DBT for Substance Use: Radical Acceptance, Grief, and Recovery-Interfering Behaviors
By Dr. Kirby Reutter, Ph.D., DBTC, LMHC, MAC & Dr. Jean Eich.
This presentation is an excerpt from the online course “DBT Expert Interviews: From Trauma to Eating Disorders“.
- 1 Transcript
- 1.0.1 Introduction
- 1.0.2 Teaching Radical Acceptance to Clients With Substance Abuse
- 1.0.3 Grief Over the Loss of Addiction
- 1.0.4 Validation and Substance Abuse
- 1.0.5 Treatment-Interfering Behaviors
- 1.0.6 Between-Session Support
- 1.0.7 Challenging DBT Skills
- 1.0.8 Adaptations to Standard DBT
- 1.0.9 Acceptance and Change
- 1.0.10 Main Points
- 2 More DBT Expert Interviews: From Trauma to Eating Disorders
In this final section, Amy Dols elaborates on the DBT themes of radical acceptance, validation, recovery-interfering behaviors, between-session support, diary cards, chain analysis, and the ultimate dialectic of acceptance vs change.
She also discusses the integration of DBT with other models, including motivational interviewing, the 12 steps, and even grief counseling.
Finally, Amy introduces the 3 different mindsets associated with recovery: addict mind, clean mind, and clear mind.
Teaching Radical Acceptance to Clients With Substance Abuse
Kirby: How do you teach radical acceptance to clients with substance abuse?
Amy: Radical acceptance is a necessary stepping stone on the path towards healing and sustained recovery. The serenity prayer is the essence of radical acceptance. “Grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.” That is the essence of radical acceptance.
Acceptance is a journey. It’s a direction that we’re flowing. Oftentimes, it’s the last step of the stages in the grieving. An addictive behavior can feel like grief for a lot of people. Anger, depression, denial, and bargaining can be common experiences in the recovery process.
Radical acceptance is the most difficult DBT skill to teach because acceptance is asking somebody to accept things that have caused them pain. That can be interpreted as an invalidation of their experience and their suffering. Many of the clients that I’ve worked with have often been told that their addiction is a choice, their psychological suffering isn’t real, their struggles are a result of a weak will, poor character, or lack of discipline.
When I’m encouraging acceptance skills as a therapist, it might feel like they’re being told by somebody that they should accept their lot in life. This sounds very similar to the invalidating messages that they’ve received. It could result in an increase in hopelessness and worthlessness.
Our clients understand acceptance and the importance of it, but many continue to struggle with it because it’s still relatively abstract. There aren’t concrete steps to take. If we’re thinking about a skillset in distress tolerance like self-soothe, it has specific behavioral approaches to change or cope. DEAR MAN has concrete steps. Radical acceptance doesn’t have that, so it can feel frustrating to people.
The things that clients want to try to radically accept that often come up in group sessions are important for a therapist to touch on. The loss of trust from others is a big theme that comes up. Another one is not being able to fall back on substances for comfort or coping anymore.
It’s important to encourage my clients to remove the shame of using and villainizing the use because it served a purpose at some point. It causes a lot of damage and we know that we’re not endorsing that behavior at all. There is a grieving process around trying to let that go. That requires radical acceptance.
Not being able to sustain a healthy relationship with substances is along that line. Maybe there’s a loss of job or relationship, financial security, housing, custody of children, freedom—if somebody was incarcerated. Radical acceptance can help with all these things.
First, there needs to be an acknowledgment of the experience and the pain, and then a recognition that some things are out of our control. Lastly, identification of ways that we can use skills to move forward because acceptance is the key to moving out of our suffering. If you want to move forward and release this heavy load that you’ve been carrying around, acceptance is a key to that. It could take a long time. We have to be patient.
