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. Author manuscript; available in PMC: 2024 Jun 16.
Published in final edited form as: Subst Use Misuse. 2023 Jun 16;58(11):1409–1417. doi: 10.1080/10826084.2023.2223283

Dialectical Behavior Therapy Skills and Urges to Use Alcohol and Substances: An Examination of Diary Cards

Matison W McCool 1, Kirk D Mochrie 2, John E Lothes 3,4, Eric Guendner 3,4, Jane St John 4, Nora E Noel 3
PMCID: PMC11172370  NIHMSID: NIHMS1992970  PMID: 37328431

Abstract

Skills learned in Dialectical Behavior Therapy (DBT) are a proposed mechanism that prompts behavior change. Few studies have examined the effects of DBT skills on treatment outcomes. No published studies have examined the effects of DBT skills on alcohol and substance use outcomes. This study examined 48 individuals in a community mental health facility that delivers DBT-adherent treatment. Utilizing intake data and diary cards, multilevel model analyses were conducted to examine the effects each DBT skills domain had on urges for participants that entered treatment with varying frequencies of alcohol and substance use. Emotion regulation and mindfulness skills domains were related to decreased urges for individuals that entered treatment with high frequencies of alcohol and substance use. Previous-day distress tolerance skills were associated with decreased urges and previous-day interpersonal effectiveness skills were associated with decreased urges for individuals that entered treatment with high frequencies of substance use. DBT skills may be a helpful mechanism to decrease urges for individuals that use alcohol and other substances. However, more research on why certain skills domains may be more effective is needed.

Keywords: Dialectical Behavior Therapy, Mechanism of Behavior Change, Urges

Introduction

Dialectical Behavior Therapy (DBT) was designed for high-risk patients at risk for suicide or non-suicidal self-injury (NSSI), which may result in death by accident. Initially, it showed efficacy for individuals with borderline personality disorder (BPD; Linehan, 1993). The process of doing DBT is an intensive outpatient treatment for individuals. Doing effective DBT requires that the therapist and patient engage in multiple components going beyond just individual therapy. Comprehensive DBT includes group skills training, telephone coaching, and the therapist being part of a consultation team (Linehan & Wilks, 2015) in addition to individual therapy. Standard (comprehensive) DBT programs effectively target and reduce symptoms of emotion dysregulation and NSSI behaviors commonly associated with BPD (Neacsiu et al., 2014). Over time, DBT has been implemented to treat various disorders, including substance use disorders (SUDs; Linehan et al., 1999, Linehan et al., 2002, Axelrod et al., 2011).

As DBT began showing efficacy with some of the highest risk patients, those with BPD, other researchers started to use and research DBT with different populations and found that DBT can be effective in treating individuals with a multitude of disorders (e.g., eating disorders - Linehan and Chen, 2005; Depression - Lynch et al., (2003); PTSD - Harned, Wilks, Schmidt, & Coyle, 2018; with adolescents - Rathus & Miller, 2014; and with high conflict couples - Fruzzetti, 2012). Panos and colleagues conducted a meta-analysis that indicated preliminary evidence to suggest the effectiveness of DBT-informed treatments for various mental health disorders (Panos, Jackson, Hasan, & Panos, 2014).

Interestingly, DBT focuses on treating ineffective “problem” behaviors instead of focusing on a specific diagnosis for treatment, which is likely why DBT is efficacious with multiple diagnoses. One of the components of DBT that may help its efficacy with so many different diagnoses is that it is philosophically built upon the dialectic of acceptance and change. That patients (and therapists) need to accept the situation as it is and work to either change the situation (through some form of behavioral change) or change how they think or feel about the situation (through some form of cognitive change) (Linehan, 1993, Swenson, 2016).

