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Dialectical Behavior Therapy for Substance Use Disorder

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1 Dialectical Behavior Therapy for Substance Use Disorder
Heather Lawson, Psy.D.

2 Training Goals Review essential characteristics of dialectical behavioral therapy (DBT). Review recent empirical research of DBT with borderline personality disorder (BPD) and substance use disorder (SUD). Learn principles to determine the appropriateness of DBT for persons with SUD. Review adaptations of DBT for SUD, including development of new skills for SUD individuals.

3 What is DBT? A structured, time-limited, cognitive-behavioral treatment (CBT) developed by Dr. Marsha Linehan in early 90’s.   Primary difference between DBT and other CBT treatments is its focus on Mindfulness. Efficacy for decreasing symptoms of BPD has been demonstrated in randomized controlled trial (RCT) studies. Research on DBT for SUD shows positive results in two RCT’s (1999, 2002).

4 DBT in a Nutshell Acceptance and Change Dialectic: DBT relies on frame of acceptance (validation) and need to change dialectic to help patients learn skills to change their lives. Ex: “Using substances works for you in the short-term to get rid of negative emotions, but it is exceedingly unlikely that you will be able to achieve your long-term goals if you continue using.” Change-Based Strategies: Skills training, behavioral analysis, exposure, contingency management

5 Modalities of Treatment
Individual psychotherapy Skills group  Core Mindfulness  Distress Tolerance  Emotion Regulation  Interpersonal Effectiveness Phone coaching Consultation team

6 Skills Core Mindfulness: Teaches patients how to focus attention so they can participate in life with awareness. Distress Tolerance: Includes skills for tolerating painful situations without doing something to make things worse. Emotion Regulation: Teaches a model for understanding one’s own emotions and skills to regulate them. Interpersonal Effectiveness: Teaches patients how to identify objectives in relational situations and use skills to meet objectives.

7 DBT: Structure of Treatment and Targets
Patients we work with have so many problems. DBT has a clear structure related to where to start with treatment targets.  Suicidal and self-harmful behaviors Reduce treatment interfering behaviors Reduce quality-of-life interfering behaviors: including substance use Increasing skills to manage life

8 Why DBT for SUD? Studies show significant overlap of BPD and SUD Linehan, 2010 BPD and SUD = troublesome combination Severe psychopathology upon hospital admissions predicts poorer outcome and early relapse among drug abusers Saxon and Calsyn, 1995; McLellan, et al., 1992, 1983; Woody, et al., 1985 Substance abuse is risk factor for suicide attempts NIMH, 2010

9 Research on DBT/SUD to date
2 Randomized Controlled Trials DBT vs. Treatment as Usual (TAU) University of Washington: Linehan, Schmidt, Kanter, Craft, et al., 1999 DBT vs. Comprehensive Validation Therapy (CVT) with 12-Step University of Washington: Linehan, Dimeff, Reynolds, Comtois, et al., 2002

10 DBT vs. TAU with BPD/SUD DBT > TAU Drug use Dropout
Global and social adjustment Treatment retention DBT gains continued at 16-month follow-up Linehan, Schmidt, Kanter, Craft, et al., 1999; University of Washington

11 DBT vs. CVT + 12-Step with BPD/SUD
Not significant; everyone got better Drug use Global and Social Adjustment CVT + 12 Step > DBT Treatment retention Linehan, Dimeff, Reynolds, Comtois, et al., 2002; University of Washington

12 Summary of Research Findings
Studies suggest that using DBT to treat individuals with BPD and SUD is effective in reducing substance use. DBT excels in addressing other problems substance-using individuals have. Studies still needed to substantiate efficacy of using recently-developed adaptations of DBT for dually- diagnosed patients.