Kirby: I explain to clients radical acceptance is tough. But not radically accepting is even harder. If you radically accept something that’s very difficult, you’re on the path to healing. If you radically accept pain, that doesn’t mean you now have no pain but you have a more manageable and bearable pain. A pain that will transform itself into something positive, redemptive, whereas if there’s something difficult in your life and you cannot radically accept it, chances are that will just get even worse.
Amy: We’re stuck in suffering when we’re not focusing on trying to work toward acceptance to move forward.
Grief Over the Loss of Addiction
Kirby: Clients can personify emotions and then change their relationship to their emotions as if it’s a person. Many times, addiction was their best friend, so they have to grieve that loss.
Amy: Right. I often do an exercise with my staff when I’m training them to work with clients with substance abuse. I have them write down answers to questions that include, “What’s your favorite comfort meal when you want to feel warm?”
I’m in Minnesota, so we all say mashed potatoes or lasagna. Then I ask them to name what they like to do the most when they want to celebrate, whom they talk to when they feel depressed, what their hobbies are, what they do when they are bored. There’s a variety of answers to all these questions.
With clients with substance abuse, oftentimes, the answer to that question or all of those questions is the same thing. It’s going back to that substance. As therapists, we’re telling them, “Take all of those things: your support network, your comfort, what you do when you’re bored, what you do when you celebrate. You need to put all of that in the trash and you don’t have that anymore.”
That’s a tall order and a scary thing to not have that to fall back on. I want people to have empathy and compassion for what we’re asking our clients to do. That goes back to the dialectical abstinence. This is going to take time to fill in those gaps and those holes where we’re asking them to take away that substance.
Kirby: Each time we remove the substance, there’s a void that needs to be replaced with a DBT skill. Going back to Kübler-Ross, the stages of grief culminate in acceptance. When a client is struggling with radically accepting something, I do grief counseling.
Let’s identify the denial. Let’s figure out the anger, the bargaining, or the depression that’s getting in the way. We work through that and the culmination is acceptance.
Validation and Substance Abuse
Kirby: How do you show and teach validation to clients with substance abuse?
Amy: First, I try to model and encourage it in the therapeutic environment at all times. That’s how people learn. Many of my clients not only have genetic predispositions to addictive behaviors but also have lacked the resources and modeling from caregivers to develop healthy coping skills.
It’s important to do psychoeducation with clients. Tell them that vulnerabilities and an invalidating environment is the perfect combination for the development of mental health issues and addiction.
The key to moving forward is balancing validation of one’s experience with the acceptance for the need to change, so I bring in the idea of the dialectical balance. We’re teaching about validation but also knowing that this has to be balanced out with change talk. Otherwise, we’ll get stuck in that place.
I want my clients to validate themselves by acknowledging that it’s understandable to want to continue engaging in those behaviors because this has worked for them. They even possibly protected them for a good chunk of time.
That’s how validation can play into clients with substance disorders. Balancing it out with this way of living is not working anymore. It’s not aligned with their long-term goals and their values. It’s likely hurting them. But they know that. They get that information through other resources. People have been telling them it’s not working, that they’re hurting themselves and other people.
When we skip that step of validation, we keep shame front and center, which can oftentimes be a trigger for future relapses. Ironically, it’s like one of those little carnival finger traps. The more that you struggle, try to fight with it, and get out, you’re going to get more stuck. We need to lean into these painful emotions or experiences to be able to release ourselves.
In group therapy, I first try to model the skill by providing validation to my clients. That’s the best way that they can learn. In the second stage, I encourage the clients to provide validating feedback with each other. Practicing giving that to each other is important. I hope that when they see me doing that practice, getting it from each other, they will eventually learn how to validate themselves. That’s the most important thing.
Some clients who struggle in group therapy will say, “Why do I have to be spending all this time in group giving feedback to other people? It’s not about them. It’s about me. I want to focus on my problems.”
I’ll tell them, “We want to change that self-talk. The things that you would say to yourself can be so invalidating, can be so harsh, and you would likely never say that to somebody else.”
