People receiving treatment for a substance use disorder or addiction will, at some point, enter an individualized addiction therapy program in which they address the “why” behind their addiction(s) and actions and learn how to replace negative behaviors with positive ones.
They are also able to manage their thoughts and emotions as they go about their daily lives.
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Behavioral therapies for substance abuse and dependence have been found to be effective in the substance addiction treatment. Here, we review two types of behavioral therapies that clients in addiction treatment have used to address their substance abuse problems beyond the surface. They are cognitive behavioral therapy and dialectical behavioral therapy.
Cognitive Behavioral Therapy (CBT) for Addiction
Cognitive-Behavioral Therapy (CBT) is a psychotherapy designed to help people change unhealthy thoughts and beliefs they are aligned with dysfunctional behaviors. CBT therapists teach specific problem-solving skills that people can use to recognize distorted thinking that can trigger them to use addictive substances. When one finishes cognitive behavioral therapy, they should:
- Have increased awareness of one’s thoughts and emotions
- Be able to identify how thoughts, behaviors, events, or situations can affect or influence emotions
- Have the tools to improve their feelings by changing dysfunctional thoughts and behaviors
Evidence-based CBT methods can boost clients’ motivations to change, moderate dysfunctional beliefs, manage their cravings, and improve their mood, says the Beck Institute for Cognitive Behavior Therapy. Aaron T. Beck, M.D., an American psychiatrist who developed cognitive therapy at the University of Pennsylvania in the 1960s, founded the institute along with his daughter Judith S. Beck, Ph.D., in the early 1990s.
According to the National Institute on Drug Abuse (NIDA), CBT was developed as a method to prevent relapse for treatment of problem drinking. Later, the approach was adapted for people with cocaine addiction.
“A central element of CBT is anticipating likely problems and enhancing patients’ self-control by helping them develop effective coping strategies,” NIDA writes.
It highlights what these specific techniques of CBT may include. They are:
- Exploring the benefits and negative consequences of continued drug use
- Monitoring one’s self to recognize cravings early and identify situations that might put one at risk for substance use
- Developing strategies for coping with cravings
- Avoiding high-risk situations and behavior
According to PsychCentral, cognitive behavioral therapy can be thought of as a combination of psychotherapy and behavioral therapy. The psychotherapy part looks at the meaning placed on items and the thought patterns that begin in childhood while the behavioral therapy looks at the connection between problems, behavior and thoughts. Helping clients identify dysfunctional ways of thinking can help develop a more accurate perspective of what is happening or taking place.
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What Happens During a Cognitive Behavioral Therapy Session?
The Beck Institute for Cognitive Behavior Therapy explains that therapists approach CBT treatment differently depending on the psychiatric disorder being treated. However, the essentials of this therapy include that there is a trust and rapport between the client from the first point of contact. The session should be collaborative, and clients should feel like they can contribute. Openness between clients and therapists aids the process of helping clients understand and respond to inaccurate ideas so they can learn how to recognize them.
During the initial session, therapists review their clients’ intake information to form a therapeutic plan. This information includes clients’ problems, symptoms, current functioning level, and history. Therapists are advised to ask clients about what they know about how therapy is conducted, they should explain to clients the cognitive-behavioral therapy model, and answer questions they may have. Clients should also understand that therapy is collaborative and that working together can help clients better understand their feelings and solve their problems.
Once the client and therapist have established a relationship in the initial meeting, the structure of future sessions typically go like this:
For about five to 10 minutes, therapists will perform a “mood check” with their clients and ask about any significant events that have happened since their last meeting, their current mood, or any significant changes or discrepancies. This check-in period helps both parties develop their connection and helps set the agenda of the meetings that follow.
For the next 30 minutes or so, CBT therapists then set the agenda by creating a short list of topics that they and their clients agree to focus on during the session. This list can include new topics or they can be a continuation of earlier topics.
At first, therapists are more active in setting the agenda, but later on in therapy, clients learn to do this on their own and become responsible for it. Both parties work together to prioritize agenda items. As clients and therapists talk about issues on the agenda, therapists will help the client determine the accuracy and usefulness of their thoughts and beliefs as it relates to the issue.
Therapists will then teach clients new skills to help them change problematic thinking and behavior that will help clients solve problems when they are not in the therapeutic setting. These exercises are designed to help people understand the root of their thinking, which typically comes from depression and anxiety disorders, and make better choices, including abstaining from substances. Clients will be asked to share any conclusions they have made and summarize what they feel is important. Either clients or therapists write these notes on paper.