Researchers have begun to examine DBT adaptations in various patient populations. DeCou et al.’s (2019), meta-analysis found promising evidence to suggest the efficacy of DBT for various mental health disorders in a myriad of settings. For example, DBT-informed treatment effectively reduced anxiety and depressive symptoms (Lothes et al., 2014) in a Partial Hospital (PH) setting with a heterogeneous sample. Mochrie et al. (2020) found that DBT helps in depressive and anxiety symptom reduction in individuals attending PH and intensive outpatient programs (IOPs).

DBT adherence can be successful in other therapeutic modalities (Swenson, 2016), with the key features being that the modes and functions of DBT are met. DBT adherent programs should include: DBT skills training, individual DBT psychotherapy, in-the-moment skills coaching, case management, and weekly DBT therapist treatment team meetings. Through these five modes of DBT, the program aims to improve patient motivation, generalize skills to patient’s behaviors, structure the environment, and enhance therapist capabilities and support motivation.

DBT in Partial Hospital and Intensive Outpatient Settings

In terms of PH programs, there is some preliminary evidence that DBT can be an effective treatment when utilized in this setting, specifically for individuals with BPD (Lenz & Del Conte, 2018). Moreover, Lothes et al. (2014) found that implementing DBT in a PH setting reduced symptoms of depression, anxiety, hopelessness, and suffering.

PH programs are often seen as a bridge between traditional (weekly) outpatient therapy and inpatient stays and are usually short, with many patients needing further treatment after discharge. Lothes et al. (2016) examined various symptoms in relation to treatment duration among 113 adults with mixed-diagnosis and found they spent an average of 23 days in the program. Lothes et al. (2021) found that the average length of stay was 26.68 (27 days) in data over five years of patients attending a PH program.

Findings from Lothes and colleagues (2016) showed that patients with a higher level of symptom acuity at intake, in combination with those who were able to attend the program for a longer duration, achieved more significant reductions in various clinical symptoms (e.g., depression, anxiety, hopelessness) from intake to discharge. Mochrie and colleagues (2020) found that individuals who opted to attend PH and IOP as stand-alone care had shorter treatment duration than those who started in a PH program and stepped down to IOP. Patients drove their care decisions based on symptom reduction and through a dialogue with their providers (therapist and/or prescriber) throughout treatment. These findings suggest that DBT can be effectively adapted for different treatment settings such as IOP and PH programs. However, there remains a lack of research in this area, particularly among patients with SUDs.

DBT for Individuals with a SUD

Foundational research on DBT for individuals with a SUD centers on randomized controlled trials (Linehan et al., 2002; Linehan et al., 1999). In these trials, DBT was more effective than treatment as usual for individuals with co-occurring BPD and SUD (Linehan et al., 1999). Additionally, compared to other treatment modalities, DBT is more efficacious for individuals with opioid use disorder (Linehan, 2002). There is also literature supporting the use of DBT within intensive outpatient programs to treat SUDs. Specifically, DBT appears to treat symptoms of emotion dysregulation that affect substance use behaviors (Axelrod et al., 2011; Maffei et al., 2018). However, few studies examined the effects of DBT on individuals with Alcohol Use Disorder (AUD).

Cavicchioli et al. (2019) found that stand-alone DBT skills training is associated with decreases in substance use behaviors, increases in emotion regulation, and increases in coping strategies for individuals in treatment for AUD and other co-occurring SUDs. Additional studies by Cavicchioli and colleagues (2020a; 2020b) continue to provide evidence for using stand-alone DBT skills training in treating individuals with AUD. While these studies utilized a global measure of DBT skills use, there are limited studies to date that examine the use of DBT skills in patients’ daily lives in relation to substance use urges and behaviors.

