The incredible value that DBT brings to the treatment of co-occurring disorders lies primarily within DBT’s emphasis on acquiring skills for emotion regulation. Many alcoholics and addicts use their drug of choice as a primary means of regulating their emotions and improving their mood states. DBT, which was originally created to help individuals with Borderline Personality Disorder — a pervasive disorder of emotion regulation — excels at assisting patients in learning healthy and effective emotional regulation skills. Once the addict and alcoholic surrenders the use of the drug, the patient is left without many useful ways to manage his or her emotions, and it is here that DBT provides needed relief.

To really understand the heart and soul of DBT, we must understand the basic function of our emotional system, something I was reminded of during a recent, unplanned visit to the emergency room. Lying on the floor of the emergency room at Cedars Sinai Hospital in Los Angeles is not a pleasant experience. The day before as I found myself curled up in the worst pain I had ever known, I began to have a backache that grew into what I later learned were the spasms associated with a kidney stone. I was leading a Family Weekend at Michael’s House in Palm Springs, California, during the day, and on the drive back that evening, sitting in the car went from uncomfortable to unbearable. I was rushing back to Los Angeles to make a dinner appointment and had a full day of clients scheduled the next day. The last thing I had time for was to be curled up in pain among the injured masses of a major urban hospital.

The kidney stone was something of a warning signal from my body. I was working long hours under the enormous stress of running an inpatient rehab facility and not drinking enough water to flush my kidneys of the normal deposits. As a result, the stones formed and my body sent a searing message that I needed to stop and do something different. The more I ignored the signal, the stronger it became until ultimately it completely overtook my awareness.

Our emotional system operates very similarly to the pain system within the body. Emotions are designed to primarily warn us of possible danger and to prompt a change in behavior, just like the pain from the kidney stone forced me to stop what I was doing and to ultimately have surgery to remove them. Emotions are intended to organize and focus our behavior in moments when we may need to react quickly, sometimes even before thinking about it.

The science of emotions is complex and growing. Despite a huge number of recent advances, much of which has been fueled by the highly profitable development of antidepressants and other psychotropic medications, some of the basic principles about emotions as described by the legendary psychologist and philosopher, William James, in the late 1800s have held true. James wrote, “My theory … is that the bodily changes follow directly the perception of the exciting fact, and that our feeling of the same changes as they occur is the emotion.”  In short, emotions are changes in bodily states.

While James went on to propose other aspects of emotions that haven’t been confirmed by the last century of research, this point has held up to investigation: When we feel an emotion, it is our brain’s perception of changes in sensations in our body. For example, your brain senses tightness in the chest and rapid heartbeat and interprets this as anger. Similar but subtly different bodily sensations are interpreted as fear. Once the brain interprets these bodily states, it floods our perceptual system with an urge to take action. When we feel anger, we have an urge to strike out. When we feel fear, we have an urge to flee the danger. Likewise, when we feel sadness we have the urge to seek the comfort of the familiar and to “hibernate” within the confines of what we know and what feels safe. Each emotion has its own identifiable bodily state and subsequent action urges.

Think of it this way. An emotion is remarkably like drinking a shot of liquor or taking a drug. Soon after drinking, the alcohol begins to affect your body in very distinctive ways. Your reaction time slows, your muscle coordination diminishes and your ability to maintain focus lessens. Likewise, when you experience an emotion, your body is responding to a unique cocktail of neurotransmitters within your nervous system that affects your entire body. When you feel strong anger, you may have sensations of being stronger than you are, and have moments of narrowed focus on the target of your anger. And just like with liquor, it takes time for the effects of the neurotransmitters to return to normal levels. In essence, you stay drunk on the emotion until these chemicals retreat to baseline, provided that you don’t “re-trigger” the emotion. Just as the alcoholic drinks until he is completely drunk and passes out, if you continually encounter the situation that is triggering an emotion, you remain in an altered state that can become more intense as the emotion is “re-triggered.”

This is where the emotional regulation skills of DBT are invaluable in teaching us how not to re-trigger the emotion so that we can “sober up” and make decisions that lead to a worthwhile life. It’s not an option for you to “abstain” from feeling (nor is it recommended, as other serious mental health issues arise), so we must learn how to live with our emotions, and more importantly, how to limit the distress that painful emotions bring into our lives.

While DBT isn’t appropriate for every substance abuser, there is emerging evidence to suggest that most components of DBT are efficacious for most alcoholics and addicts, and when the patient struggles with a co-occurring condition, DBT is therapeutic and effective.