The more you practice using that voice of validation, of acknowledgment with others, then we can adopt that with ourselves. It’s like a muscle that they’re working out.
Kirby: I like to think of the cheerleading skill in DBT as learning to self-validate. Because our clients are never going to get enough external validation that they need, especially in a crisis moment. Therefore, at some point, they’re going to have to learn to be their self-validators.
Amy: The beauty of that is their cup can always be filled up by themselves. They don’t have to look to other people for acknowledgment of their existence because that’s hard.
If you’re surviving off of scraps from others, it’s going to feel unstable and anxiety-provoking. But if you’re the one that can give yourself that strength, it’s abundant. You can give it to yourself at all times. It’s an empowering message as well.
Kirby: If you are completely dependent on external validation, maybe you’ll get it or maybe you won’t. Regardless, your life hinges on what other people do or don’t do, whereas self-validation is self-replenishing. It’s always accessible.
Kirby: Are there any treatment-interfering behaviors that you encounter with clients with substance abuse that are problematic? How do you address those challenges?
Amy: The primary way we address treatment-interfering behaviors is through the behavior chain analysis. The most common one is a slip or a relapse.
It’s a requirement for the clients that I work with that if there’s any recovery-interfering behavior or any other treatment-interfering behavior, they have to prepare a behavior chain analysis. There has to be this written homework that is presented to the group. It’s not meant to be in a shaming or punitive way. It’s for us to stretch out the decision-making process, figure out what and how can we learn from this.
I’ll tell my clients, “Pretend this is a laboratory and we’re doing all these different experiments. If the experiment goes awry, you don’t say, ’That sucked, I guess I’m never going to try that again.’ No. You go back and you analyze the data and you look at what could you tweak, what could be different, and you learn from it.”
Oftentimes, that’s how we get to big biological or technological advances. We move forward and there’s a lot of progress when we make mistakes. First, we take this nonjudgmental and neutral approach to treatment-interfering behaviors and we try to learn.
The behavior chain analysis document has been slightly modified for the needs of clients with substance abuse disorders. We’ll ask about the typical things like vulnerabilities, triggers, urges, and actions but we’ll also incorporate relapse prevention. Our clients need to be able to start planning for the future since we know that an experience of a slip or a relapse can be the catalyst for continued use.
I tell my clients to use the bridge-burning skill to identify how they will remove their access to substances and whom they’re going to reach out to for sober support. That could be attending to relationships.
There are other skills that they will use at various levels of urge intensity. The push away skill or distraction skill might work when you have a lower level urge. But when you’re at a 9/10, you need to call for help. There are different skills to use based on different intensity levels.
Lastly, I want my clients to think about the future. How will they celebrate their success? How will they feel when they’re able to put a “No” on their diary card because they didn’t act on the urge to use substances?
I want them to start to go through that rehearsal in their minds, start to live that out, and imagine what it might feel like to start building the neural pathway of success. Just as important as engaging in healthy behaviors, it’s important to reflect on the good choices we’ve made to solidify that pathway.
Kirby: How do you provide between-session support to your clients?
Amy: We offer brief phone coaching during office hours. I encourage my clients to connect with peer recovery support, like a sponsor through a recovery support program, or a certified peer support specialist. They can get it through the county services, too.
We want our clients to stay connected with DBT through the daily engagement with the diary card and the skills. People often struggle in DBT to get their journal card homework done every day. This is why I stress the importance of it. I say, “You have to think about these skills when you’re not here and that’s how you’re going to stay connected with DBT.”
Our program is moving a little bit away from the adherence to Marsha Linehan’s model. We don’t have a 24-hour coaching line, but we see each other more often. It’s an intensive outpatient. Instead of 1 day a week, we have 3 days a week plus individual therapy and we’re available office hours.
Challenging DBT Skills
Kirby: Are there other DBT skills that are challenging in addition to radical acceptance?