Mechanisms of Behavior Change in DBT

A mechanism of behavior change is behavior that a patient utilizes to promote later change in treatment goals (Magill et al., 2015). Lynch and colleagues (2006) proposed that DBT has unique mechanisms of behavior change. Amongst these mechanisms are the skills domains utilized in DBT skills training. These domains include emotion regulation, distress tolerance, interpersonal effectiveness, and mindfulness skills. The unique skills that Linehan (1993) identified targeted areas of skill deficits among individuals with BPD. As the biosocial theory postulates, individuals with BPD may utilize behaviors (NSSI, suicidal behavior, substance use, etc.) to decrease the intensity of unwanted emotional states (Linehan, 1993). Thus, DBT aims to teach individuals additional coping skills that can replace ineffective problem behaviors to regulate their emotions.

While the skills learned in DBT are proposed mechanisms of behavior change, few studies have examined their effects as mediators to date. Neacsiu et al. (2010) found that increased DBT skills use mediated the relationship between time in treatment and suicide attempts, control of anger, and NSSI. Additionally, increases in DBT skills use are associated with decreased substance use behaviors for individuals in treatment for AUD (Cavicchioli et al., 2019). While these studies are critical in providing evidence that skills use changes behavior, they do not offer insight into DBT skills use at shorter time intervals.

Stepp and colleagues (2008) examined DBT daily diary cards and found that increased DBT skills use was associated with decreased BPD symptom severity. Additionally, Probst et al. (2018) examined DBT diary cards and found that on days individuals successfully utilized DBT skills, their suicidal ideation tended to be lower. The research focused on DBT skills use daily, and weekly intervals primarily focused on BPD symptoms (suicidal ideation, NSSI). To date, no studies have utilized DBT diary cards to examine the effects of DBT skills on urges to use alcohol and other substances.

Thus, the current study examined the weekly use of DBT skills on urges amongst individuals in a community mental health program with varying frequencies of self-reported alcohol and substance use. Utilizing the skills deficit model framework in DBT, each unique skills domain could significantly predict decreases in urges. For example, one purpose of distress tolerance (DT) skills is to survive crises without making things worse. Emotion regulation (ER) skills aim to reduce unwanted emotions linked to drinking behaviors and increase positive emotions (Koerner, 2012). Mindfulness skills may help individuals learn to notice urges and implement other strategies, and interpersonal effectiveness (IE) skills may help patients engage in effective drink/drug refusal skills. Therefore, we hypothesized that each skills domain would have a negative relationship for urges and that this relationship would be most substantial for individuals who entered treatment with a high frequency of alcohol or substance use. Additionally, to support a more causal relationship through temporal precedence (Cole & Maxwell, 2003), we also examined the effects of previous-day DBT skills domains on urges to use. In all, we examined eight total models; one for each skills domain on the same day and one for each skills domain on the previous-day.

Materials and Methods

Participants

Participants included 48 individuals from a community clinic’s DBT PH program in the southeastern United States. The sample was predominately white (N = 42; Black N = 3; Puerto Rican N = 1, Asian N = 1, Biracial N =1) females (N= 38), that worked blue collar jobs (N = 20). Participants primary and secondary diagnosis (if present) mostly consisted of major depressive disorder (N = 31 and N = 5, respectively). Approximately 18% of the sample was formally diagnosed with AUD, and 17% were officially diagnosed with a SUD at intake into treatment. For a breakdown of demographic characteristics, including primary and secondary diagnoses, please see Table 1.

Table 1.

Demographic Charactersitics

Baseline Characteristic n %
   Subgroup
Gender
    Female 38 79%
    Male 7 15%
    Trans-Female 2 4%
    Trans-Male 1 2%
Occupation
    Unemployed 14 29%
    Blue Collar 20 42%
    Grey Collar 13 27%
    White Collar 1 2%
Primary Diagnosis
    Major Depressive Disorder 31 65%
    Alcohol Use Disorder 4 8%
    Bi-Polar Disorder 7 15%
    Substance Use Disorder 1 2%
    Generalized Anxiety Disorder 1 2%
    Posttraumatic Stress Disorder 3 6%
    Schizoaffective Disorder 1 2%
Secondary Diagnosis
    None 16 33%
    Major Depressive Disorder 5 10.5%
    Borderline Personality Disorder 4 8.33%
    Alcohol Use Disorder 4 8.33%
    Bi-polar Disorder 1 2%
    Panic Disorder 1 2%
    Substance Use Disorder 4 8.33%
    Generalized Anxiety Disorder 3 6.5%
    Posttraumatic Stress Disorder 10 21%
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Note: One individual carried a third diagnosis of an AUD and two individuals carried a third diagnosis of a SUD.

