Is DBT a Breakthrough in Recovery Treatment?

Building bridges between the different aspects of our human nature has been something of a passion of mine. Read More

Building bridges between the different aspects of our human nature has been something of a passion of mine. In one situation after another—religion, spirituality, meditation, therapy, movement, creative expression and more—I kept running up against what felt like limitations that resulted from separating all of who we are into pigeonholes and treating them without reference to the rest. It’s the equivalent of what one can easily encounter in physical medicine, where the doctor who examines your digestive system doesn’t consult the one that checks your lungs or heart or brain.

Over time, I felt this particularly strongly between the spiritual and the psychological—even though “psyche,” the root of the word “psychological,” means soul as much as it does mind. In the ancient world, the distinction between these two, regardless of culture, east or west, didn’t exist. The oneness, the unity of self, was what counted. If something was wrong, it meant the unity had somehow been weakened or broken and needed to be restored.

Recovery and DBTAs I worked with different systems and methods, it seemed to me that spirituality often began where psychology left off, and the assumptions they worked with were quite different. Spirituality presumes a reality greater than the visible world, whether “supernatural” or not. Most psychology, on the other hand, tends to presume a material framework and uses a disease model inherited from medicine to treat problems. The limits of “the good,” of what is even possible, in the psychological view, are set by physical reality and the senses; in the spiritual view, we have senses and perceptions beyond the five physical ones, and help or support can come from beyond or deep within ourselves, from sources that transcend the physical alone.

The problem, it appeared, was that both of these broad fields were too often working apart from each other, so that no one was building bridges between them. I came to feel that I needed a greater context for dealing with my issues than the purely personal; but the high goals and attainments of spirituality seemed beyond my reach. How could I think about “enlightenment” or “spirit” when I couldn’t even manage my money or relationships very well? I needed to connect lower and higher, body, mind and spirit.

Over time, I found people who felt like I did and who helped me make those connections, and it was just as important and healing as I’d suspected. I’m profoundly grateful to all of them, whether clergy, therapists, artists or martial artists, in helping me to develop a more complete model of human nature and our role in the universe. I’ve also kept an eye out for new methods that incorporate this type of approach.

So I perked up a few months ago when I heard about a system called DBT, short for “Dialectical Behavioral Therapy.” It’s quite a mouthful, I know; you can see why they abbreviated it. But it’s a very interesting approach, one that holds out great promise for helping many, including those within the recovery community.

Put simply, dialectics is a method of getting at the truth of a matter by holding a dialogue between two or more people with different views. In ancient Greece, among other cultures, this was part of philosophy. The views held can sometimes be in conflict; the effort is to reach a point of balance and harmony.

What DBT does is apply this method both internally, to the psyche of the individual being treated, and externally, in the therapeutic relationship between client and healer. It does this with a particular eye toward correcting problem or destructive behaviors.

DBT began to develop during the 1980s through the work of Marsha Linehan, a psychology researcher at the University of Washington, as an outgrowth of Cognitive Behavioral Therapy. Her focus was particularly on increasing the ability of those in treatment to regulate emotion and behavior by recognizing what triggered their negative states and reactions and altering them through a greater understanding of the whole process of thoughts, feelings and behaviors, and mastering new coping skills. The long-term goal was bringing their whole being into better balance through the dialectic, or union of opposites within, leading to a life worth living as defined by the client.

Like Cognitive Therapy, DBT is evidence-based. As Kaitlyn Mercy writes in her article “Using DBT Skills in Addiction Recovery,” “DBT has been shown to be helpful in a variety of situations and has been used to treat many different mental health conditions, including eating disorders, bipolar disorder, anxiety, depression, post-traumatic stress disorder, and substance use disorders.”

Critically, one of the differences between CBT and DBT that may make the latter a better choice for those in recovery is that some of the cornerstones of DBT have been drawn from the spiritual traditions and their ways of healing, including radical acceptance of self and one’s problems; mindfulness and the ability to step back and observe one’s thoughts, feelings and sensations without getting pulled into them; and developing a greater capacity for handling upsetting situations and the difficulties inherent in life. Many of these aspects of DBT come directly from contemplative and meditative practices, but have been adapted to meet the needs of those with specific psychological and behavioral challenges.

