“I’ve been transformed by the very therapy that I developed,” claims Dr. Marsha Linehan, the creator of dialectical behaviour therapy (DBT). This is primarily used for people battling suicidal thoughts and self-harm behaviour but has been proven to be just as eﬀective in treating substance use disorders.
Dr. Linehan deﬁnes addictive behaviour as that which is engaged in repeatedly, occurs very often, is problematic, is ineffective, and has negative outcomes. When the aﬄicted try to stop it, they can’t. Common addictive behaviours include excessive drug use, working, shopping, smoking, sex indulgence, exercising, caﬀeine/alcohol ingestion, texting, gaming, gambling, and shoplifting.
An important method Dr. Linehan teaches patients struggling with mental health and substance use issues is radical acceptance. It is one of DBT’s ‘distress tolerance’ tools, which help patients manage overwhelming emotions. Radical acceptance helps patients stop wishing there had been a different outcome. It encourages them to recognize that events occur as a result of other reasons. Most importantly, it develops healthier and happier relationships.
“Once I realized I had to teach clients acceptance,” Dr. Linehan recalls, “I realized at the very same moment in my own personal life that I had somehow lost my ability to accept. I had to learn it myself.” So she took a sabbatical from her job to go to a Buddhist monastery. Within days, she found exactly what her clients needed. “(The monks) had a way of teaching it that I could translate.” During a two-month stay at Chester Abbey and a separate visit to a Catholic priest in Germany, she had a similar epiphany. The basic message was, “Radically accept everything and let go of desires.”
She realized: “The spiritual part of myself was the core part of myself. Understanding that was an amazing experience. It had a transformative eﬀect on me. It gave me a home. The practice of radical acceptance is what will transform you. But it has to be a regular practice. It doesn’t mean you shouldn’t try to change things. You only have to radically accept the moment you’re in, and the past (because you can’t change both). But you can try to change the next moment. You can’t change anything if you don’t accept it, because if you don’t, you’ll try to change something else that you think is reality.” Dr. Linehan’s aha moment formed the basis of DBT. She now uses it, not just to prevent people from killing themselves, but also to help a lot of people with drug abuse problems heal and reclaim their lives.
Accepting reality by exploring emotions
DBT supplements creative arts therapy. Also known as expressive therapy, this has various branches, the most popular of which are music, art, and dance. This method provides the tools necessary to break addictions, like learning how to respond to negative stimuli, emotions, and life situations.
Creative arts therapy is also a relaxation and ‘happiness’ tool. Used in both individual and group counselling, it improves the patient’s physical, mental, and emotional well-being. It helps patients get in touch with their inner selves. It reduces anger, stress, depression, and irritability.
Recreational activities and the creative process make both positive (calming) and negative (triggers hidden memories) changes to the brain. They are beneficial to those who have difficulty expressing feelings or thoughts in words.
Why is expressive therapy effective?
Creative arts therapy, in combination with behavioural therapies like DBT, has proven to be successful in addiction treatment and drug rehab partly because of its enjoyable nature. People tend to stick to regimens when they’re having fun. Even those who don’t consider themselves talented like to express themselves creatively. Some people who have difficulty expressing themselves ﬁnd that they can do so through creative pursuits. Using expressive arts – art, music, and dance – self-conscious patients shed their inhibitions, enabling them to explore feelings and thoughts, which help them deal with substance use or mental health issues.
Expressive therapy is secular, which appeals to those who don’t respond well to religious or philosophical dogma. That’s why it works for a lot of addicts who haven’t been helped by 12 Step programs, which have a religious element to them. Art, music, and dance are inclusive. They work across beliefs and philosophies.
Instruments of change
Art, dance and music therapy can be used as coping mechanisms and mindfulness tools. The visual arts help elicit unpleasant or uncomfortable emotions and bring them to the surface, often without the patient being aware. This externalization of negativity can be therapeutic because the ‘bad feelings’ can be left on something tangible, like canvas, cloth, paper, or a digital platform. The artist-patients can decide whether to keep the artwork or throw it away as a method of internal cleansing. Some works of art can even reveal the triggers to, or identify the origin, of the addiction.