Materials

Baseline Alcohol and Substance Use

To decrease patient and clinician burden of the research paperwork at the community clinic, alcohol frequency was coded from the initial patient intake into the treatment. Research assistants coded alcohol use on a 0 to 7 scale (0- no lifetime use, 1- use in lifetime, 2- one to two times every three months, 3- once per month, 4- once every two weeks, 5- once per week, 6- two to four times per week, 7- almost every day). Overall, six participants endorsed drinking nearly every day during intake.

Baseline substance use was calculated in the same manner as baseline alcohol use. During intake, participants answered questions related to their frequency of cannabis, cocaine, opioid, and amphetamine use on a 0 to 7 scale (0- no lifetime use, 1- use in lifetime, 2- one to two times every three months, 3- once per month, 4- once every two weeks, 5- once per week, 6- two to four times per week, 7- almost every day). The four substance use items were averaged to create a mean frequency of substance use at intake into the clinic. Participants also answered questions measuring the DSM-5 substance use disorder criteria in the initial intake. Two participants met the criteria for a moderate substance use disorder, and eight met the criteria for a severe substance use disorder.

DBT Diary Cards.

Participants completed their DBT diary cards at the beginning of the group each weekday. During this time, they filled out their diary cards for the following day. For example, on Tuesday, they would fill out their diary card for Monday, and on Monday, they would fill in their diary card for Friday, Saturday, and Sunday. On one side of their DBT diary card, they circled whether or not they used a specific skill on each day of the week. The diary card included seven skills in the mindfulness domain, seven skills in interpersonal effectiveness, eight skills in emotion regulation, and nine skills in distress tolerance. Participants reported their urges to use on the opposite side of the diary card (0-10). The total number of skills under each domain was summed to create the number of skills participants used under each domain per day. For descriptive statistics of daily DBT skills and baseline alcohol and substance use, please see Table 2.

Table 2.

Means and Standard Deviations of Variables

Sample M SD
Baseline alcohol use 2.92 2.36
Baseline substance use 0.65 0.91
Daily ER skills 2.10 1.71
Daily Mindfulness skills 1.36 1.53
Daily DT skills 1.88 1.66
Daily IE skills 1.02 1.54
Daily urges to use 1.68 2.86
Length of stay 69.69 45.86
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Program Description

Participants met 4 hours per day, five days per week, in a DBT skills training constructed based on Linehan’s (2015) DBT training manual. The skills group included teaching the four core DBT skills domains, a check-in where participants discussed their use of skills, and challenges to implementing skills in their day-to-day lives. Participants also met with an individual DBT therapist weekly and had access to a 24-hour coaching phone. Additionally, therapists all belonged to a weekly DBT consultation team that monitored adherence to DBT. Lastly, all participants met weekly with a nurse and once weekly with a prescriber to manage medications while in the PH program. More detail on the PH program and qualifications for admission can be read in previous papers (Lothes et al., 2021; Mochrie et al., 2020; Mochrie et al., 2019). Some individuals transferred to the IOP program, which was primarily distinguished by the amount of time individuals spent in the DBT skills training group (9-hours per week in IOP versus 20-hours per week in PHP). The IOP program included three 3-hour DBT skills groups per week, access to a DBT individual therapist, an on-site prescriber, and a DBT coaching phone. Individuals in the PHP and IOP program were asked to consider abstinence sampling during their treatment. However, receiving treatment was not contingent on maintaining abstinence from alcohol or other substances.

