasing the use of substances, underlying and problematic thought processes and behaviors remain that require treatment to recover from addiction successfully and long-term. After a thorough mindfulness education, the group then engages in two mindfulness practices that reflect “Participate.” These two activities are recommended to be interactive and include movement within the group process. This stimulates interest and participation from the group member. The group is then provided time to process what they have learned and implement this new skill over the next week.
Week two dives further into mindfulness; mindfulness is believed to be the “core skill” of DBT and must be thoroughly practiced. Group members are educated on the “How” and “What” skills of DBT. At this point, each group in the curriculum will initiate with a mindfulness practice, even when educating on other skills. This will assist a client in becoming present, engaged, relieve stress and anxiety, and allow them an opportunity to start their day on a positive note. The facilitator may choose how to incorporate this, but simply a guided meditation practice would be sufficient. Group members begin to look forward to these moments to allow their minds freedom from suffering while being educated on and experiencing the benefits of mindfulness. The group is then navigated throughout a series of mindfulness practices and exercises which will serve the rest of the group time. If able, group members are taken on a mindfulness walk, with the only directive to abstain from talking. They are then asked to describe what they observed. It is important to note that this group session is meant to be interactive, providing a group member with the opportunity to explore how mindfulness can work for them. The benefits of using mindfulness consistently are discussed, and group members are encouraged to use this as a tool in their recovery process.
Week three continues with mindfulness, and during this group, additional education is provided into the benefits of using mindfulness to manage symptoms of trauma and PTSD. How trauma impacts the nervous system is discussed and utilizing mindfulness skills to mitigate these symptoms is strongly reinforced. The group engages in an extended, guided meditation in a comfortable position of their choosing. This allows them the freedom to explore how trauma is trapped in their bodies and how to use mindfulness as a self-soothing experience. Group members follow up by processing their experience with mindfulness and reviewing the homework assignments they have completed. It is encouraged not to view mindfulness education to be completed at this point but instead used daily while learning new skills and a powerful part of the recovery process.
Week four introduces Distress Tolerance skills which are incredibly beneficial to those who struggle with rapidly shifting emotions that lead to behavioral consequences. The connection between untreated emotions and problematic behaviors is highly reinforced, with each client explicitly identifying how emotional mismanagement has led to behavioral problems and outcomes in life. This allows a person to begin taking responsibility for their actions while also receiving validation that the core of the problem is understandable and treatable. Clients are educated on using STOP and TIP skills, and multimedia outlets are used to demonstrate others using these skills in their own practice. I have found the STOP and TIP skills highly beneficial to those in early recovery to slow down impulsivity and prevent further behavioral destruction.
Week five continues with Distress Tolerance, carefully processing and analyzing an individual’s use of the skills learned while also introducing new skills along the way, including ACCEPTS and Radical Acceptance. Group members participate in varying activities, meant to keep the group exciting and informative, and encouraging to use the skills taught. The group deviates from shame-based thinking, and an acceptance of using unhealthy coping skills is understood by all. The language that is taught and communicated strays from words such as “bad” or “wrong,” but instead, we are encouraged to view high-risk behavior as “dysfunctional” or “unhealthy,” allowing a person to understand their behavior but also empower them to find change in their lives through practical use of skills.
Weeks six and seven cover Emotion Regulation Skills. This initiates with understanding the function of emotion and barriers to being able to manage emotions effectively. Again, group members stray from shame-based thinking by being provided with education into the biosocial theory of emotion. Each group member is asked to specifically identify their barriers to effectively manage their emotions but is encouraged against using their biological differences as an excuse to engage in unhealthy behavior. Group members are then taught how to correctly identify emotions, as this is something that many individuals seeking treatment for dual-diagnosis purposes struggle with. Critical DBT skills taught during the Emotion Regulation sessions include Check the Facts, Opposite Action, and Reducing Vulnerability to Emotion Mind. Group members are provided with homework assignments to practice these skills over the next coming weeks.
Week eight is the final session of the curriculum, and group members explore their “Life Worth Living” goals. Creating a Life worth Living is central to DBT. Group members explore what life was like before coming to treatment. This is done to remind clients precisely what they are fighting for when they come to treatment. In therapy, it is helpful to recall the destruction of active addiction and untreated mental health disorders in a safe environment, serving as a reminder of what a person is breaking themselves free from. Group members take turns, without shame, sharing with one another the details of their lives before treatment. This is often a very emotional experience for a person. However, they are then empowered to detail what their “life worth living” or “perfect life” will look like now that they have reached sobriety and are gaining back control over their mental health disorders.
In the treatment setting, a wide range of individuals are seeking help. Many individuals seeking help have been struggling with complex, underlying, and severe emotional problems and often reach to drugs, alcohol, and self-destructive methods as a way to soothe. As a result, individuals seek help because their self-destructive strategies exacerbate their problems, resulting in extraordinarily high-risk and destructive behavior. This is understandable and needs to be met with an attitude of acceptance rather than shaming and judgment. Only then can a person begin to lift their head up, break through the shame, and believe they are worth finding a life of purpose. With DBT, they discover that they are not alone and are equipped with a toolbox of skills readily available for use when facing new life challenges in recovery. DBT works. It is effective and can reach everyone in the treatment setting if implemented in a practical and informative way.
Linehan, Marsha M. DBT Skills Training Manual. 2nd ed., New York, The Guilford
Linehan, Marsha M. DBT Skills Training Handouts and Worksheets. 2nd ed., New
York, The Guilford Press, 2015.
Linehan, Marsha M. Cognitive-Behavioral Treatment of Borderline Personality
Disorder. New York, The Guilford Press, 1993.