“God, grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” – Serenity Prayer
Abstinence Without Relapse
Dialectical behavioral therapy for substance abusers is designed to promote abstinence and prevent relapse. The term dialectical refers to the integration of two opposites. In DBT the primary dialectic is acceptance and change. A fundamental principle of DBT is uniting these two seemingly opposing ideas; promoting behavioral change while also encouraging acceptance and tolerance of distressing feelings and situations. One without the other has been proven to result unsuccessfully. For example, many patients are sensitive to criticism and putting a sole emphasis on behavioral change can cause patients to feel bad, shut down emotionally, or even act out against their therapist. However, solely focusing on encouraging the patient to accept distressful life events can also result in negative outcomes such as the patient thinking their therapist is ignoring or minimizing their suffering. The synthesis of both acceptance and change keeps the patient productive; working towards changing one set of problems while accepting, or at least tolerating, distress evoked by other problems.
Desire for Change and Acceptance
The addition of dialectics to traditional cognitive behavioral therapy is extremely important as it balances the desire for change with acceptance. It implements the idea that everything is connected, change is constant, and opposing forces, such as acceptance and taking action to change, can be unified to find balance. The DBT treatment plan targets specific substance-abuse behaviors including decreased abuse of substances, alleviated discomfort associated with abstinence or withdrawal, reduced urges and cravings to use, avoided situations and cues to abuse, and increased community support of healthy behaviors.
Expectation and Commitment
When addressing abstinence, the DBT dialectic approach pushes for change in the form of putting an immediate and permanent end to drug abuse while also addressing the fact that if relapse occurs, it does not mean the patient cannot achieve their desired result. In an act of acceptance, the dialectic approach implements nonjudgmental, problem-solving responses to relapse. In the Dialectical Behavioral Therapy model, the patient’s therapist is the primary treatment provider and, with the patient, establishes the expectation of abstinence in the first session together. The permanent cessation of drug use can seem difficult at first, so instead, the therapist usually encourages the patient to identify and commit to a designated length of time that seems within reach such as a day, a week, or a month. By having the client identify his/her own length of time and commit to it, the patient feels powerful and in control of his recovery. The therapist also teaches the patient to ‘cope ahead’ in which the patient learns how to anticipate potential situations and cues for high-risk situations, and prepare how they will respond.
Abstinence is established by promoting change. Subsequently, abstinence is supported by encouraging acceptance. DBT treats relapse as a problem to solve instead of a patient failure. For example, if a relapse occurs the therapist will help the patient analyze the events that led to the drug use. The patient can then identify behaviors and situations that led them to use, and apply this knowledge to future situations. Additionally, the therapist helps the patient make a quick recovery from the relapse by easing any negative emotions and thoughts the patient might feel after.
Creating an Effective Environment
To successfully accomplish the goals of the treatment, DBT focuses on creating an effective environment in which the patient can learn four fundamental skills of DBT. These four skills include mindfulness, interpersonal relations, distress tolerance, and emotional regulation. Mindfulness is about being completely aware and focused on the present moment instead of being distracted and thinking about the past or worrying about the future. This can also be described as acceptance of the self and of current circumstances. Interpersonal relations involve teaching patients how to create and maintain happier, more fulfilling relationships. Distress tolerance focuses on developing coping skills and managing distress instead of trying to escape from it. Emotional regulation teaches patients how to identify and regulate their emotional responses without becoming overwhelmed or acting impulsively.
DBT has been proven to reduce substance abuse, improve the patient’s well-being, and keep patients invested and engaged in treatment. The effectiveness of this form of therapy is largely due to the patient’s development of the four fundamental skills described above. The completion of a DBT program shows enormous promise in helping patients successfully overcome addiction.