Procedure

The study was approved by the IRB at a local university. Informed consent was gained from every participant during their intake into the clinic. Following their initial intake interview, participants were placed into the PH program and completed their treatment, filling out their diary cards every day they were present during treatment. Out of a possible 3,344 days, participants completed 2392 urges to use items, indicating a 71.53% completion rate. A previous study examining intake and discharge data over five years revealed an average stay of approximately 26 days (Lothes II et al., 2021). For some participants, insurance companies may approve additional days beyond the average 26. Therefore, we entered length of stay as a covariate into all models to control for length of stay and potential move to the intensive outpatient program.

Data Analysis

Because the data violated the assumption of independence in ordinary least squared regressions (i.e., the data was nested within participants across days), we analyzed our data using multilevel modeling procedures (Raudenbush et al., 1995; Raudenbush & Bryk, 2002). To reduce the impact of person-level differences on level-1 parameter estimates, the daily skills variables (level-1 predictors) and preceding days’ urge to use (level-1 covariate) were all person-centered (Nezlek, 2011). Additionally, alcohol use frequency and substance use frequency at treatment entry (level-2 variables) and length of stay (level-2 covariate) were grand mean-centered (Nezlek, 2011). Lastly, we probed cross-level interactions in each model where a skills domain achieved a significant result. In the case of a significant interaction effect, we probed the interaction to determine the effects of DBT skills domains on urges for those at varying frequencies of alcohol and substance use at intake.

We modeled each of the four skill domains separately. Additionally, we modeled each skill domain in two separate models: the previous-day and the same-day skill domain. For example, we modeled ER skills in the following ways. We entered same-day regulation skills (level-1 predictor), baseline alcohol use frequency (level-2 predictor), baseline substance use frequency (level-2 predictor), length of stay (level-2 covariate), an interaction between same-day ER skills and baseline alcohol use frequency, and an interaction term between same-day ER skills and baseline substance use frequency into one model. For the second model, we entered previous-day ER skills (level-1 predictor), previous-day urges (level-1 covariate), baseline alcohol use frequency (level-2 predictor), baseline substance use frequency (level-2 predictor), length of stay (level-2 covariate), an interaction term between previous-day ER skills and baseline alcohol use, and an interaction term between previous-day ER skills and baseline substance use frequency into one model. This process was repeated for each skill domain, resulting in eight models.

We utilized the lme4 (Bates et al., 2014) package in R to conduct our primary analyses and the interactions (Long, 2019) package in R to probe the interactions and calculate simple slopes. In the case of a significant interaction, simple slopes were calculated at plus 1 SD and minus 1SD for baseline alcohol and substance use frequencies. The data and code are openly shared at: https://osf.io/48n2s/?view_only=4370989543a94d9a9cd00f75f16b8628.

Results

Length of stay, baseline substance use frequency, and baseline alcohol use frequency did not significantly predict urges in any of the eight models. Therefore, to simplify the presentation of the eight models, we present estimates, confidence intervals, t values, and p values of each skill domain in Table 3 and the estimates, confidence intervals, t values, and p values of the interaction terms in Table 4. We present the simple slope analyses’ estimates, t, and p values in the text below.

Table 3.

The effects of skills domains on urges to use.

Skills Domain β t CI p
   Variable
Mindfulness skills models
    Same-day mindfulness skill −0.141 −3.367 −0.22 - −0.06 0.001
    Previous-day mindfulness skill −0.133 −3.663 −0.20 - −0.06 <0.001
    Previous-day urges 0.558 28.728 0.52 – 0.60 <0.001
ER skills models
     Same-day ER skill −0.123 −3.804 −0.19 - −0.06 <0.001
     Previous-day ER skill −0.071 −2.476 −0.13 - −0.01 0.013
     Previous-day urges 0.559 28.719 0.52 – 0.60 <0.001
DT skills models
     Same-day DT skill 0.020 0.582 −0.05 – 0.09 0.560
     Previous-day DT skill −0.059 −1.979 −0.12 - −0.00 0.048
     Previous-day urges 0.563 29.027 0.53 – 0.60 <0.001
IE skills models
     Same-day IE skill −0.059 −1.501 −0.14 – 0.02 0.134
     Previous-day IE skill −0.102 −2.986 −0.17 - −0.03 0.003
     Previous-day urges 0.562 28.983 0.52 – 0.60 <0.001
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Table 4.