13 DBT for BPD with SUD Essentially same treatment with slightly different emphasis on: Picking targets Skills modifications and development of new skills for SUD patients Attachment strategies for difficult-to-engage patients Targets adapted for BPD with SUD Substance use (Goal is Abstinence + Functionality) Lying Teaching dialectic of emotional vulnerability and self-invalidation Building a life living (overarching goal of DBT)

14 Case to Illustrate Application of DBT for BPD with SUD
25-year-old, single, Caucasian female Diagnosed with MDD, Recurrent, In Full Remission, BPD, Alcohol and Cocaine Abuse. Frequency of cocaine use typically 3x/weekly. Alcohol use on average: 5x/weekly, 1-5 glasses of wine.

15 DBT Has Many Ways to Separate People from Addiction
One way is through this doorway of understanding the dialectic of emotional vulnerability and self-invalidation.

16 What is Emotional Vulnerability?
Heightened sensitivity Increased intensity Slow return to baseline

17 What is Self-Invalidation?
Self-invalidation: Non-acceptance of one’s thoughts, feelings, and behaviors “I shouldn’t be this way.” “I’m flawed.” “I’m broken.” “I’m an addict.” Oversimplifying substance abuse problem: “I’ll never do this again.” “I can be perfect today.”

18 Dialectic of Emotional Vulnerability and Self-Invalidation in Treatment
DBT has transparency. Provide psychoeducation and share dialectical poles with patients: "You’re stricken with intense sadness when the guy you like at work doesn’t say hello to you (emotional vulnerability). Then, you judge your emotional reaction (self-invalidation) causing feelings of shame.” “The combination of emotional vulnerability and self-invalidation increases urges and likelihood of substance use.” “Skills to regulate emotions and validate yourself will help decrease the likelihood of that you will use.”

19 Rationale for Abstinence Goal for BPD with SUD
The difficulties experienced by BPD patients with SUD make it exceeding difficult for them to use in moderation. Focusing on abstinence, as opposed to harm reduction, increases the length of time to use. Encourages re-conceptualization of identity that’s helpful to achieve goal of sobriety. Linehan, 2010

20 Dialectical Abstinence Model
DBT expects abstinence as a goal, yet recognizes patients lack skills to stay sober and build a life worth living without substance use. DBT teaches strategies for abstinence and harm reduction = dialectical abstinence. Patients with emotion dysregulation and self-invalidation are prone to Abstinence Violation Effect (huge risks for “oh, screw it” factor). Large risk that relapse can be lethal due to body physiology changes. Message: Have to be abstinent and have to be careful how to get there.

21 Metaphor of DBT Synthesis of Dialectical Abstinence
“If you get one flat tire, you don’t get out of the car and let all the air out of all your tires.” Find your own personal stories to develop metaphors bring concepts to life for patients.

22 Strategies for Abstinence
Burn bridges with dealers/users Planning other activities to do instead of using Spending time with people who will reinforce not using Remind self of reasons to stay abstinent Public announcement of quitting Avoiding cues (identification of cues and use of worksheet) Using skills

23 Strategies for Harm Reduction
Phone coaching (similar to AA’s use of sponsor) Remind self why being on drugs is harmful Contact clean people Get rid of substances so can’t use more than already have Cheerleading: “I can climb back on the wagon.” “One slip is not a disaster.” Do a chain analysis Use pros/cons skill of stopping now Turn the mind away from extreme thinking and look for the middle ground

24 Use of Dialectical Abstinence in Session
“You’ve tried to control your use of alcohol and cocaine for years and haven’t been able to. Your frequency of use has increased and worsened your depression. I understand how it’s hard to quit when all of your friends use. However, it’s unlikely things will get better for you unless you stop. I’m going to teach you set of strategies to get and stay clean, as well as skills to get you back on track in case you slip.”

25 Use of Diary Cards to Reduce Substance Use
Patients are instructed to complete diary cards each day. If don’t do, asked to do in session (use of negative reinforcement). Diary cards are reviewed beginning of session with targets kept in mind. Do chain analysis for targets/problem behaviors. Get commitment. Practice skill in office to reduce target or problem behavior. Troubleshoot what would get in the way of skills working.

