For this blog, I want to talk a little bit about how we address substance use issues in DBT. Research on DBT for substance use has been occurring since the 90s. Marsha Linehan noticed that, among her clients with BPD, many of them also had co-occurring substance use difficulties. At the time, the grant funding climate in the U.S. was such that funding for treatment research focused on substance use was a little easier to get than some other types of funding. Moreover, because many of the things we do in DBT were already components of effective treatment for substance use, DBT seemed to be a natural fit. Since then, several studies have shown that DBT has promise in the treatment of people who are struggling with substance use difficulties (Haktanir & Calendar, 2020).
In contrast with the idea that substance use and mental health problems are separate issues requiring separate approaches, in DBT, we address them all together within a comprehensive treatment program. People have often asked us whether clients need to be “clean” and sober before they begin our DBT program. Our typical answer is that, unless the client urgently needs medical detox, they are welcome to seek our services. We would not exclude someone because they are struggling with substance use problems, nor would we kick someone out of treatment because they are continuing to use substances.
Another idea that influences how we help people with substance use is that of prioritizing treatment targets. Within DBT, we have a sort of priority list, or what we call a hierarchy of treatment targets. At the very top of the list is life-threatening behaviour, because let’s face it, you can’t benefit from therapy if you’re dead. The next highest priority is therapy-interfering behaviour, such as things that client or therapist might do that make it hard for the client to benefit from therapy. The third priority is what we call quality-of-life-interfering behaviour. This involves anything the client is doing, or anything going on in the client’s life, that makes it hard for them to build a life worth living. It is in this category that substance use problems usually fall. These days, though, many of us have had discussions about the idea that certain types of substance problems could be elevated to the life-threatening category, given the toxic drug supply.
If a client is struggling with substance-abuse problems, we use the list above collaboratively to come up with treatment goals. The basic idea is that, if the client wants to change their substance use or if their substance use is leading to higher priority problems, then it becomes a focus of treatment. So, if my client says that they would like to talk about reducing smoking, drinking, or other substance use, we will definitely talk about it, and treatment would focus on ways to help with that. If my client does not seem to want to address their drinking, but it becomes clear that their drinking is making them suicidal, or that they are showing up to my therapy sessions drunk, then we will have to address it in some way. This doesn’t mean that they must stop drinking now or that they’re out of therapy. Instead, we’d probably start by keeping track of drinking and reducing the harm that comes from drinking. We would talk about ways to make it so that drinking doesn’t happen in a way that makes the client more likely to be a risk to themselves. We would also talk about the timing of drinking and find ways that the client can use coping skills to avoid drinking before therapy sessions, and so on. If this eventually results in some behaviour change, and the client would like to work on reducing drinking, we would do that as well. With both of these clients, we would also be working on the mental health challenges that might be contributing to or exacerbated by substance use.
In summary, the basic ideas I want to get across in this blog are: 1.) We see substance use and mental health problems as intricately intertwined in DBT, and we treat them both. 2.) One way that we do that is to collaboratively define treatment goals according to a priority list, often referred to as the hierarchy of treatment targets in DBT. ~Alexander L. Chapman, Ph.D., R.Psych.