The interaction effects of the DBT skills domains and baseline alcohol and substance use frequencies.

Skills Domain β t CI p
    Interaction term
Mindfulness skills models
     Same-day mindfulness skill*BLAU −0.052 −2.818 −0.09 – −0.02 0.005
     Same-day mindfulness skill*BLSU −0.151 −2.519 −0.27 – −0.03 0.012
     Previous-day mindfulness skill *BLAU 0.003 0.189 −0.03 – 0.03 0.850
     Previous-day mindfulness skill*BLSU −0.101 −1.820 −0.21 – 0.01 0.069
ER skills models
     Same-day ER skill*BLAU −0.041 −2.814 −0.07 – −0.01 0.005
     Previous-day ER skill*BLSU −0.073 −1.683 −0.16 – 0.01 0.093
     Previous-day ER skill*BLAU 0.012 0.911 −0.01 – 0.04 0.362
     Previous-day ER skill*BLSU −0.147 −3.807 −0.22 - −0.07 <0.001
DT skills models
     Same-day DT skill*BLAU −0.013 −0.752 −0.05 – 0.02 0.452
     Same-day DT skill*BLSU 0.050 1.051 −0.04 – 0.14 0.294
     Previous-day DT skill*BLAU 0.012 0.848 −0.02 – 0.04 0.397
     Previous-day DT skill*BLSU −0.031 −0.736 −0.11 – 0.05 0.462
IE skills models
     Same-day IE skill*BLAU −0.017 −0.850 −0.06 – 0.02 0.395
     Same-day IE skill*BLSU −0.015 −0.266 −0.13 – 0.10 0.790
     Previous-day IE skill*BLAU −0.008 −0.474 −0.04 – 0.03 0.636
     Previous-day IE skill*BLSU −0.109 −2.173 −0.21 – −0.01 0.030
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Note: BLSU: baseline substance use frequency; BLAU: baseline alcohol use frequency.

ER skills

Same-day ER skills use significantly predicted decreases in urges. The interaction between same-day ER skills and baseline alcohol use frequency also achieved significance. We probed the simple slopes (Figure 1) and the results indicated a significant decrease in urges for those that entered treatment with higher alcohol use frequency (β = −0.229, t = −4.680, p < 0.001). For those that entered treatment with lower alcohol use frequency, the relationship between ER skills and urges did not achieve significance.

Figure 1.

Figure 1.

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The interaction between same-day emotion regulation skills and baseline alcohol use frequency.

Note: * p < 0.001

In the model of previous-day ER skills on urges, previous-day ER skills and previous-day urges significantly predicted urges. Additionally, the interaction between previous-day ER skills and baseline substance use frequency achieved significance. The simple slopes for the interaction (Figure 2) indicated a significant slope for those at −1SD of baseline substance use (β = −0.209, t = −4.499, p < 0.001) and no significant slope for those that entered treatment reporting no substance use.

Figure 2.

Figure 2.

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The interaction between previous day emotion regulation skills and baseline substance use frequency.

