Dialectical Behavior Therapy (DBT) For Veterans With Addictions

Veterans often struggle with mental health concerns, which can be related to the nature of their work.¹ This can have a significant impact on their quality of life and also affect their families.¹ Therapies like dialectical behavior therapy (DBT) may be beneficial for Veterans who are facing certain mental health challenges.

This article will help you understand what DBT is, how DBT is used for addiction treatment, DBT modules and goals, and whether DBT is covered by the VA or VA benefits.

What is Dialectical Behavior Therapy?

Dialectical behavior therapy (DBT) is a form of therapy that was originally developed by Dr. Marsha Linehan in the 1990s to treat borderline personality disorder (BPD).² Linehan developed DBT to specifically treat self-harm and parasuicidal behaviors in women with BPD, but its uses have since broadened to a wide range of additional mental health conditions in different populations.²

DBT is based on principles of cognitive-behavioral therapy (CBT) and involves different components.² It is designed to teach people new and improved behavioral and coping skills to help them better manage challenging emotions and certain mental health symptoms.²

The term dialectical refers to the connection between conflicting ideas.² DBT aims to aid people in integrating and accepting their conflicting emotions and ideas and changing maladaptive behaviors by helping them develop and practice different DBT skills.²

Since its inception, DBT has been studied in randomized clinical trials and shown to be effective for many other disorders.²

DBT Uses & Addiction Treatment

While DBT was initially developed to treat BPD, it is now also effectively used to treat a range of mental health conditions, including:

• Substance use disorders (SUD), including comorbid BPD and SUD.^2,3
• Mood disorders like depression, including treatment-resistant depression.^2,3
• Eating disorders like binge eating disorder, anorexia nervosa, or bulimia nervosa.²
• PTSD. ²
• Non-suicidal self-injury.⁴
• Anger.⁴

DBT can be effective for treating addiction/SUDs, both with and without co-morbid BPD, but it has been mainly studied for SUDs in people with BPD.⁵ It can be helpful and effective for treating SUDs in Veterans, although studies have only looked at limited populations and have not yet fully investigated its specific uses or benefits for substance use in Veterans.⁵

The Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs and Practices has listed DBT as one of the evidence-based psychotherapies for reducing drug use, and VA DBT programs are offered at several VA sites across the country.⁴

DBT for alcohol use disorder or other SUDs can help Veterans with addiction by teaching specific skills to help them regulate negative emotions without engaging in dysfunctional coping skills, like substance misuse.³ It can help Veterans learn how to reduce behaviors that interfere with their quality of life and lead to substance use, all while helping them develop healthier coping skills that will allow them to enjoy improved well-being.³

DBT Modules & Goals

DBT typically involves three main components for the person in treatment, including a skills training group, individual psychotherapy, and telephone consultation, but the exact structure can be modified depending on the treatment center.²

In the skills training component, DBT involves 4 modules, including:

• Mindfulness. This component teaches people ways to observe, describe, and participate fully in their day-to-day lives and helps them develop nonjudgmental ways to live in the present moment.² This can help people develop better control over impulsivity and behaviors that can occur due to intense emotions.²
• Interpersonal effectiveness. Veterans and others who enter DBT often present with complex issues, such as trauma, childhood abuse, or neglect.² They may have difficulty trusting others or have unstable relationships due to problems with tolerating conflict. This module helps people develop improved interpersonal skills, such as asking for what they need, becoming more assertive, learning to say “no”, and coping with conflict.²
• Emotional regulation. People who receive DBT often struggle with intense emotions that trigger dysfunctional behaviors.² This module focuses on aiding people in developing control over their emotions by helping them identify their emotions, recognize obstacles to changing their feelings, learn to use mindfulness, learn how to avoid negative situations where they feel more vulnerable, and find ways to increase positive life events.²
• Distress tolerance. This module helps people develop better tolerance for stress and pain by helping them learn to experience and accept their situation without struggling against it, and teaches methods for self-soothing, distracting, and adjusting unhelpful thoughts when they occur.²

In addition to the skills training component, people generally participate in weekly individual psychotherapy sessions that focus on specific target behaviors, and telephone consultation where the person can contact their therapist when necessary for guidance.² VA DBT treatment programs may involve at least 6 months of treatment, with weekly individual therapy sessions, weekly DBT skills group, access to DBT phone coaching, and a weekly consultation with a therapist.^4,6

The main goals of DBT for SUDs are:

• To teach emotional regulation skills that help people avoid unhelpful ways of managing their emotions.³
• To reduce behaviors and obstacles that interfere with the person’s quality of life and that promote drug-seeking behaviors.³
• To help people cultivate more appropriate behaviors that help them function in a healthier and more adaptive way and that help them create a meaningful and worthwhile life.³

DBT Statistics & Success Rates

Studies have found DBT to be effective for treating substance use disorders, but studies have mainly examined those with co-morbid BPD; more research is needed on DBT’s benefits for people without BPD who are struggling with SUDs. One study of people with BPD and polysubstance dependence found that DBT participants, compared to community treatment-as-usual participants, had better treatment retention (64% vs. 27%) and significant reductions in drug use.⁵

Although research is limited and there is not yet conclusive research on the effectiveness of DBT for SUDs in Veterans, it has been shown to be helpful for treating BPD in Veterans. One study of Veterans who received DBT for BPD showed a decrease in the use of mental health services from an average of 92.8 visits in the year before treatment to an average of 48.2 visits in the year after treatment.⁴

Is DBT Covered by the VA or Veteran Benefits?

Yes, DBT should be covered by the VA and VA benefits, but you may need to be enrolled with the VA for certain services, and it can also depend on your needs and situation.⁸

As mentioned earlier, DBT is offered at several VA locations around the country, but not all locations currently offer DBT programs. You can call the VA at 1- 800-827-1000 to inquire about facilities that offer DBT and to ask about your benefits and coverage.⁸

The 2008 Mental Health Parity and Addiction Act requires health insurers to cover services for mental health, behavioral health, and substance use disorders in a way that is comparable to their physical health coverage.⁹ DBT is a mental health treatment that should also be covered, at least in part, by many health insurance plans, including Tricare, Medicaid, and Medicare, providing that your plan offers mental health coverage and depending on the setting and program, but you should inquire with your insurance plan to verify your exact benefits.⁹ You may be able to use other health insurance options alongside VA benefits to cover costs as well.¹⁰