An action plan, formerly known as “homework,” is assigned. Though the name has changed, actions plans are not optional. Judith S. Beck. Ph.D., explains why, writing, “Therapists emphasize that most of the work in getting better happens between sessions. A significant part of each session involves helping clients figure out what they need to do outside of the therapy office to feel better and regain a good level of functioning. We tell clients: It isn’t enough just to come and talk for 50 minutes a week. The way people get better is by making small changes in their thinking and behavior every day.”
During CBT meetings, therapists review Action Plans with their clients and hold discussions that may include questions such as, “What was learned in the Action Plan?” “What problems arose?” “How might those problems be solved in the future?” This review can be short or last the entire session. An Action Plan can be learning how to practice solutions to problems by changing behavior or creating rational responses to dysfunctional thinking, among other things.
Therapists use elements of cognitive behavioral therapy, such as activity scheduling, to address agenda items, and are responsible for keeping the meetings on track. Therapists also summarize sessions. They offer a review of what happened and give their clients feedback. They also ask clients for their feedback about the session. This is a good time for clients to tell their therapists what they would like to see happen in future sessions.
Sessions typically last no more than 30 minutes to an hour, and take place once a week or once every two weeks.
Does Cognitive Behavioral Therapy Work?
According to NIDA, research shows that skills learned through cognitive behavioral approaches last after treatment ends. CBT is also a short-term approach that is compatible with inpatient or residential treatment programs that last a month or longer. It also addresses where the client is now in this point in time and targets those behaviors that trigger clients to use. Also, according to NIDA, there is research that is exploring how pairing CBT with medications for drug abuse and with other kinds of behavioral therapies can enhance its benefits. Before choosing a CBT-based therapy, consult with an experienced therapist to see if the approach is the right one for you or your loved one.
Dialectical Behavior Therapy (DBT)
Dialectical Behavior Therapy (DBT) is a type of cognitive behavioral psychotherapy that is designed to help clients identify and change negative ways of thinking and work on making positive changes in behavior. People who enter this kind of therapy may exhibit harmful or self-destructive behaviors.
American psychologist Marsha M. Linehan, Ph.D., initially developed Dialectical Behavior Therapy in the 1970s to treat people with borderline personality disorder (BPD) who exhibited suicidal behavior. Since then, DBT has been adapted to treat other mental health problems, such as depression, eating disorders, post-traumatic stress disorder (PTSD), and substance abuse and addiction. Those with mood swings, impulse control, social difficulties, anxiety/OCD, anger management, and Attention-deficit/hyperactivity disorder (ADHD) may also benefit from DBT therapy.
It has been described as a modified form of cognitive behavioral therapy that teaches clients skills that help them cope with unhealthy behaviors as they work toward changing them. However, it differs from cognitive behavioral therapy in that dialectical behavior therapy requires a weekly group therapy meeting where skills are taught in an environment that offer clients safety and support.
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What Does Dialectical Mean?
The word “dialectical” can be a bit intimidating to the eye because it sounds clinical. But as Charles H. Elliott, Ph.D., explains in this PsychCentral article, “Dialectics represent the mind’s way of understanding concepts by understanding and appreciating their polar opposites.”
Elliott also writes, “Dialectics are based in part on the fact that we cannot fully understand any of these abstract concepts without appreciating that they consist of bipolar opposites with a higher level of integration somewhere in between them.”
Some examples of bipolar opposites are light and darkness, introvert and extrovert, love and hate, and many others.
In Dialectical Behavior Therapy, the opposite, and perhaps conflicting, concepts of acceptance and change are brought together. Clients practice accepting themselves, including any uncomfortable feelings, thoughts, or situations they may have, along with the desire to change, and therapists work with them to resolve any perceived conflicts clients have between these two concepts, which can be viewed as two extremes.
Dialectical Behavior Therapy Has 4 Modules
Dialectical Behavior Therapy is a comprehensive program of treatment with four standard parts:
Individual therapy, which helps the client focus on applying the skills and strategies that are in sync with their specific treatment goals
A therapist consultation team that focuses on helping clients receive the most effective treatment possible for their needs
Group skills training that teaches clients the four skill modules taught in standard DBT therapy. They are mindfulness (focusing the mind and centering the self), distress tolerance (learning how to deal with stress without making impulsive or destructive choices), interpersonal effectiveness (learning how to deal with others and getting needs met in healthy ways), and emotion regulation (understanding one’s emotions). In addition to all of these, recovering substance users learn a set of skills that specifically address addictions.
