The mind of an addict is like an untamed horse, running wild
and full of emotion; it cannot be controlled. DBT and 12-Step
work tames that wild horse, bringing the mind into focus and
regulating emotions.

Dialectical Behavior Therapy (DBT) has found its way into addiction treatment. Originally developed as a therapeutic tool for women diagnosed with Borderline Personality Disorder, DBT currently has been modified by many treatment professionals for use in the field of addiction. Numerous published articles describe its effectiveness within this population (Linehan, MM, Schmidt, H, Dimeff, LA, Craft, JC, Kanter, J and Comtois, KA 1999; Kienast, T and Forester, J, 2008).

Addiction literature demonstrates the utility of 12-Step programming in supporting recovery (Galanter, M, 2007; Piderman, KN, Schneekloth, TD, Pankratz, VS, Maloney SD and Altchuler, SI, 2007), and the 12-Step approach is commonly integrated into addiction treatment programs. 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. We have learned that the two modalities complement and support each other in strengthening our patient’s recovery.

The focus of DBT is to create a dialectical lifestyle that reflects balanced behavioral patterns, such as balanced actions, balanced emotions and balanced cognition (Linehan, 1993). 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.

DBT Targets and 12-Step Philosophy

DBT literature identifies specific targets that must be addressed in the therapeutic process (Linehan, MM, 1993). These targets can be found throughout 12-Step literature and are an integral part of step work.

The DBT target of Emotional Dysregulation focuses on affective lability and problems with anger. Internal unmanageability, as described in 12-Step literature, is closely linked with the DBT target of emotional dysregulation as it focuses on the emotional volatility of addiction.

“Emotional volatility is often one of the most obvious ways in which  we can identify personal unmanageability” (NAWS, 1998, p 4).

Interpersonal Dysregulation involves the development of chaotic relationships and fears of abandonment. The Big Book (AAWS, 2001) describes the progressive destruction of relationships:

The alcoholic is like a tornado roaring his way through the lives  of others. Hearts are broken, Sweet relationships are dead. Affections  have been uprooted. Selfish and inconsiderate habits have kept the home in turmoil. We feel a man is unthinking when he says that sobriety is enough. He is like the farmer who came up out of his cyclone cellar to find his home ruined. To his wife, he remarked, “Don’t see anything  the matter here, Ma. Ain’t it grand the wind stopped blowin’?” (p 82).

Prior to entering the 12-Step fellowships, many addicts find themselves in a state of mental, emotional and spiritual bankruptcy. Bankruptcy then becomes a common topic of recovery in 12-Step meetings. Mental bankruptcy is connected with the DBT target of Cognitive Dysregulation. The focus is addressing dissociative responses and/or paranoid ideation.

“We were prisoners of our own mind and condemned by our own guilt” (NAWS, p 7).

In 2007, after careful review of DBT and 12-Step literature, CeDAR developed an integrated group model for primary care and extended care patients.

Mindfulness

Mindfulness is the foundation of DBT practice (Linehan, MM, 1993). It has been described as “moment to moment, nonjudgmental awareness, cultivated by paying attention” (Kabat-Zinn, J, 2007). Linehan (1993) conceptualizes our “States of Mind” as Reasonable Mind, Emotional Mind and Wise Mind.

Reasonable Mind is described as the state of mind we experience when do not have an emotional attachment to what we are focusing on; we are logical and rational. In Emotional Mind, our emotional state controls the way we see the world and make decisions; we don’t use logic or rational thinking to solve problems. Wise Mind is the balanced state of mind; we use logic and rational thinking, along with an awareness of our emotional state, to become aware of what is and to act in a thoughtful manner. Mindfulness practice supports patients in centering themselves in the Wise Mind state. Moving from extreme thinking to a Wise Mind involves finding the middle ground, living in the spiritual principle of surrender and staying balanced.

There are many examples of the three states of mind in 12-Step literature. For example, the Big Book (AAWS, 2001) 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.”

This reading demonstrates how Emotional Mind can be a trickster and will create the illusion of being reasonable. This concept is extremely important in recovery, since it emphasizes how an individual’s thought process is compromised and difficulty arises when relying on one’s own thinking and willpower. NA states, “it is a ‘we’ program” and AA reminds us that “your best thinking got you here”.

Mindfulness meditation, emphasized in step work, allows for quieting the mind and focusing energy and strength.

“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” (NAWS, 2008, p 46-47).

The core concepts taught in the mindfulness module of DBT are to quiet the mind and to begin to trust one’s own perceptions, judgments and decisions. Addicts reinforce negative behaviors by acting judgmentally. 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” (NAWS, 2008, p 96).

Distress Tolerance

There are five groups of skills taught in the DBT module of distress tolerance. These skills teach individuals to tolerate uncomfortable situations and to 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 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 Big Book (AAWS, 2001), Bill describes how going to his old hospital and talking to another alcoholic would move him from self-pity, resentment and despair and “save the day.” Contributing can be seen as similar to service work, a vital element in any 12-Step fellowship.

Accepting reality is the last of the five skills groups within the distress tolerance module. 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 that relates 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 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.

The authors will present this material at the West Coast Symposium on Addictive Disorders (WCSAD) in June 2010. The Symposium offers the opportunity to share innovative clinical practice with other addiction professionals.

References

Alcoholics Anonymous World Services, Inc. Alcoholics Anonymous, Fourth Edition. New York City: Alcoholics Anonymous World Services; 2001.
Galanter M. Spirituality and recovery in 12-Step programs: an empirical model. J Subst Abuse Treat 2007;33:265-72.

Kabat-Zinn J. Arriving at Your Own Door: 108 Lessons in Mindfulness. New York City: Hyperion Books; 2007.

Kienast T, Foerster J. Psychotherapy of personality disorders and concomitant substance dependence. Curr Opin Psychiatry 2008 Nov;21:619-24.

Linehan MM. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York City: The Guilford Press; 1993.

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.

Narcotics Anonymous World Services, Inc. The Narcotics Anonymous Step Working Guides. Van Nuys, Calif.: Narcotics Anonymous World Services; 1998.

Narcotics Anonymous World Services, Inc. Narcotics Anonymous, Sixth Edition. Van Nuys, Calif.: Narcotics Anonymous World Services; 2008

Piderman KM, Schneekloth TD, Pankratz VS, et al. Spirituality in alcoholics during treatment. Am J Addict 2007 May-Jun;16:232-7.

For the purpose of continuing education, the course objectives of this article are:

• Discus how Dialectical Behavior Therapy is successfully used in addiction treatment.
• Describe the similarities between the “DBT Targets” and 12-Step philosophy
• Review how 12-Step philosophy has been integrated with DBT Skills Groups and identify DBT Skills within the 12-Step literature