Amy: That’s the main one.
DEAR MAN is interesting because it’s more concrete. Clients are excited to learn about it because they want to know how to be more assertive and how to set boundaries. I find that the difficulty in that skill is that it’s often misunderstood.
We label the DEAR MAN skills as “This is how you can learn to be assertive, communicate effectively.” Oftentimes, clients see it as “This is the way that I’m going to get what I want” or “This is how I’m going to advocate for myself without thinking about the other person.”
I bring up this funny example that I had in a group session a long time ago. Somebody said, “I want to do a DEAR MAN on you. I just think that you’re so awful and I needed to say that.” That wasn’t a DEAR MAN. The client was expressing how he felt. There’s this misconception that being aggressive or assertive in that way means that you’re using DEAR MAN.
To offset that, I will make sure that when I’m teaching that skill, I’ll tell clients this is about improving the relationship quality, having clear communication, practicing being direct in how you feel, and also processing this a little bit before you do it.
Clients can write it out or talk to somebody about what they want to say with this DEAR MAN so that they are thinking about solutions. First of all, the client should’ve wondered, “What am I feeling? What are the actual objective facts? How do I want to improve this relationship by communicating clearly?” I think that DEAR MAN takes a lot of clarification.
Kirby: I’ve also faced those same challenges with DEAR MAN. I’ve modified that. I call it DEAR Adult for several different reasons. I use the same acronym of DEAR but I expand it a little bit more for the reasons you’ve mentioned.
The D, I still use it as describe. But for E, it’s not just express, it’s also empathize with how the other person feels. There needs to be this two-way street.
I still use the A for assert, but I also use it to appreciate the other person’s perspective. Don’t just assert what you want and need. I also use the A for apologize, if necessary.
For reinforce, I try to make clear that this isn’t just about reinforcing your request. It’s about reinforcing the quality of the relationship.
You mentioned how DEAR MAN is very concrete and sequential, whereas radical acceptance is more nebulous, abstract, and theoretical. You used grief counseling to provide the steps. This makes radical acceptance a little more concrete and tangible for our clients. We’re going to work through some denial and then we’ll work through some anger and bargaining.
Adaptations to Standard DBT
Kirby: Are there other adaptations you’ve made to standard DBT specifically for clients with substance abuse?
Amy: We see each other more often. This is an intensive outpatient level of care for DBT. Most DBT programs are 1 day a week. There was a need in the population for clients who have more severe suicidality, severe depression, and anxiety symptoms that need to be out of the house and into programming, connecting with people more often.
There are some additional skills that we teach to clients with substance abuse. We cover dialectical abstinence in group therapy and the addiction states of mind.
There’s the addict mind, which is all the behaviors, thoughts, and feelings associated with addiction. There’s the clean mind, which is the “pink cloud” or not oversimplifying recovery. The last stage is the clear mind, which is understanding the risks for relapse but also being excited about recovery and fully engaging in it. The addiction state of mind is new.
We’ll talk about processing resentments and making amends in interpersonal effectiveness, aligning with the 12 steps in that way.
When people come into our programming, we require a chemical health screening to be completed before being placed. In addition to gathering background information about their use, we also spend some time talking about their motivation to change and to participate fully in this program as well.
We have the substance use behavior prevention plan and the adapted diary card where people report on the intensity of urges, recovery-interfering behaviors, and sober support.
Kirby: Do you integrate other models into your work with clients with substance abuse?
Amy: Motivational interviewing is the number one model that I encourage my trainees and students to learn about. I use it when working with ambivalent clients, responding to and normalizing resistance, listening to client’s needs and goals, and making the treatment planning process collaborative.
The preparation to work with this population is not complete until you know about motivational interviewing. When I mention the 12 steps, we bring in those to have the language be familiar for our clients.