Kaitlyn Mercy also notes the greater level of optimism about human nature that distinguishes the DBT approach. As she points out,

DBT assumes a few different things:

  • People are doing the best that they possibly can in their current situation
  • Problems are not always one person’s fault, but it is their duty to try to resolve it
  • People want their situation to improve
  • Everyone is capable of learning new behaviors that will improve and change their lives.
  • By making these assumptions and holding the belief that unwanted thoughts and behaviors are learned and reinforced, DBT works to unlearn these thoughts and behavior patterns through a number of exercises and coping skills.

This no-fault, no finger-pointing or blaming is approach is valuable in working with anyone, but is especially important in helping those whose struggles with substances or other forms of addiction developed in relation to harsh judgments of them, often early in life before critical thinking skills could be learned or applied. Yet in its optimism about our ability to learn and change, it also assumes our capacity to take responsibility for our lives if given the chance to do so. And in stressing that change can be a matter of better learning, it identifies the “problem” as incorrect learning—not us.

Dialectical Behavioral Therapy has a lot of tools for change in its toolbox, several of which have been proven to benefit those working with substance abuse and/or mental health disorders, which often go hand in hand. Four of the key tools used by DBT are Distress Tolerance; Emotional Regulation; Mindfulness; and Interpersonal Effectiveness.

When any of us experience distress, our first desire is to get rid of the feeling. But if we haven’t learned adequate coping skills, and have instead learned maladaptive ones, we may reach for a substance for relief or act out inappropriately if relief isn’t available. By teaching the client distress tolerance skills, they learn to better regulate their emotional responses to charged situations and how to accept and bear their current distress without jumping into an escape from it.

Similarly, DBT teaches one how to manage emotions rather than being controlled by them. Observing and understanding our triggers and how our emotions actually work gives us a handle on them and increases the number of available options in emotionally difficult situations.

Is DBT a Breakthrough in Recovery Treatment?Woven throughout much of DBT is the principle of mindfulness, which research has shown is beneficial in relation to many different human needs and difficulties. Developed originally in Southeast Asia in the Buddhist tradition and taught to monks, the principles have proven highly adaptable to nontraditional settings, including interpersonal relationships and counseling, classroom settings, prisons, and corporate environments. In DBT use, mindfulness means being totally aware of one’s inner and outer situation: thoughts, feelings, sensations, behaviors, actions, and relationships with others and the world. One of the effects of substance use and mental disorders can be difficulty staying present in the moment, without withdrawing into one’s private inner world, detached from everything else. By learning to step back from our inner turmoil and see and feel it for exactly what it is and how it arises and goes away, we can gradually learn that the monster is not as ferocious or unbeatable as we once thought. And being present can lead to having presence as one’s own authentic self.

As we grow inwardly through mastering these skills, we are also enhancing our ability to function in the world in relation to others. By learning to see the dialectic between our needs and those of others, and the demands the world places on all of us, we find the balance between them. Improving our communication skills results in lowered levels of conflict with others and makes our relationships more nurturing and happy. This is Interpersonal Effectiveness.

As DBT has four main tools, it also has four main goals. These are:

  1. Transitioning from out of control to in control
  2. Moving from emotional unavailability to emotional regulation and engagement
  3. Building a healthy life and solving everyday problems
  4. Transitioning from feeling incomplete to feeling connected and complete

Employing the tools discussed above helps clients to understand themselves better and manage stress, which helps them reduce or eliminate dangerous and reckless behaviors, including substance abuse and self-harm. As the capacity to fully experience and tolerate one’s emotions grows, the tendency to close down to others weakens, and better relationship skills can be learned. DBT also is notable for beginning this challenging work not by tackling the most difficult issues first, but by focusing initially on less intense ones, so that a basic level of stability in life is achieved. And by creating a vision of a desirable life, the emphasis shifts from “what’s wrong” and “what’s wrong with me” to “what do I really want” and what would a good life really look like, for me?

Through its inclusion of core philosophical methods and spiritual and meditative techniques, DBT is expanding the range of therapeutic approach with a larger view of who we are, ultimately. Its flexibility and presentation of a variety of options and choices means that we are not limited by somebody else’s worldview, but can define our own. It looks to me like one of those bridges between the personal and the spiritual I was seeking earlier in life. I hope it will prove to be that for many who are suffering with addiction and all of the usual stresses of this life.