Edited by Hannah Stephens, Independent Prescriber - Substance Misuse Services
Intervention based on Dialectical Behavioural Therapy for the Treatment of Problems related to substance use
Dialectical Behaviour Therapy (DBT) was originally developed to manage impulsivity and instability symptoms in Borderline Personality Disorder (BPD). Studies have also demonstrated its benefit in Substance Use Disorder (SUD) populations, for which BPD is a highly prevalent comorbidity. DBT is also indicated for the adolescent population due to their developmental stage and prevalence of emotional dysregulation, making them particularly vulnerable to early onset drug use, subsequent maladaptive behaviours, and severity of substance dependence. Compared to DBT, Cognitive Behavioural Therapy (CBT) has demonstrated higher disengagement and relapse rates.
DBT is based on the concept that reality consists of opposing forces, and for every thesis, there is an antithesis, with dialectical change occurring when synthesis is found between each polarity. This achieves dynamic activity, change and acceptance, based on developed learning that the individual and external environments are in an ongoing transaction, for which influence can be maintained by the individual and comfort with such reality achieved.
Zen principles underpin acceptance-orientated strategies, seeking to increase self-acceptance by understanding that behaviours are understandable in context, and change-orientated strategies are based on behavioural principles such as problem-solving and social skills.
DBT-SUD adopts the perspective that substance use is a learned behaviour (rather than a disease-model approach) to mitigate negative emotions, or replace with a pleasurable state, achieve a state of disassociation, or a response to social or environmental triggers. Abstinence-focus and engagement with the recovery community are core principles in DBT-SUD, with lapse and relapse embraced as a learning opportunity to mitigate feelings of guilt, hopelessness and potential resignation from support. In the process of seeking dialectical abstinence, individuals move from the ‘addicted mind’ to the ‘clean mind’, preceded by abstinence and a sense of future immunity from substance use, increasing risk of relapse. A comfortable state of alternating between the two is a third state of mind; the ‘clear mind’, and therapeutic goal of DBT-SUD.
A randomized-control clinical trial of women with SUD and BPD assigned usual treatment vs DBT, found significantly higher drug reduction rates amongst the DBT vs control group. DBT participants also experienced greater gains in global and social adjustment. Further studies have demonstrated DBT to achieve decreased symptoms associated with SUD and increased abstinence prevalence, and improved emotional regulation, regardless of initial severity of substance use or emotional dysregulation. A study looking to prevent alcohol consumption amongst university students aged 18-21, drinking 2-3 times per week found DBT to achieve sustained reduction in alcohol consumption.
Whilst DBT interventions can be more costly to implement, doing so corresponds with fewer hospital admissions and psychopathologies and relapse events, improved quality of life and suggesting longevity of cost-savings in the management of SUD.
Commentary
This study identifies the efficacy of DBT across addiction populations but may be particularly beneficial to younger population groups in a prevention capacity, when substance use may be recreational or hazardous, but doesn’t meet the threshold for addiction interventions.
Conceptualising addiction as a learned behaviour may also redirect recovery narratives and facilitate a greater sense of control and influence to achieve identified goals, and build confidence and resilience based on greater understanding and acceptance of self. If CBT practices are well established in addiction treatment, based on the prevalence of BPD in addiction populations, DBT should also feature in core provision.
DBT also emphasises wellness practices and engagement with the recovery community, which by virtue of these external processes, may provide a more holistic and dynamic approach to recovery than with the largely internalised processes of thought challenging and behaviour modification in CBT, which in turn increases recovery capital, reducing risk of relapse and disengagement.
The practical nature of DBT facilitates, reflection, activity and perhaps most importantly connection, to self and others, which given the prevalence of BPD in SUD, and increased risk of harm typical with this comorbid presentation, is surely an investment worth making.
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