Program Integrates DBT, Twelve Steps
Developed for clients with multiple diagnoses, Dialectical Behavioral Therapy has been shown to be effective in addiction treatment. A new program unites the therapy with traditional approaches to addiction recovery.
Dialectical Behavioral Therapy (DBT) was initially developed for severe and chronic multi-diagnosed clients. Since its inception, there has been extensive research on using DBT with a variety of populations, such as those with personality disorders, post-traumatic stress disorder, self-harm and suicide thoughts, and anxiety and eating disorders, including those with substance use disorders (Linehan et al. 1999). Numerous research articles describe the effectiveness of utilizing DBT in substance abuse treatment (Kienast and Foerster 2008; Bornovala et al. 2005).
In light of this research, many addiction treatment and mental health centers have begun implementing DBT programming. Addiction literature also clearly demonstrates the utility of Twelve Step programming in supporting recovery, and this approach is commonly integrated into many addiction treatment programs (Galanter 2007; Piderman et al. 2007). DBT and Twelve Step philosophy have many conceptual similarities. Both are empirically supported treatments. Because they both work well, it makes sense to integrate the two effective approaches.
Initially, Linehan (1993) reorganized diagnostic criteria for borderline personality disorder (BPD) into five different "targets," or areas, and these areas have come to define DBT:
- Emotion dysregulation is the core feature of the disorder and involves affect lability (the regular occurrence of unstable or disproportionate emotional displays) and problems with anger
- Interpersonal dysregulation is the cluster of symptoms that has to do with chaotic relationships and fears of abandonment. An example of how the fear of abandonment plays out is when we observe clients vacillating between idolizing and hating another person.
- Self-dysregulation involves identity disturbances, a confused sense of self, and a sense of emptiness.
- Behavioral dysregulation includes suicidal behaviors, impulsive behaviors, and deliberate self-injury behaviors.
- Cognitive dysregulation involves dissociative responses and paranoid ideation.
In addition to developing the five DBT target areas, Linehan (1993) developed the DBT four stages of treatment. The goal for each stage appears below.
- Stage 1 focuses on moving the client from severe behavioral dyscontrol to behavioral control. Quiet desperation is the internal chaos that clients continue to feel after they have moved into behavioral control.
- Stage 2 moves the client from quiet desperation to non-anguished emotional experiencing.
- Stage 3 focuses on moving clients from experiencing problems in living to being able to experience ordinary happiness and unhappiness.
- Stage 4 moves clients from feelings of incompleteness to developing the capacity for joy and freedom.
The goals of these four treatment stages correspond with the goals of Twelve Step focused recovery. Twelve Step principles and philosophy have similar goals found in The Steps, and they, too, correlate well with the DBT stages of treatment.
How do the Twelve Steps correlate with the DBT four stages of treatment?
The Twelve Step spiritual principle behind Step One is surrender. The behavioral dyscontrol discussed in Stage 1 of DBT is seen in the attempts clients make to control people, places, things, and situations. The clients often lash out in desperation and have difficulty "letting go." In the process of working Step One, clients move from behavioral dyscontrol to behavioral control by learning to surrender and trust the process.
Stage 2 of DBT can be seen as a continuation of working Step One and Step Two. "Coming to believe" in Step Two is about surrender and awareness. Clients become aware that feelings are temporary and that they can work through them. When working Step Two, clients begin building a spiritual sense of self. They are then able to experience emotions without anguish and they become "more comfortable in their own skin."
In Stage 3 of DBT, clients continue to work Steps One and Two and begin working the spiritual principles of Step Three. Clients move from experiencing problems in living to being able to experience ordinary happiness and unhappiness through their faith in a Higher Power.
Stage 4 of DBT encompasses the remainder of the Steps. Working Steps Four through Twelve allows clients to grow spiritually and to learn how to have a positive relationship with themselves. Through this work they start building the capacity for joy and freedom.
What are the goals of Integrating Dialectical Behavior Therapy with the Twelve Steps?
The goals of Integrating DBT with the Twelve Steps are to teach clients to stay focused and aware in the present moment, to use coping skills during distressing times, to increase interpersonal effectiveness, to regulate emotions, and, finally, to live an engaging life in recovery. We believe that the best way to accomplish these goals is by integrating the two evidence-based practices discussed here. These practices are widely used in both mental health and substance abuse practices.
Excerpted from Integrating Dialectical Behavior Therapy with the Twelve Steps: A Program for Treating Substance Use Disorders, by Bari Platter and Osvaldo Cabral. Hazelden, 2012.