DBT vs ACT in Addiction Treatment: A Comparative Analysis

Introduction

Addiction is a complex disease that requires extensive treatment. Without correctly understanding the impact of addiction on the individual and society, we cannot fully grasp the importance of treating it. Social workers play a critical role in assisting those battling addiction, and having a thorough understanding of available treatment options helps them employ tried and tested methods for supporting their clients.

Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT) are theories associated with mindfulness and acceptance that emphasize understanding behaviors as acts in context. DBT and ACT are both effective in treating addiction, though they do so differently (Amirian et al., 2018). Addiction is a problem faced by numerous individuals across the United States, and uncovering the best strategies for treatment is essential for those working to assist people impacted by it. DBT is a type of cognitive-behavioral therapy focusing on the psychosocial aspects of treatment (Cavicchioli et al., 2020), emphasizing the importance of collaborative relationships, skills development, and client support. ACT, by contrast, aims to assist clients in accepting what they cannot control (De Alarcón et al., 2019).

When looking at how to help clients overcome their addiction, clinicians should consider strategies with demonstrated impact. Considering the number of families separated due to addiction, better approaches to this challenge are needed. Comparing the two theories and how they are used in addiction treatment expands the available knowledge base and enables social workers to make more informed decisions about care.

Dialectical Behavior Therapy (DBT)

DBT is a type of cognitive-behavioral therapy focusing on the psychosocial aspects of treatment (Cavicchioli et al., 2020). It aims to teach the client how to live in the moment, regulate their emotions, develop healthy ways of coping with stress, and improve their relationships with others. Cognitive-behavioral therapy identifies and modifies negative thinking patterns and encourages positive behavioral changes. Originally developed for the treatment of borderline personality disorder, DBT has since been found effective in treating depression, substance abuse, bulimia, bipolar disorder, binge eating, and post-traumatic stress disorder.

According to DeCou et al. (2019), DBT focuses on delivering therapeutic skills in four areas: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Mindfulness concentrates on improving the client's ability to accept and stay present in the current moment. It assists the client in paying attention to what is happening internally and using their senses to tune in to what is happening around them in a nonjudgmental manner. Using mindfulness techniques, the client can slow down and focus on healthy coping skills when in the midst of emotional pain, helping them stay calm and avoid engaging in automatic negative thoughts and impulsive behavior.

Distress tolerance focuses on increasing the client's tolerance of negative emotions rather than trying to escape from them (Veilleux, 2019). It helps the client accept themselves and their current situation. Clients learn techniques for handling a crisis, such as distraction, improving the moment, self-soothing, and weighing the pros and cons of not tolerating distress. Distress tolerance prepares the client for intense emotions and empowers them to cope using a positive long-term outlook.

Emotion regulation focuses on strategies for managing and changing intense emotions that are causing problems in the client's life. The client learns how to navigate powerful feelings effectively — identifying, naming, and modifying their emotions. When clients can recognize and cope with intense negative emotions, they reduce their emotional vulnerability and create space for more positive emotional experiences. Interpersonal effectiveness covers techniques that allow the client to communicate assertively with others, strengthening relationships and maintaining self-respect (DeCou et al., 2019).

With a focus on helping the client move past destructive, out-of-control behaviors like addiction and toward envisioning and articulating their goals, DBT empowers clients to pursue and sustain the goals they set for themselves. In DBT, the client works together with the therapist to set goals that are personally meaningful (DeCou et al., 2019). The client learns coping skills and strategies for decreasing harmful behaviors, substituting destructive behaviors with effective, life-enhancing ones. Importantly, DBT does not focus on abstinence from substances per se; rather, it focuses on building a life free from the destructive behaviors that accompany substance abuse.

DBT's influence stems from the philosophical perspective of dialectics — bringing two opposites together. Acceptance and change are the two opposites reconciled within DBT, and using both together yields better results than using either alone. DBT employs a multistage approach to help clients overcome addiction. The first stage addresses the most self-destructive behavior, such as substance abuse, with the priority being to decrease or cease substance use that could lead to physical harm or death. The second stage addresses quality-of-life skills such as distress tolerance, emotional regulation, and interpersonal effectiveness, with the goal of reducing behaviors that could interfere with therapy. In addiction treatment, the therapist works to reduce the client's physical discomfort from withdrawal to ensure they remain present in therapy sessions. The third stage concentrates on improving relationships and self-esteem, while the final stage promotes greater joy and relational connection. For the client to build a better life, they need healthier relationships and the readiness to face life's challenges (Moghadam et al., 2020).