The visual arts don’t just include the obvious (drawing, sketching, painting), but also creating sculptures or collages, scrapbooking, gardening, and working with mixed media.
Digital media production involves creating a piece of art using computer-aided design, such as ﬁlm and video production (vlogging), animation, digital photography, digital imaging manipulation, creating apps, and developing virtual reality software and environments.
The pursuit of crafts oﬀers avenues for expression too, such as papier mâché, needlepoint, crocheting, knitting, and cross-stitching. These traditional approaches are recommended for their stress-reducing qualities. Use of art that soothes or disciplines the hyperactive brain includes pottery, using a zen garden, building structures with Lego, or molding images with Play-Doh.
Visual art therapy includes lesser-known modalities like doll building, road drawing, and altering publications. Doll building involves decorating a blank dummy. Road drawing allows patients to relate their lives—or how they see themselves—to what they draw or paint. Book alteration involves changing the manner in how the work is presented. A printed book’s format can be changed to an ebook or an audio ﬁle, for example. Art therapists observe how the resulting dolls, roads, and altered books relate to patients’ addictions. And let’s not forget the literary arts: creative writing, blogging, poetry, journalling.
Music uniﬁes people across ethnicities, cultures, language, religion, sexual orientation, and race. Not just a medium of expression, it’s also a source of inspiration. The creation of music or simply, appreciation of it, helps tremendously in addiction recovery. Incorporating music in therapy oﬀers a productive way of managing cravings by presenting an outlet for expression of both negative and positive emotions and thoughts.
There have been instances when particular songs have brought back patients who had been catatonic for many years. It may be a musical genre or popular song reminiscent of “the good times”, or a piece that holds special meaning, like a song played during their wedding.
A song can act as a trigger to reliving a painful memory too. Though unpleasant, music therapists sanction this to compel patients to deal with, and eventually heal from, a traumatic experience. Lyrics can help previously reluctant patients get in touch with their feelings and prime them to share.
Music therapy involves interventions, such as relaxation training, singing, listening to music, writing songs, creating sound, playing games and instruments, music improvisation, and staging presentations incorporating music. Patients engage their emotions through sounds and words. These can be done socially or in solitary. Music therapy cultivates connections to encourage change.
This type of therapy comes in two modes: active (creating) and passive (listening). Regardless of method, it regulates heart rates and is beneficial to overall health. One doesn’t need to have a wonderful voice or the ability to play an instrument. Music appreciation and creation can be participated in by anyone. Those uncomfortable showcasing their talents can join activities like drum circles, songwriting, and analyses of lyrics and themes. Professional musicians and DJs who have lost their mojo can go back to practising their craft through music therapy.
Music therapy is particularly beneficial to adolescents, young people, and older adults suffering from cognitive decline, such as Alzheimer’s disease. Mellow music is used to relax. Faster beats are handy for improving concentration. Drumming is helpful for dealing with pain or trauma.
As it helps with preventing relapse, treatment centres and medical facilities include music therapy in their treatment programs. Patients discuss particular songs or pieces that aﬀect or inﬂuence them. If a song changed their lives, how did it make them feel? What was it about the song that made them react?
Dance/movement therapy (DMT) is a movement-based treatment for substance use disorders. The American Dance Therapy Association deﬁnes DMT as “the psychotherapeutic movement used to integrate emotional, cognitive, and physical aspects of a person.” Its focus is on movement behaviour in a therapeutic relationship. Expressive movements are either choreographed (done in an established style like salsa) or freestyle (improvised). They are done with music or without. They may be conscious or unconscious.
DMT is sometimes referred to as a ‘dance to recovery’ when used to treat addiction. This is because patients are taught to experience body sensations (like cravings) while managing upsetting emotions.