For more information on the evidence to support DBT in substance dependence treatment, below is a brief bibliography:

American Psychiatric Association, 1998. Gold Award: Integrating dialectical behavior therapy into a community mental health program. Psychiatric Services 49(10):1338-1340.
Beautrais, A.L.; Joyce, P.R.; and Mulder, R.T., 1999. Cannabis abuse and serious suicide attempts. Addiction 94(8):1155-1164.
Cacciola, J.S., et al., 1995. Treatment response of antisocial substance abusers. Journal of Nervous and Mental Disease 183(3):166-171.
Cacciola, J.S., et al., 2001. The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients. Drug and Alcohol Dependence 61(3):271-280.
Darke, S., et al., 2004. Borderline personality disorder, antisocial personality disorder and risk-taking among heroin users: Findings from the Australian Treatment Outcome Study (ATOS). Drug and Alcohol Dependence 74(1):77-83.
Dulit, R.A., et al., 1990. Substance use in borderline personality disorder. American Journal of Psychiatry 147(8):1002-1007.
Frances, A.; Fyer, M.R.; and Clarkin, J.F., 1986. Personality and suicide. In: J.J. Mann and M. Stanley (Eds.), Psychobiology of Suicidal Behavior (Vol. 487). New York: Annals of the New York Academy of Sciences, pp. 281-293.
Koons, C.R., et al., 2001. Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy 32(2):371-390.
Kosten, T.A.; Kosten, T.R.; and Rounsaville, B.J., 1989. Personality disorders in opiate addicts show prognostic specificity. Journal of Substance Abuse and Treatment 6(3):163-168.
Linehan, M.M., 1987. Dialectical behavior therapy: A cognitive behavioral approach to parasuicide. Journal of Personality Disorders 1:328-333.
Linehan, M.M., 1993a. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, M.M., 1993b. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.
Linehan, M.M., in press. Skills Training Manual for Disordered Emotion Regulation. New York: Guilford Press.
Linehan, M.M., et al., 1991. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry 48(12):1060-1064. Linehan, M.M., et al., 1999. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addictions 8(4):279-292. Linehan, M.M., et al., 2002. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for border
line personality disorder. Drug and Alcohol Dependence 67(1):13-26. Linehan, M.M., et al., 2006. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality dis
order. Archives of General Psychiatry 63(7):757-766.
Linehan, M.M.; Dimeff, L.A.; and Sayrs, J.H.R., in press. Dialectical Behavior Therapy for Substance Use Disorder. New York: Guilford Press.
Linehan, M.M., and Heard, H.L., 1999. Borderline personality disorder: Costs, course, and treatment outcomes. In: N. Miller and K. Magruder (Eds.), The Cost Effectiveness of Psychother
apy: A Guide for Practitioners. New York: Oxford University Press, pp. 291-305. Linehan, M.M.; Heard, H.L.; and Armstrong, H.E., 1993. Naturalistic follow-up of a behavioral treatment for chronically parasuicidal borderline patients. Archives of General Psychiatry
50(12):971-974.
Links, P.S., et al., 1995. Borderline personality disorder and substance abuse: Consequences of comorbidity. Canadian Journal of Psychiatry 40(1):9-14.
Lynch, T.R., et al., 2003. Dialectical behavior therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric Psychiatry 11(1):33-45.
Marlatt, G.A., and Donovan, D.M., 2005. Relapse Prevention: Maintenance Strategies in the Treatment of Relapse Prevention. New York: Guilford Press.
McKay, J.R., et al., 2000. Prognostic significance of antisocial personality disorder in cocaine-dependent patients entering continuing care. Journal of Nervous and Mental Disease
188(5):287-296.
Nace, E.P.; Davis, C.W.; and Gaspari, J.P., 1991. Axis II comorbidity in substance abusers. American Journal of Psychiatry 148(1):118-120.
Rossow, I., and Lauritzen, G., 1999. Balancing on the edge of death: Suicide attempts and life-threatening overdoses among drug addicts. Addiction 94(2):209-219.
Rutherford, M.J.; Cacciola, J.S.; and Alterman, A.I., 1994. Relationships of personality disorders with problem severity in methadone patients. Drug and Alcohol Dependence 35(1):69-76.
Safer, D.L.; Telch, C.F.; and Agras, W.S., 2001. Dialectical behavior therapy for bulimia nervosa. American Journal of Psychiatry 158(4):632-634.
Stone, M.H.; Hurt, S.W.; and Stone, D.K., 1987. The PI 500: Long-term follow-up of borderline inpatients meeting DSM-III criteria. I: Global Outcome. Journal of Personality Disorders
1:291-298.
Telch, C.F.; Agras, W.S.; and Linehan, M.M., 2001. Dialectical behavior therapy for binge eating disorder. Journal of Consulting and Clinical Psychology 69(6):1061-1065.
Trull, T.J., et al., 2000. Borderline personality disorder and substance use disorders: A review and integration. Clinical Psychology Review 20(2):235-253.
van den Bosch, L.M., et al, 2005. Sustained efficacy of dialectical behaviour therapy for borderline personality disorder. Behaviour Research and Therapy 43(9):1231-1241.
Verheul, R., et al., 2003. Dialectical behaviour therapy for women with borderline personality disorder: 12-month, randomised clinical trial in The Netherlands. British Journal of Psychiatry
182:135-140.
Zanarini, M.C., et al., 2004. Axis I comorbidity in patients with borderline personality disorder: 6-year follow-up and prediction of time to remission. American Journal of Psychiatry 161(11):2108-2114.