DBT can be delivered in different settings, most commonly group therapy, individual therapy, and phone coaching. In group therapy, patients are placed in a group setting and taught behavioral skills. Individual therapy involves learning behavioral skills one-on-one with a therapist, with the skills adapted to the client's specific life challenges. Phone coaching allows patients to contact the therapist between sessions for coping guidance. It should be noted that DBT is most effective as part of a broader treatment plan, as there is no conclusive evidence that it is sufficient as a stand-alone intervention for substance abuse disorder.

Acceptance and Commitment Therapy (ACT)

Acceptance and Commitment Therapy (ACT) is a psychotherapy technique used for a wide range of applications. As a form of cognitive-behavioral method, it is used primarily to treat substance abuse disorders (Arjmand Ghujur et al., 2019). ACT is a mindfulness-based therapy framework that emphasizes acceptance, mindfulness, and personal values. It is an action-oriented approach rooted in traditional cognitive-behavioral therapy (CBT) and behavior therapy. As an empirically based psychological intervention, ACT uses mindfulness and acceptance strategies alongside commitment and behavior-change strategies to increase psychological flexibility — that is, the ability to contact the present moment fully as a conscious human being (Arjmand Ghujur et al., 2019).

Through ACT, clients learn how to stop avoiding, struggling with, and denying their inner emotions. Instead, they come to accept that their deeper feelings are appropriate responses to certain situations and need not prevent them from moving forward. Based on this understanding, clients begin accepting the hardships they face and commit to making behavioral changes regardless of what is happening in their lives. ACT is similar to DBT in that both teach the value of mindfulness meditation and Eastern meditative practices. However, ACT places a greater emphasis on cognitive defusion. In times of distress, a person may become fused with their feelings and thoughts, inflating the importance of their emotions rather than objectively recognizing that they may be overreacting. In many cases, people begin believing these feelings and thoughts, mistaking them for facts about themselves and the world.

ACT teaches the client to notice and acknowledge these feelings and thoughts as having no inherent importance beyond what they have subjectively assigned to them (Osaji et al., 2020). This strategy can be effective when a client is overwhelmed by feelings of distress and inadequacy that push them toward alcohol or drug use. By remaining objective rather than emotionally reactive, clients become better equipped to manage their responses to distress. ACT is built on six core principles:

Acceptance focuses on eliminating denial. A client will remain entangled in the same emotionally or physically grinding problems if they do not accept their reality. Denial perpetuates self-destructive behaviors as the client attempts to cope with underlying issues. People often go through life avoiding anything that induces suffering without understanding that pain is an inherent part of human experience. When one welcomes pain rather than fleeing from it, they acknowledge the current situation and make space for the full range of thoughts and emotions. Because addiction frequently stems from the urge to avoid discomfort (Osaji et al., 2020), acceptance encourages the client to consciously practice letting go of that impulse and replacing it with compassion. A person must accept their circumstances before they can find ways of changing them — or adjust themselves to cope with what cannot be changed.

Defusion trains the client to detach their behaviors, ego, and identity from their thoughts so they can view things objectively. Thinking about getting high does not make a person an addict; acting upon the thought is what creates harm. Defusion therefore aims to give the client control and power over the impulses manifesting in conscious thought and desires. The client learns they have the power to act or not act on their thoughts. Defusion emphasizes that thoughts do not represent reality or facts, allowing the client to reframe their thoughts and avoid identifying with negative ones. Some techniques used in defusion include observing a thought without judgment, labeling automatic responses, and singing the thought aloud to reduce its emotional charge.

Presence is similar to the mindfulness teachings found in mindfulness meditation. The client learns to be present in the moment rather than dwelling on the past or anticipating the future. Staying in the present restores mental balance and harmony. When working with addiction clients, it is vital to approach rehabilitation on a moment-to-moment basis. Clients often use drugs and alcohol to escape their present moment, and helping them understand that the past is gone and the future is uncertain returns their focus to the now. Being present involves observing current thoughts and feelings without judgment rather than trying to forcibly suppress them. Encouraging clients to remain present helps prevent relapse, reduces the power of cravings to dictate behavior, and supports their ability to sustain sobriety as their body adjusts.

Self-awareness focuses on the principle that when a person is more self-aware, they are less likely to operate on autopilot and engage in impulsive and self-destructive behavior (Ahmad & Nurwianti, 2020). Self-aware individuals maintain greater control over themselves and their actions. Individuals struggling with addiction are often lacking in self-awareness, which contributes to their self-destructive patterns. With self-awareness, an addict is more likely to recognize and resist cravings when they emerge, and to understand that there is more to life than substances and short-term gratification.