DM therapists observe patient motion to identify strengths and weaknesses. They ‘listen’ to the body to determine patient needs. They teach their dancers to obtain information from their bodies and thoughts, and use these to make better-informed decisions to improve their lives. Patients learn to accept current memories, like in DBT. They acknowledge that they cannot change the past, but can either change how they respond to the present or learn new responses.
Marian Chace is known as one of the founders of dance therapy , but Carl Jung ﬁrst promoted the idea of dance in psychotherapy as early as 1916. Chace went on to become the ﬁrst president of the American Dance Therapy Association (ADTA). Founded in 1966, ADTA advocates the expansion of dance therapy. In 1993, the National Institutes of Health’s National Center for Complementary and Alternative Medicine funded ADTA to include dance therapy in the treatment of medical illnesses.
A related branch of DMT is somatic psychology, which examines the body in the present. Psychologists look for unconscious motion called ‘movement tags’, which reveal triggers of a particular experience.
What does DMT entail?
Patients form a circle, then the practitioner guides them with warm-up movements set to music. Participants share this experience with each other in a discussion. The therapist examines and emulates the movements of each participant. This is the equivalent of a counsellor listening and providing feedback during a regular session.
The body-based modality is beneficial in ﬁnding the root of substance use problems because it manifests itself in feelings and sensations—as opposed to verbal expression. Through DMT, patients discover what happens to their bodies when they are upset: shortness of breath, shakiness, dizziness, for example. Therapists teach them how to identify, stop, or slow these down before they become unmanageable.
In 2014, Koch et al responded to the challenge of providing evidence that DMT works by publishing their meta-analysis study in The Arts in Psychotherapy . The study revealed that DMT has “useful, positive impacts on quality of life, depression, anxiety, well-being, mood, aﬀect, and body image.”
Elements of art-based therapies
The interactive aspect in expressive therapy presents opportunities to relate with fellow addicts in life-aﬃrming ways, in addition to reconnecting with oneself. This promotes overall social health. The group aspect in expressive therapy diminishes the shame and stigma that comes with addiction. Patients are comforted knowing there are others going through the same experience.
Substance abuse can wreak havoc, not just on users’ brain chemistry, but also on emotions. Many people who lose themselves during their alcohol or drug use discover that they can ﬁnd their way back through creative pursuits.
Benefits of expressive therapy
- Life realization—encourages reﬂection, self-awareness and personal growth
- Responsible exploration of negative and positive emotions
- Visualization of the recovery process and lifestyle change
- Positive changes to brain chemistry
- Provision of a medium for hard-to-express thoughts and emotions
- Resolution of hidden trauma
- Externalization and processing of internal conﬂict, repressed feelings, and buried concerns
- Opens the lines of discussion, especially taboo topics
- Boosts conﬁdence and builds positive self-esteem
- Increases levels of ‘happy hormones’, thereby improving mood and behaviour
- Helps patients get in touch with inner selves
- Regulates cardiac functions
- Decreases anxiety, stress, anger, and depression
- Improves physiological functioning
- Hastens recovery and promotes overall wellness
- Resolves denial dilemmas
- Eliminates resistance to treatment
- Encourages communication and builds social skills
- Reduces guilt and shame
- A great motivational tool
- Assists with maintaining lasting sobriety
- Promotes emotional, visual, and internal connection with one’s life path
- Gives a sense of belonging and combats loneliness, especially for the isolated
- Helps patients deal with heartbreak, grief, loss, separation anxiety, and related forms of emotional conflict
- Music, dance and art therapy can all be continued in the form of enriching hobbies when the formal treatment program has come to an end
- Declutters one’s psyche
- Sifts through emotional baggage
- Tames unruly thoughts
- Promotes creativity
- Explores one’s uniqueness
- Diminishes self-doubt
- Fosters empowerment and compassion
- Improves problem-solving capabilities
- Reinforces positive interconnection between mind and body
- Identifies negative themes that repeat themselves
- Reﬂects patients’ unconscious personas
CBT: DBT’s origin
DBT, a modified form of cognitive behavioural therapy (CBT), oﬀers a multi-level approach in treating mental illness and substance abuse disorders. Its goal is to build conﬁdence and provide coping skills to handle stressors. It uses mindfulness techniques to reduce a person’s negative thoughts and behaviour. It is used to treat borderline personality disorder (BPD), depression, eating disorders, suicidal ideation, and substance use disorders (SUDs).