26 Case Example: Use of Diary Card for Substance Use
Patient did not do diary card, so asked her to do retrospectively. Verbalized observations: “Sunday through Tuesday were great days, you used a lot of skills and felt pretty good. You drank and looked for cocaine on Wednesday and had unprotected sex with guy you didn’t know that you later regretted. You drank alone on Thursday and searched for coke...”

27 Case Example: Use of Diary Card for Substance Use
Decide on recent episode in which target behavior occurred to review in session. “Let’s go over your most recent incident of substance use and unprotected sex and see if we can figure out where you could have done something differently.” Asked patient if there was something in addition to our BA she wanted to talk about for relationship building and reinforcing in session trouble-shooting behavior.

28 Use of Behavioral Analysis for Substance Use
Figure out problem. Conduct behavioral analysis (BA): vulnerabilities, precipitating event, interpretations, antecedents, links, consequences. Analyze chain of events and figure out where train came off tracks. Generate solutions and new behaviors.

29 Case Example: Use of BA Vulnerability Factors Holiday period (1/1/11)
Recent exposure to family Sleep deprivation Recent blow-up with roommate

30 Case Example: Use of BA Precipitating Events, Antecedents, Links
Disappointed in morning when a guy she is interested in doesn’t get back to her, Later upset that a guy she likes at work doesn’t interact with her during her shift, Has downward comparison thoughts,

31 Case Example: Use of BA Precipitating Events, Antecedents, Links (continued) Experiences intense emotion dysregulation, Passes bar on way to train, Decides to drink to alleviate emotional pain, Meets guy at bar and under influence, goes home with him, does cocaine and has unprotected sex with him.

32 Case Example: Use of BA Consequences Pros/Cons
While she alleviates emotional pain in short-term, the next day she experiences self-disgust, regret about wasting money when she doesn’t even have money for rent, and significant depression. Pros/Cons Patient identifies pros/cons of substance use and pros/cons of not using.

33 Case Example: Use of BA Solution Analysis
Self-validation related to holidays being hard time. Unmindfulness of upsetting thoughts. Focusing attention instead on upcoming positive things and “mastery” experiences to replace harmful thoughts. Pros/Cons thinking before entering bar. Not walking on street where bar she likes is located. Observe urge and “surf it.” Call/text therapist.

34 Skills Developed for patients with SUD
Burning bridges; options for decent life: Delete phone numbers, tell people you’re quitting, join sober activities. Urge surfing: Use of imagery to tolerate urges without acting on them. Adaptive denial: Let go of identifying self as addict. Alternate rebellion: Finding alternative ways to be counterculture, and to satisfy thrill associated with the “chase” involved in substance use.

35 Skills Developed for patients with SUD
Avoid and eliminate cues for substance use: Mindfulness Change numbers Get rid of paraphernalia Move TIP (Temperature/Intense Exercise/Progressive Muscle Relaxation) Involves use of physiology to regulate emotions. Ex: Submerging face into ice water and holding breath, eliciting “dive response” — this has been found to help regulate emotions.

36 DBT for SUD: Focus on Urges
Psychoeducation about urges (normalization of urges, episodic nature of them, fluctuate in intensity, giving into them reinforces them). Have patients mindfully monitor urges on diary cards. Techniques to resist acting on urges (mindfulness, pros/cons thinking, imagery, e.g., Samurai chopping head of urge with a saber).

37 Attachment Strategies
Identify this as potential problem at first session. Asks patients where to find them should they disappear. Increase contact with patient in first few months in effort to get patients to connect (text, , call). Speak to team to avoid burn-out and try to think of as a puzzle and challenge instead of annoying patient.

38 When to Refer? BPD with SUD
Non-BPD with SUD with many complicating problems E.g., emotion regulation, behavioral dysregulation, relationship problems, impulsivity, suicidal and self-harmful behaviors Multiple Axis I and Axis II problems Non-BPD with SUD for whom other treatments haven’t worked

39 Thank You Questions or comments? Heather Lawson, Psy.D.

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