Value identification builds the client's new foundation for living. Our lives may be controlled or invaded by others' values or societal norms, causing us to live inauthentically and feel disempowered. Value identification offers a way to circumvent external pressure. It allows the client to clarify their personal truths and then pursue them. Rather than worrying about what others think, the client is encouraged to focus on what they genuinely want from their life. This shift enables the client to move away from destructive behaviors that undermine recovery and toward a life aligned with their own values.

Commitment to action represents the application of everything the client has learned during their ACT sessions (Ahmad & Nurwianti, 2020). At this stage, the client implements what they have been taught and begins modifying their belief system. They commit to ending their alcohol and drug addiction and building a sober life. The goal is for the client to take concrete steps that align with their values and lead to positive change. Negative feelings and thoughts will still arise, and the client must understand these are part of the process; with time, they will learn to manage them. Commitment to action reflects the client's willingness to make healthy life modifications in pursuit of lasting sobriety.

References

Ahmad, S. F., & Nurwianti, F. (2020). Using Acceptance and Commitment Therapy (ACT) in a group setting to increase quality of life in university students with social media addictions. 3rd International Conference on Intervention and Applied Psychology (ICIAP 2019) and the 4th Universitas Indonesia Psychology Symposium for Undergraduate Research (UIPSUR 2019).

Amirian, K., Mami, S., Ahmadi, V., & Mohammadzadeh, J. (2018). Comparison of the efficacy of Acceptance and Commitment Therapy (ACT) and Dialectical Behavior Therapy (DBT) on impulsivity in addicted people.

Arjmand Ghujur, K., Mahmoud Aliloo, M., Khanjani, Z., & Bakhshipour, A. (2019). Effectiveness of acceptance and commitment therapy (ACT) in relapse prevention in methamphetamine addict patients. Yafteh, 21(1), 38–51.

Berzoff, J., Flanagan, L. M., & Hertz, P. (2021). Inside out and outside in: Psychodynamic clinical theory and psychopathology in contemporary multicultural contexts (5th ed.). Rowman & Littlefield.

Cavicchioli, M., Ramella, P., Vassena, G., Simone, G., Prudenziati, F., Sirtori, F., Movalli, M., & Maffei, C. (2020). Dialectical behaviour therapy skills training for the treatment of addictive behaviours among individuals with alcohol use disorder: The effect of emotion regulation and experiential avoidance. The American Journal of Drug and Alcohol Abuse, 46(3), 368–384.

De Alarcón, R., de la Iglesia, J. I., Casado, N. M., & Montejo, A. L. (2019). Online porn addiction: What we know and what we don't — A systematic review. Journal of Clinical Medicine, 8(1), 91.

DeCou, C. R., Comtois, K. A., & Landes, S. J. (2019). Dialectical behavior therapy is effective for the treatment of suicidal behavior: A meta-analysis. Behavior Therapy, 50(1), 60–72. https://doi.org/10.1016/j.beth.2018.03.009

Gross, Y. (2020). Erikson's stages of psychosocial development. The Wiley Encyclopedia of Personality and Individual Differences: Models and Theories, 179–184.

Moghadam, M., Makvandi, B., Bakhtiyar Pour, S., Ehteshamzadeh, P., & Naderi, F. (2020). A comparison of the effectiveness of Dialectical Behavior Therapy (DBT) and mindfulness training in improving sleep quality and reducing distress tolerance in drug-addicted treatment seekers. Journal of Health Management & Information Science, 7(1), 33–41.

Nagel, E. (2020). Methodological issues in psychoanalytic theory. In Psychoanalysis, scientific method, and philosophy (pp. 38–56). Routledge.

Osaji, J., Ojimba, C., & Ahmed, S. (2020). The use of acceptance and commitment therapy in substance use disorders: A review of literature. Journal of Clinical Medicine Research, 12(10), 629. https://doi.org/10.14740/jocmr4311

Stilwell, P., & Harman, K. (2019). An enactive approach to pain: Beyond the biopsychosocial model. Phenomenology and the Cognitive Sciences, 18(4), 637–665. https://doi.org/10.1007/s11097-019-09624-7

Veilleux, J. C. (2019). The relationship between distress tolerance and cigarette smoking: A systematic review and synthesis. Clinical Psychology Review, 71, 78–89. https://doi.org/10.1016/j.cpr.2019.01.003