Dialectical behavior therapy (DBT) is a treatment for borderline personality disorder, but patients with substance use disorder (SUD) can benefit from it, according to treatment professionals. We have been hearing more about this lately, so we made some calls to investigate.

As a treatment for SUD alone, there is no research supporting the use of DBT. But there is research supporting the use of DBT in treating SUD and comorbid personality disorders. Two treatment professionals we interviewed say incorporating it with other types of treatment is useful, mainly because so many people with SUDs have comorbid disorders.

Hazelden Betty Ford

The Hazelden Betty Ford Foundation uses DBT in individual and group sessions, said Joseph Lee, M.D., medical director of the youth program. “We use DBT all the time,” he said, adding that it is used for all ages.

Evidence shows that DBT reduces hospitalizations, self-injurious behaviors, emergency room visits and suicide attempts, said Lee. “Even if you’re a bean counter in an insurance company, you would want these services available,” he said. And even though DBT “became popular because of borderline personality disorder, the model is applicable to patients who may not meet the criteria fully,” he said.

Another reason that DBT is appropriate is that there are so many similarities between borderline personality disorder and SUDs, said Lee, a psychiatrist. “We know that a significant portion of people with SUDs have personality disorders that resemble borderline personality disorder,” he said. In addition, personality disorders make people more likely to be addicted, he said. “Both populations — people with SUDs and people with borderline personality disorders — have much greater rates of suicide and self-harm, and greater problems with emotional regulation and coping with stress,” he said.

DBT is a form of cognitive behavioral therapy, utilizing strategies to deal with impulses. There is also a mindfulness component, which can make the spirituality aspects of treatment easier to comprehend, said Lee.

Raleigh House of Hope

At the Raleigh House of Hope in Denver, Colorado, Osvaldo Cabral, director of operations of the Awakenings Recovery Program, created a model using traditional DBT, but reworking some skills to make a better fit with SUD treatment. “The core therapeutic work is focused on emotion regulation coping skills,” Cabral told ADAW.

He gave two examples showing how he altered DBT to be useful for SUD treatment.

  • One patient had tried to commit suicide by shooting herself in the mouth, prior to entering SUD treatment. “She did pull the trigger and she was badly disfigured and spoke through the side of her mouth,” said Cabral. Using traditional DBT, the therapists used the skill of “comparisons” in which patients compare themselves to others dealing with similar issues (in SUD applications, a patient might say “at least I just drank and didn’t use heroin,” for example). In the case of the woman who shot herself, after she came to the DBT group, she said, “‘I’m so glad we had that group, because some of the people in here are really messed up,’” Cabral recalled. “We were shocked because she had recently tried killing herself, was disfigured, couldn’t talk very well, and was using comparisons as a way to be judgmental and detach from others.” So instead, the skill of “comparisons” got changed to “count your blessings,” which is more in the spirit of the purpose of the skill, as well as being more in line with 12-Step philosophy, said Cabral.
  • Another patient — 36 years old when he came to treatment — had severe emotional dysregulation and had used substances since the age of 11. “He did not have any other coping skills and had difficulty relating to others because of his intense cognitive distortions,” said Cabral. “We practiced the skills used in the integrative model of DBT and 12-Steps,” he said. It turned out that the DBT-related skill of “contributing” was actually the 12-Step service work, and that the DBT concept of radical acceptance was the 12-Step concept of surrender. “Through the use of distress tolerance and the interpersonal effectiveness skills, the client was able to lower the intensity of his emotions and allow the frontal lobe to kick in and proceed in a rational, adult manner in the face of conflict,” said Cabral. Both DBT and 12-Step principles were used to strengthen his recovery; the patient has been in recovery for four years and is an active member of his fellowship, as well as a sponsor.

Cabral and his colleague, Bari Platter, both received intensive training on DBT at the Linehan Institute. They will be presenting on DBT at the annual meeting of the National Association of Addiction Treatment Providers in Fort Lauderdale, Florida, in May.

Research

Federal experts told ADAW that while DBT is a proven treatment for borderline personality disorder, there is no research on its use for SUDs alone.

“The original research on DBT was for suicide prevention and borderline personality disorder,” said Kim Johnson, Ph.D., director of the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (SAMHSA). “There is a version that was designed to be used with people who have SUDs, but the purpose was for co-occurring disorders,” she said. “I haven’t seen DBT by itself as an SUD treatment.”

And from the National Institute on Drug Abuse: “DBT has a strong evidence-base for patients with borderline personality disorder but has not been studied with substance use disorders alone. There was a recent review that looked at four small studies and found that it is effective in reducing substance use, suicidal/self-harm behaviors, and improving treatment retention for patients with this co-morbidity. However, we are not aware of any studies that looked at DBT for SUD alone.” For the abstract of the review, go to http://www.ncbi.nlm.nih.gov/pubmed/25919396.

Lee agreed that using research-based treatment is particularly important as the SUD field faces increased scrutiny.

“The ‘I’ve been sober for 20 years and I know you’ is complete bunk,” said Lee. “So we struggle with standardization and raising the bar for professionalism.” But on the other end of the spectrum, in general, there can be barriers with costs and certification. “The goal is to keep fidelity to the model,” he said, adding that there are modules and tools that can be used even if the provider is not certified in a particular technique.

“We don’t get into the certification thing” with Linehan, he said of Hazelden Betty Ford. “But we do use a manual, which is widely available, to keep fidelity as much as possible.” In addition, some of the Hazelden Betty Ford psychologists have been trained separately in DBT.

(For an abstract of an article about using DBT for SUDs written by DBT founder Marsha M. Linehan, Ph.D., and focusing on the 12 Steps, go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797106. Emails and phone calls to Linehan and Behavioral Tech, which is owned by Linehan and sells the training for DBT, were unreturned.)