CBT identifies behaviour patterns that lead to destructive actions and thoughts, then recommends alternative ways of thinking to regulate negative emotions and prevent dangerous behaviour.
Dr. Linehan developed DBT in the 1970s after she had used CBT to treat suicidal women. She found that CBT wasn’t always eﬀective due to its focus on rejecting distressing thoughts. So she combined the mindfulness techniques of acceptance and CBT’s change modalities to create DBT. Negative thoughts are now accepted. Patients learn to balance acceptance and change to resolve problems.
DBT has been modified to address SUDs. Called DBT-SUD, it reduces drug use in those with BPDs. Patients struggling with BPD harbour a distorted view of themselves, have unstable relationships, and engage in impulsive behaviour.
DBT involves four components: individual psychotherapy, group skills training, phone coaching, and ongoing support from therapists. It incorporates these modules:
- Distress tolerance: teaches people to make appropriate decisions in challenging moments. Patients learn crisis survival skills.
- Interpersonal eﬀectiveness: patients learn eﬀective ways of dealing with others and handling difficult situations.
- Emotional regulation: patients learn to control emotions to manage psychological pain.
- Mindfulness: a mental state of awareness and acceptance of the present environment, including thought and emotion, without judgement. Patients learn to control thought and behaviour, so these won’t rule their lives. Mindfulness, used with experiential movement like DMT, helps manage uncomfortable sensations. It explores correlations between feelings and actions, such as cravings leading to substance abuse. As patients go through the expressive process, they become more open to the creative kind. This increases self-knowledge, which prepares them for recovery.
What are IOPs?
CBT, DBT, and therapies involving the creative arts are usually included in intensive outpatient programs (IOPs). These treat BPDs, bipolar disorders, depression, suicidal ideation, and substance use disorders not dependent on detox. The main treatment format is group therapy, but outpatient clinics also oﬀer individual or family therapy.
Patients can continue studying or working while on IOPs. Typical IOP duration is six to 30 hours a week. IOPs are said to be more eﬀective than individual therapy for SUDs.
The cost of IOP treatment ranges from $250 to $350 a day. More intensive modalities are more expensive. Detoxes and inpatient rehabs range from $500 to $650 a day. Partial hospitalization programs cost $350 to $450 a day.
Whatever type of treatment you choose: a recreational therapy such as art, dance or music therapy, or a behaviour-based therapy like CBT, it’s important to ﬁnd one best suited to your needs. If unsure, the ﬁrst step is to have an addiction expert or psychiatrist evaluate your case.
 “Marian Chace: Dancer & Pioneer Dance Therapist”. American Dance Therapy Association. 2014.
 Koch, Kunz, Lykou, and Cruz. “The Eﬀects of Dance Movement Therapy and Dance on Health-Related Psychological Outcomes: A Meta-Analysis”. The Arts in Psychotherapy, 41(1), 46-64. 2014.
American Music Therapy Association
“Substance Abuse: Clinical Issues in Intensive Outpatient Treatment”. Substance Abuse and Mental Health Services Administration. 2006.
Hohmann L, Bradt J, Stegemann T, Koelsch S. “Eﬀects of music therapy and music-based interventions in the treatment of substance use disorders: a systematic review”. 2017.
Photo credit: Scott Robinson. This picture has a Creative Commons attribution license.