A telephone consultation, or phone coaching (as needed) from clients’ individual therapists who can help clients navigate a crisis that may happen between sessions or when they need help employing the skills learned in therapy
How Long Is Dialectical Behavioral Therapy?
Standard DBT is typically offered for one year in an outpatient treatment setting. Weekly individual therapy sessions meet for one hour a week, weekly group skills training sessions meet for 1.5-2.5 hours a week, and a therapist consultation team meeting can last from about one to two hours.
Dialectical Behavior Therapy for Substance Abuse, Addiction
Dialectical Behavior Therapy for Substance Use Disorders (known as DBT-SUD) also has been modified to help people who have a mental health disorder and substance dependence or addiction at the same time, a condition known as co-occurring disorders or dual diagnosis. DBT-SUD uses the same treatment strategies and protocols as DBT, but it specifically addresses behaviors related to substance use.
BehavioralTech.org gives the example that in DBT-SUD, an emphasis can be placed on dialectical abstinence. But the focus on abstinence also will be balanced with strategies for harm reduction in the case that a slip, or lapse, does occur.
For DBT-SUD clients, substance abuse is the main target, behavioral targets are set, which are specific to substance abuse. In the 2008 paper titled “Dialectical Behavior Therapy for Substance Abusers,” by Linda A. Dimeff and Marsha M. Linehan, these targets may include:
- Decreasing abuse of substances, including illicit drugs and legally prescribed drugs taken in a manner not prescribed
- Alleviating physical discomfort associated with abstinence and/or withdrawal
- Diminishing urges, cravings, and temptations to abuse
- Avoiding opportunities and cues to abuse, for example by burning bridges to persons, places, and things associated with drug abuse and by destroying the telephone numbers of drug contacts, getting a new telephone number, and throwing away drug paraphernalia
- Reducing behaviors conducive to drug abuse, such as momentarily giving up the goal to get off drugs and instead functioning as if the use of drugs cannot be avoided
- Increasing community reinforcement of healthy behaviors, such as fostering the development of new friends, rekindling old friendships, pursuing social/vocational activities, and seeking environments that support abstinence and punish behaviors related to drug abuse
The 4 Stages of Dialectical Behavior Therapy
Clients attempt to gain control over problematic and possibly life-threatening behaviors, which may include suicide attempts or self-injury. In DBT-SUD, this may include excessive drinking and/or drug use, or it may include reckless behaviors that stem from such use, such as losing a job or custody of one’s children because of substance abuse.
At this stage, clients learn to focus on improving the quality of their lives. This includes improving their relationships and building their self-esteem. Reasonable goal-setting is also a part of this process. Happiness and stability are key goals to achieve in this stage.
Clients’ behaviors are stable but emotional health issues may remain. Clients focus on these emotions and begin to explore them in a safe space. This may include recalling and accepting the facts of a traumatic event that has occurred. According to Psych Central, the goal of Stage 2 is to reduce clients’ traumatic stress. “This is achieved by remembering and accepting facts of earlier traumatic events, reducing stigmatization and self-blame, reducing the denial and intrusive response syndromes and resolving dialectical tensions regarding who to blame,” writes Christy Matta, MA, for PsychCentral. Clients’ work on the targets identified in Stage 2 begins only when behaviors are under control.
Therapists help clients advance to the next level and continue to help them maintain their happiness and success and attain fulfillment.
How Effective Is DBT?
Dialectical behavior therapy is an evidence-based treatment, which means it has been repeatedly tested and rigorously evaluated, shown to be supported by data that stand independent of theory, and can be reproduced in different settings.
Behavioral Tech, which was founded by DBT’s creator, Marsha Linehan, offers research that supports its effectiveness in treating a variety of mental health disorders, including major depression, bipolar disorder, PTSD, and eating disorders. DBT has been found to be effective for people across age, race/ethnicity, sexual orientation, and gender. An experienced therapist can help clients decide if dialectical behavior therapy is right for them.
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Beck Institute for Cognitive Behavioral Therapy. Retrieved March, 2018 from https://beckinstitute.org/about-beck/
Grohol, John M., Psy. D. (2018, April 7). What’s the Difference Between CBT and DBT? Retrieved March, 2018 from https://psychcentral.com/lib/whats-the-difference-between-cbt-and-dbt/
CHapman, Alexander L., (2006 September). Dialectical Behavioral Therapy. Retrieved March, 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2963469/#__sec3title
Linda A. Dimeff, Ph.D.1 and Marsha M. Linehan, Ph.D. (2008, June). Dialectical Behavioral for Substance Abusers. Retrieved March, 2018 from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797106/