DBT meets the 12 Steps
Dialectical Behavior Therapy (DBT), founded by Marsha Linehan, PhD, was initially developed for women diagnosed with borderline personality disorder. Recently, there have been numerous research articles describing the effectiveness of utilizing DBT in substance abuse treatment.1,2 In light of this research, many addiction treatment centers have begun implementing DBT programming.
Addiction literature also demonstrates the utility of 12-Step programming in supporting recovery, and the 12-Step approach is commonly integrated into addiction treatment programs.
3,4 The Center for Dependency, Addiction and Rehabilitation (CeDAR) at the University of Colorado Hospital has successfully developed programming that integrates DBT and 12-Step philosophy.
In DBT, the focus is on creating a dialectical lifestyle that reflects balanced behavioral patterns such as balanced actions, balanced emotions and balanced cognition. Similarly, working the 12 Steps results in creating a balanced lifestyle. Alcoholics Anonymous (AA) offers “the promises of the steps” and Narcotics Anonymous (NA) gives the promise of “freedom from active addiction.” Both of these gifts of working the steps complement DBT's focus.
The four stages of DBT move from addressing severe behavioral dyscontrol to creating the capacity for joy and freedom. In addition to describing four stages of treatment, DBT literature also identifies specific targets that must be addressed in the therapeutic process. The targets of DBT can be found throughout 12-Step literature and are an integral part of step work. The table on the following page outlines the similarities between DBT targets and 12-Step philosophy.
In 2007, CeDAR committed to providing DBT services to both primary care and extended care patients. In primary care, mindfulness and distress tolerance modules are taught and practiced in DBT skills groups. The extended care program reinforces continued practice of mindfulness and distress tolerance skills, and introduces the “interpersonal effectiveness” module. Primary care groups are gender-specific and are held once a week. Extended care patients participate in mixed-gender skills groups twice a week.
Mindfulness
Mindfulness is the foundation of DBT practice. It has been described as “moment to moment, nonjudgmental awareness, cultivated by paying attention.”7 Linehan describes the “States of Mind”: reasonable mind, emotional mind and wise mind.8 Mindfulness practice supports patients in centering themselves in the wise mind state.
One characteristic of an addict is extreme thinking. The addict is able to achieve a balanced state by using mindfulness practice to move from extreme thinking to wise mind. Wise mind is the middle ground; recovery involves finding that middle ground and staying balanced. At CeDAR, mindfulness and the states of mind are emphasized to reinforce the importance of taming the mind and finding the balanced path.
12-Step literature also provides examples of the three States of Mind. The AA Big Book describes emotional mind on page 36:
“Suddenly the thought crossed my mind that if I were to put an ounce of whiskey in my milk it couldn't hurt me on a full stomach. I ordered a whiskey and poured it into the milk. I vaguely sensed I was not being any too smart, but felt reassured as I was taking the whiskey on a full stomach. The experiment went so well that I ordered another whiskey and poured it into more milk. That didn't seem to bother me so I tried another.”6
This reading illustrates how emotional mind can be a “trickster” and will create the illusion of being reasonable. This concept is extremely important in recovery, as it emphasizes how an individual cannot rely on his/her own thinking and willpower for the answers.
The NA Basic Text describes meditation as being an important part of building successful recovery. Mindfulness meditation allows for quieting the mind and focusing energy and strength. This type of meditation targets the mental component of addiction, which is obsession of the mind:
“Quieting the mind through meditation brings an inner peace that brings us into contact with the God within us… A basic premise of meditation is that it is difficult, if not impossible, to obtain conscious contact unless our mind is still.”9
The core concepts taught in the mindfulness module are to quiet the mind and to begin trusting one's own perceptions, judgments and decisions. By being judgmental, the addict reinforces negative behaviors. Perceptions and viewpoints change in order to feed the addiction and allow it to play a primary role in the person's life. The skill of “acting non-judgmentally” (from the “how” skills) emphasizes “principles over personalities” and strengthens the concept of open-mindedness:
“A new idea cannot be grafted onto a closed mind. Being open-minded allows us to hear something that might save our lives… Open-mindedness leads us to the very insights that have eluded us during our lives…we no longer need to make fools of ourselves by standing up for non-existent virtues. We have learned that it is okay to not know all the answers, for then we are teachable and can learn to live our new life successfully.”9
Distress tolerance
The DBT distress tolerance module includes five groups of skills that teach individuals how to tolerate uncomfortable situations and decrease intense emotional reactions. Prior to recovery, the addict medicates, numbs and avoids experiencing unwanted emotions. In early recovery, the intensity of new emotions may be overwhelming. Practicing distress tolerance provides the individual with skills to get through difficult times.
The five groups of skills taught in the distress tolerance module can also be identified in 12-Step literature. For example, the skill of contributing has to do with helping others in order to help oneself. On page 115 of the AA Big Book, Bill describes how going to his old hospital and talking to another alcoholic would move him from self-pity, resentment and despair and would “save the day.” Service work is a vital element in any 12-Step fellowship.
Accepting reality is the last of the five skills groups within the distress tolerance module. “Radical acceptance,” “turning the mind” and “willingness vs. willfulness” are the focus of this skills group. The concept of “radical acceptance” has to do with ceasing to fight reality and being tolerant of whatever the situation brings. A central concept of radical acceptance is that pain creates suffering only when we refuse to accept the pain. One 12-Step slogan related to this concept is “pain is inevitable, misery is optional.”
The AA Big Book devotes an entire chapter to the concept of acceptance. The Serenity Prayer, said in thousands of 12-Step gatherings, reminds those in the fellowship of the importance of accepting what is and “letting go.”
Radical acceptance and the 12-Step concept of surrender are imperative for those moving toward successful recovery. Without either, internal unmanageability and the inability to “let go” will continue to be roadblocks in the process of recovery. Step One emphasizes the essential need for surrender. Individuals must surrender in order to move successfully through the remaining steps.
CeDAR has found that providing DBT skills groups complements other aspects of the program. Staff continuously witnesses the benefits of integrating DBT skills into 12-Step programming. By putting these ideas into practice, the foundation of recovery is reinforced and patients begin moving toward a life worth living.
More Online
For another perspective on DBT's usefulness in addiction treatment, visit https://www.addictionpro.com/roes1108.
References
- Kienast T, Foerster J. Psychotherapy of personality disorders and concomitant substance dependence. Curr Opin Psychiatry 2008 Nov; 21:619-24.
- Linehan MM, Schmidt H, Dimeff LA ,et al. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. Am J Addict 1999 Fall; 8:279-92.
- Galanter M. Spirituality and recovery in 12-Step programs: an empirical model. J Subst Abuse Treat 2007; 33:265-72.
- Piderman KM, Schneekloth TD, Pankratz VS ,et al. Spirituality in alcoholics during treatment. Am J Addict 2007 May-Jun; 16:232-7.
- Narcotics Anonymous World Services, Inc. The Narcotics Anonymous Step Working Guides. Van Nuys, Calif.:Narcotics Anonymous World Services; 1998.
- Alcoholics Anonymous World Services, Inc. Alcoholics Anonymous, Fourth Edition. New York City:Alcoholics Anonymous World Services; 2001.
- Kabat-Zinn J. Arriving at Your Own Door: 108 Lessons in Mindfulness. New York City:Hyperion Books; 2007.
- Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York City:The Guilford Press; 1993.
- Narcotics Anonymous World Services, Inc. Narcotics Anonymous, Sixth Edition. Van Nuys, Calif.:Narcotics Anonymous World Services; 2008.
