DBT for Substance Use Disorders (Part 1)

Jun 6, 2022 | DBT for Specific Populations

This feature by Nick Salsman, PhD, ABPP is Part 1 of 2 in a series about DBT for substance use disorders. In this first part, Nick describes how DBT-SUD utilizes the approach of dialectical abstinence in the assessment and treatment of SUDs and how DBT-SUD utilizes the hierarchy of targets in Pretreatment and Stage 1.

The most important thing to know about Dialectical Behavior Therapy for individuals with Substance Use Disorders (DBT-SUD) is that you must be proficient in providing standard DBT in order to do DBT-SUD. When practicing DBT-SUD, therapists employ all of the same principles, strategies, and interventions that they use when doing standard DBT.

DBT-SUD is a treatment for individuals with co-occurring disorders, that is, those who have both a SUD and a mental health diagnosis. Most research on DBT-SUD is with individuals who have SUD and Borderline Personality Disorder (BPD), although some research has been conducted with individuals with other mental health diagnoses that involve severe emotion dysregulation.

What distinguishes DBT-SUD from standard DBT is that there are a set of strategies that are used specifically in DBT-SUD (e.g., there are skills that Marsha Linehan developed for when addiction is a crisis) and there are ways that standard DBT strategies are uniquely employed in DBT-SUD.

Another important principle to remember is that while standard DBT can and often should be used with individuals with substance use problems, DBT-SUD offers ways to augment DBT in a manner that can enhance reduction of problematic substance use.

This first in a series of two blog posts describes how DBT-SUD utilizes the approach of dialectical abstinence in the assessment and treatment of SUDs and how DBT-SUD utilizes the hierarchy of targets in Pretreatment and Stage 1. The second post will describe the use of special treatment strategies in DBT-SUD including the skills for when the crisis is addiction.

DBT-SUD anchors its approach to the treatment of SUDs in dialectical abstinence. Dialectical abstinence seeks to synthesize two divergent approaches to treating SUDs: abstinence-based approaches and harm-reduction approaches.

A major advantage of abstinence-based approaches is that individuals abstain from substance use for longer periods of time as individuals fully embrace a commitment to sobriety. The disadvantage of these approaches is that when people lapse into substance use they take longer to return to abstinence. This is particularly problematic for individuals who have pervasive emotion dysregulation, such as those with BPD, due to the abstinence violation effect.

The abstinence violation effect involves a high degree of negative emotions that accompany a relapse, which can create further conditions for continued substance use (i.e., relapses lead to emotion dysregulation, which leads to further substance use). A major advantage of harm-reduction approaches is that people can get back to sobriety more quickly when they relapse because they have planned for how to be effective when they have lapses (i.e., they help people prepare for the abstinence violation effect). However, a disadvantage is that people who take a harm reduction approach are more likely to have relapses more quickly than people who take an abstinence approach. Dialectical abstinence synthesizes both approaches by having people fully commit to sobriety while planning to be effective in reducing the harm if and when lapses occur. While dialectical abstinence capitalizes on the advantages of both approaches, it also means that individuals who are practicing it are always working at it. There are no breaks.

DBT-SUD utilizes the same stages and targets as those used in standard DBT.

In pretreatment the targets are orientation and commitment. In stage one the goal is to move from behavioral dyscontrol to behavioral control. In DBT-SUD pretreatment, the orientation to dialectical abstinence begins in the first session, where the expectation of abstinence is clearly communicated and commitment strategies are utilized to obtain and strengthen the client’s commitment to abstinence. In pretreatment DBT-SUD, the therapist also weaves in orientation to a number of other elements including treatment of SUDs and behavioral patterns that typically arise as a part of substance use (e.g., lying behaviors) and how those behaviors are targeted in DBT.

After therapist and client complete the tasks of pretreatment, including collaboratively developing and strengthening the client’s commitments, the DBT-SUD client enters stage one of treatment, where the focus is on targeting the behaviors that most contribute to behavioral dyscontrol. The hierarchy of targets in DBT-SUD and standard DBT is the same: reducing life-threatening behavior, reducing therapy-interfering behavior, reducing quality of life-interfering behavior, and increasing behavioral skills. The key distinction in DBT-SUD is that therapist and client agree that the top quality of life-interfering behavior that will be targeted is substance use.

Read here for part 2 of this series, in which we will review how special treatment strategies are utilized by the DBT-SUD therapist to enhance the effectiveness of the treatment for co-occurring disorders.

Nick L. Salsman, PhD, ABPP is a professor of psychology at Xavier University where he is the director of the Xavier University Psychological Services Center and runs the Xavier University Dialectical Behavior Therapy (DBT) program. Dr. Salsman is a fellow of the American Psychological Association, Society for Clinical Psychology. Read his full bio here.


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