Another model that we integrate into DBT is the stages of change. We use DBT skills to increase awareness of an individual’s motivation to change. Then we want to move forward and engage in the change process. I will do the whole teaching on the stages of change when I’m in group sessions.
Kirby: I operationalize the acceptance with the stages of grief that we talked about because that lays out the stages of acceptance. Then I use the stages of change from motivational interviewing to conceptualize change, so I have something concrete to figure out where a client is at with acceptance or change on any given issue.
I use motivational interviewing to balance acceptance and change. I view it as a synthesis of them.
Acceptance and Change
Kirby: How do you apply acceptance and change in clients with substance abuse? Do you help them to accept where they’re at and what motivates them?
Amy: I love the theme of self-sufficiency and empowerment in motivational interviewing where you’re putting the onus on the client. That is woven into the philosophical approach that we take at our clinic. The clients are the experts on themselves and they need to be the leader of their treatment team.
Sometimes it’s a unique experience for the client that we’re serving because maybe they’ve been filtered through a lot of different programs where they’re treated like a prisoner or like somebody who’s done all these bad things and they’re over-pathologized.
We want to break down that experience by saying, “You are in charge here. You’re in the lead. I’m here to guide you and reflect on the hierarchy of needs and things that are important.”
Ultimately, they’re the ones that are creating their path forward and they need to tell us about that.
Kirby: What are your favorite DBT skills that you use in your personal life?
Amy: My favorite skill is BPE, building positive experiences mindfully. I’m a fun-loving person and I want to experience all that I can. It’s empowering to know that if I want to feel good feelings, I just need to tune in to my environment.
The way that I practice this skill is in nature and with my family. I’ve chosen these 2 things purposefully because they’re free and abundant. It makes me feel more connected to my surroundings. I feel more balanced and grounded when I’m connecting to positive experiences.
I have my clients list out all the things that make them happy. Oftentimes, they are things like a new pair of socks or clean sheets, these simple things that we forget about. I have them read it to each other and we’re all giggling and smiling. I realize we’re talking about these things that we like and our mood has changed. That’s a super fun skill for me to practice and also teach.
- It’s helpful to conceptualize addiction as an unhealthy relationship in the same way it’s possible to develop an unhealthy dependence on a real person. Since giving up an addiction is like losing a relationship or even a best friend, grief counseling is sometimes necessary to help clients work towards a state of radical acceptance. DBT is also highly compatible with other forms of recovery, including motivational interviewing and the 12 steps.
- Learning to manage recovery-interfering behaviors is the DBT version of relapse prevention, which is a critical aspect of substance abuse treatment. The following DBT interventions assist with relapse prevention: diary cards, between-session support, and chain analyses, which help clients identify the vulnerabilities, triggers, urges, and behaviors that lead to relapse.
- DBT has 3 mindsets related to recovery: addict mind, clean mind, and clear mind. Addict mind is actively engaged in the addictive behavior and isn’t concerned with recovery, abstinence, or sobriety. Clean mind recognizes the need for physical sobriety but erroneously assumes that maintaining sobriety will be an effortless process. Therefore, clean mind fails to acknowledge and prepare for triggers that result in relapse. Clear mind is the synthesis of the other 2 minds. Clear mind recognizes the need for maintaining sobriety while simultaneously recognizing the ongoing addictive tendencies, urges, and triggers that could potentially result in relapse.
More DBT Expert Interviews: From Trauma to Eating Disorders
- DBT for Chronic Pain: Distress Tolerance and Emotion Regulation
- DBT for Teens: Teaching Distress Tolerance, Emotional Regulation, and Interpersonal Effectiveness
- DBT for Trauma: Dialectical Thinking and Distress Tolerance
- DBT Skills for Emotional Dysregulation in Psychosis: A Clinical Case Study
- Emotional Regulation, Interpersonal Conflict, and DBT Skills for Eating Disorders
- DBT for Bipolar Disorder: Informal vs Formal Mindfulness