Life changed for me that night some twenty-five years ago; but at the time, I would have no idea just where it would take me. I assumed, as did most everyone else in the late 1980’s, that my life was no longer infinite as young men of 26 years, bewitched by the narcissism of youth, foolishly believe. Yes, I would die and probably sooner rather than later. This, in the days and weeks after that night in the San Francisco fog, I would come to accept as fact.

And why wouldn’t I? As a young therapist with a newly-crafted PHD, I had already seen so much devastation from the HIV epidemic. Young men were going blind, tapping with canes their way down streets lined with gay bars. Others were slipping into eternal idiocy with dementia. Still others went to work one day, fell ill the next, and were laid to rest within the same week. “Where is John?” is a question even I knew never to ask. It didn’t matter who it was–if they suddenly disappeared from the scene–you just assumed they had succumbed to the plague.

That was more than two decades ago, and since you are now reading my words, you know that I am still alive. Fortunately for me, a combination of good genes, perhaps a weak strain of the virus and the invention of the “cocktail” in 1996 turned my near-death experience into a manageable chronic illness. I was one of the very lucky ones who narrowly escaped with my life.

Only now have I come to understand the profound impact that virus has had on who I was and what I have become. It gave me my life to live in hurry. I had places to go, people to meet, jobs to treasure and quit, and many miles to travel before the darkness descended. For the better part of 10 years, I lived under a cloud of a temporary future. Before the HIV “cocktail” of medications, no one knew how long it would take for the virus to ultimately destroy my immune system. For some, it was almost immediate; others showed very few effects for almost ten years before becoming ill. After the cocktail, we all wondered when the clever virus would outsmart the antiviral medication and once again invade our immune systems as it had for the unlucky ones.

As it turned out, those dire futures never materialized for me, but I wouldn’t come to trust this until the century rolled over. In that time, I lived in fast-forward, always trying to get the very best—or at least the most—out of life before the final fog descended. I craved, no I demanded that life deliver everything I wanted. The clicking of my viral clock was loud and undeniable. I had nothing, not time nor love, to waste.

Ironically, HIV became one of the greatest gifts of my life. This truth runs very deep in me, my loves and my career. HIV radically changed my hunger and thirst for what is authentic and wonderful in life. I needed desperately to penetrate to the very core of things before precious time ran out. I wanted to taste it all. I wanted to know for myself–know like I know my own name–what the meaning of my life is. So much of what I had known and lived as a gay man in America had taken for a wild ride and left me wanting something more; something, as the dear Sylvester sang, mighty real.

With these hounds of time and mortality nipping at my heels, I dove into my own life and my work. I needed to know what was truly meaningful and not just the accepted counterfeits, proclamations of educated men who observe and rarely live life fully. I had learned so much in school and knew so very little of what mattered.

Like me, many gay men struggle more than do most other people in this world with finding our true, authentic voice. While HIV turned up the volume on my struggle with shame and authenticity, it is the same struggle experienced by gay men who have never been touched by the disease. As a group of men, we are undeniably present and visible in the world, yet our true inner worlds remained buried deep within the tight grip of a rejected child who wants acceptance and love. Modern heterosexual culture is, for the most part, undeniably hyper-masculine and invalidating of men who love other men. And as painful as this is, there is even a deeper wound of invalidation that prevents many gay men from discovering their true authenticity and inner passion. It is best summed up as we will never be like mom and dad. All children, straight and gay, are biologically predisposed to seek the approval and acceptance of their parents by mirroring the parents’ behavior. When it comes to the deeply fundamental behaviors of romance, tenderness and intimacy, we cannot mirror our parents in these. Instead, we are different. In the child’s world, being different is akin to risking abandonment, separation, and ultimately death. To avoid such intolerable feelings, we unknowingly but steadily abandoned our true selves and attempted to become something that was more desirable in straight world. In essence, we gave away our power for a seat at the table.

The experience of invalidation and the resulting wounds of shame we sustained are documented in-depth in my book, The Velvet Rage. For too long, many of us have lived lives that are beautiful facsimiles of the expectations of others rather than creations of our own authenticity and joy. We have excelled at beauty and succeeded at success, and still, there remains a nagging emptiness and a knowing that something is missing. It is something that seems vaguely familiar and childlike but is just beyond the reaches of our minds.

It is here that our journey to regain the missing pieces of our selves begins. Some pieces we deliberately traded off, others we abandoned and allowed to wither away, and still others were taken from us by the well-meaning but misguided guardians of our childhood. In The Velvet Rage, I chronicle our crusade into the challenges of adulthood without having been given the armor or the sword that our straight brothers were gifted by their fathers and a world that understood and accepted them. How we learn to fight our battles, love our men, and ultimately find lasting passion and fulfillment is where the story of The Velvet Rage ends. Far from the closet of shame, we ultimately find our true self and the authentic life we were always meant to have.