Note: * p < 0.001; ^ p = 0.008

Mindfulness skills

The same-day mindfulness skills model results indicated a significant main effect of mindfulness skills and significant interaction effects between mindfulness skills and baseline alcohol and substance use frequency. First, we conducted a simple slopes analysis for the interaction between mindfulness skills and baseline alcohol use (Figure 3). Individuals that entered treatment at higher alcohol use frequencies tended to experience decreases in urges on days they used more mindfulness skills (β = −0.269, t = −4.242, p < 0.001). Individuals that entered treatment with lower reported alcohol use frequency did not experience a decrease in urges relative to their mindfulness skill use. Next, we probed the interaction between same-day mindfulness skills and baseline substance use frequency (Figure 4). The results indicated that individuals who entered treatment at higher substance use frequencies tended to experience decreased urges when they used more mindfulness skills (β = −0.284, t = −4.247, p < 0.001). The simple slopes for those at low substance frequency did not achieve significance.

Figure 3.

Figure 3.

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The interaction between same-day mindfulness skills and baseline alcohol use frequency.

Note: * p < 0.001

Figure 4.

Figure 4.

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The interaction between same-day mindfulness skills and baseline substance use frequency.

Note: * p < 0.001

For the model assessing previous-day mindfulness skills, previous-day mindfulness skills were significantly associated with decreased urges. Previous-day urges were positively associated with urges. We observed no significant interaction effects between previous-day mindfulness skills and baseline alcohol or substance use.

DT skills

In the model examining same-day DT skills, no predictor achieved significance. In the model examining previous-day DT skills, previous-day DT skills significantly predicted a decrease in urges. Previous-day urges again predicted an increase in urges. No interaction effects reached significance.

IE skills

In the model examining same-day IE skills, no predictors achieved significance. In the model examining previous-day IE skills, IE skills significantly predicted a decrease in urges. Again, previous-day urges also predicted an increase in urges. The interaction between previous-day IE skills and baseline substance use frequency achieved significance. When probing the simple slopes (Figure 5), individuals who entered treatment at higher substance use frequencies tended to experience decreases in their urges on days after they reported using more IE skills (β = −0.206, t = −3.625, p < 0.001). There was no association between the previous-day’s IE skills and urges for individuals that entered treatment at low substance use frequencies.

Figure 5.

Figure 5.

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The interaction between previous day interpersonal effectiveness skills and baseline substance use frequency.

Note: * p < 0.001; ^ p = 0.003

Discussion

Overall, the study predictions achieved mixed results. Each skill domain significantly predicted decreases in urges in some fashion. Mindfulness skills appeared to be the most impactful across time and alcohol and substance use frequency. Specifically, same-day and previous-day mindfulness skills were associated with significant decreases in urges. Additionally, same-day mindfulness skills interacted with baseline alcohol and substance use frequencies. Those who entered treatment reported a high frequency of substance or alcohol use tended to experience the sharpest decrease in urges as they increased their use of mindfulness skills. Mindfulness skills are taught in many different treatment modalities, including DBT (Irving et al., 2009; Linehan, 1993; Sipe & Eisendrath, 2012; Witkiewitz & Bowen, 2010). However, the present study is the first to examine the relationship between DBT mindfulness skills and urges in daily life via DBT diary cards. With mindfulness skills impacting urges across time, it may be beneficial for those skills to be taught early in DBT treatment programs focusing on substance and alcohol use.

Additionally, same and previous-day ER skills were associated with decreased urges. Same-day ER skills appeared to be most effective for those that drank more frequently, and previous-day ER skills appeared to be most effective for those that used other substances more regularly. These skills may be practical for urges as some hypothesize urges to be an emotional state (Franken, 2003). The ER skills domain aims to help patients reduce unwanted emotions and understand and regulate the emotions they are experiencing (Koerner, 2012). Alcohol and substance use may be a behavior that aims to regulate emotions (Sher & Grekin, 2007), and replacing drinking with ER skills could be a potential mechanism that decreases urges.

For DT skills, only previous-day DT skills achieved significance. The DT skills aim to help patients in DBT tolerate crises without worsening the problems (Linehan, 2014). For individuals who use alcohol and drugs frequently, urges could be considered a crisis if the urges increase the likelihood of a lapse or other problematic behaviors. Same-day DT skills may not have reached significance as the temporality of the skills used and urges could be too spread out via a daily diary. Individuals may have been more likely to use DT skills when their urges were high. Thus it would appear in a daily diary study that DT skills do not affect same-day urges. Further studies utilizing ecological momentary assessment methodologies could further explore how DT skills affect urges in real-time.

Lastly, previous-day IE skills were associated with decreased urges. This association was most robust for individuals that entered treatment reporting high frequencies of substance use. IE skills could potentially affect urges in a variety of manners. First, they could directly impact urges via substance/drink refusal. Additionally, IE skills can be used to achieve meaningful relationships and interactions that thus maintain a regulated emotional state. More studies examining the mechanisms of individual IE skills are needed.

Limitations

First, our study included a small number of participants from one DBT program in the southeastern United States. Furthermore, the PH program was not limited to those with an AUD or SUD. Therefore, the generalizability of our models is likely limited. Additionally, this study followed only 48 participants during their community clinic stay. This small number of individuals limits the power of the level-2 predictors and interactions. Also, the DBT diary cards only allow for a skill to be circled once daily, even if a participant may have used those skills multiple times during the day. This limits the accurate measure of the number of DBT skills used during a day. It could be that participants were utilizing the same DBT skill multiple times in one day and that the repetition of the skill helped account for a change in urges. Another limitation is the measure of urges on the diary card. Urges were measured as a single item that could account for substance use and alcohol urges. Additionally, the single-item measure of urges limits the measure’s reliability, and future studies would do well to examine multiple-item measures of the urge domain.

Future Directions

Much research is needed to examine the effects of core DBT skills on urges and substance use as individuals could be using skills to prevent urges, reduce urges, or reduce actual alcohol and substance use Studies utilizing ecological momentary assessments could better understand the moment-to-moment relationship between DBT skills, urges to drink or use, and alcohol and substance consumption. It could be that certain skills may be more effective in reducing the link between urges and actual use and intensive longitudinal studies may help tease apart these complex relationships. The skills learned in DBT are theorized to be a mechanism of behavior change unique to those in DBT treatment (Lynch et al., 2006). Additional studies examining the growth rate of skills use over time and how that growth rate predicts behaviors related to alcohol and substance use could help spur unique implementations of DBT to those with an AUD and SUD. Future studies are needed to examine the proposed mechanisms of each skill as well. The paced breathing skill in DBT posits that breathing in for eight seconds and out for four seconds will slow the heart rate down and decrease the experience of distress. The opposite action emotion regulation skill aims to regulate specific emotions by engaging in behaviors opposite of the action urge related to the unwanted emotion (Linehan, 2014).

Studies examining each individual skills are warranted to better understand these proposed mechanisms and potentially develop more streamlined therapies. Additionally, understanding the proposed mechanisms may inform just-in-time interventions that could increase skills generalization outside of the traditional therapeutic context. Lastly, our study did not capture the potential of other DBT treatment ingredients and treatment timing to affect changes on urges. Further studies examining how phone coaching and the order in which the skills are taught could help better understand how individuals change substance use behaviors while receiving DBT treatment.

Conclusion

The current study was the first to examine the relationship between DBT skills domains and urges over time amongst individuals who entered treatment with varying frequencies of alcohol use. Within this small sample, the increased use of ER, DT, IE, and mindfulness skills were associated with decreased urges. This paper extended the skills deficit theory of DBT (Linehan, 1993). When individuals in DBT begin to use skills instead of other problematic coping mechanisms, there should be a behavior change. The present study found that specific skills domains may be more related to decreased urges depending on alcohol or other substance use frequencies. Future research is warranted to examine why these domains may be more closely related to decreased urges for certain groups of individuals.

Funding Statement:

Matison McCool was supported in part by the National Institute on Alcohol Abuse and Alcoholism of the National Institutes of Health [AA018108]. The content is the sole responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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