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Dialectical Behavior Therapy for Patients Dually Diagnosed With Borderline Personality Disorder and Substance Use Disorders: Page 2 of 2

Dialectical Behavior Therapy for Patients Dually Diagnosed With Borderline Personality Disorder and Substance Use Disorders: Page 2 of 2

The Basics of DBT

Dialectics in DBT-SUD refers broadly to both a worldview and a process of
change. Using a dialectical worldview, the disease, disorder and symptoms are
not treated. Instead, patients are considered as whole individuals whose
problem behaviors occur in specific contexts. Accordingly, an ongoing and often
moving target for the DBT-SUD therapist is to understand the relevant context
in which drug use and other problem behavior occurs, in order to better predict
and control these behaviors. As a process of change, dialectics refers to the
practice of arriving at a working truth for any given moment. For every point
(thesis) that is made a counterpoint (antithesis) can be taken, until a
synthesis between these oppositional positions emerges that appears to be
effective. The synthesis is then examined for what is left out, what may not
actually be useful or for likely barriers to implementation.

For example, a patient may state their desire not to talk about a recent
lapse in drug use, with a corresponding preference to talk about an event from the
past week that is upsetting. If the therapist rigidly insists on talking about
the lapse, the patient and therapist may be at an impasse. Instead, the DBT-SUD
therapist may look for ways to discuss both the recent lapse and the upsetting
event, by searching for threads that connect the two seemingly disparate

Another example of a dialectic is the stance taken
in DBT-SUD about whether the best model for substance use is abstinence or harm
reduction. Arguably, there are pros and cons to each approach. Rather than
uniformly adopting one of these two apparently contradicting models, however,
DBT-SUD includes elements of both abstinence and harm reduction approaches, a
stance called dialectical abstinence. This refers to the complete and total
emphasis on abstinence on the one hand, with, on the other hand, a planned
approach in the event of lapse or relapse that is designed to mitigate harm and
resume abstinence.

Biosocial theory.
As is standard DBT, the theoretical model underpinning DBT-SUD includes three
primary factors: temperamental emotional vulnerability, the history and/or
presence of an invalidating environment(s), and problems with emotional dysregulation. According to Linehan
(1993a), individuals with BPD are hypothesized to suffer from biologically
mediated (e.g., temperament) problems with emotional vulnerability, whereby
these patients respond quickly to a wide range of stimuli (sensitivity). The
magnitude of such reactions is high (reactivity), and, once emotionally
aroused, it takes a long time to return to previous levels of emotional arousal
(slow return to baseline). In addition, individuals with BPD frequently report
growing up in and/or currently living in social environments characterized by
physical and sexual abuse/neglect, as well as invalidation of internal
experiences, such as emotions and thoughts. The biosocial theoretical framework
underpinning DBT suggests that the reciprocal and transactional influence of
emotional vulnerability and environmental invalidation together give rise to
the pervasive problems with regulating emotions thought to underlie BPD
criterion behaviors (Linehan, 1993a).

Modes and functions.
As a comprehensive treatment, there are multiple modes of DBT-SUD, each with
corresponding functions. Group skills training is a weekly meeting wherein
patients learn new skills and are assigned behavioral homework in mindfulness,
emotion regulation, distress tolerance and interpersonal effectiveness.
Mindfulness skills target improvements in awareness of internal experiences
(e.g., emotions) without judgment and with effectiveness. Emotion regulation
skills are designed to reduce vulnerability to emotions (e.g., improve sleep),
increase positive emotions, accept emotions, and change specific emotional
states using behavioral and cognitive skills. Distress tolerance skills are
intended to assist patients in tolerating the ordinary pain of life without
inadvertently engaging in behavior that leads to unnecessary suffering. For
example, patients are taught ways to get through strong emotions such as anger,
shame or sadness without harming themselves or using drugs. Finally,
interpersonal effectiveness skills are designed to increase patients' ability
to ask for what they want or say no to others more effectively, to better develop
and maintain relationships, and to preserve their self-respect. Group meetings
resemble the classroom more than customary group psychotherapy. Patients
describe attempts to practice skills homework, and group co-leaders teach new
skills each week.

. In addition to group skill training, DBT-SUD patients
attend weekly individual psychotherapy sessions. These meetings generally last
50 to 60 minutes, but can be shortened or extended as needed across treatment.
The frequency also can be varied as needed. For example, patients who are
complying with treatment and responding well may find it rewarding to attend
more than one session per week. Daily diary cards are used to monitor target
behaviors, such as drug use and relevant antecedents and consequences. Frequent
analyses are conducted to understand the variables that control problem
behaviors, and skills are woven into planning for future contexts. Individual
therapy sessions emphasize validation of the patient's internal experiences and
effective behavior, coupled with ongoing problem solving, solution generation, analyses of solutions and iterative refinements of
solutions. Using an ongoing balance of acceptance and change strategies, a
primary goal of individual therapy sessions is to increase or sustain patient
motivation to participate actively in treatment.

. Treatment once a week may be insufficient for patients
with BPD and SUDs. Because crises can be unrelenting
between weekly appointments, and in light of the myriad treatment target that
are evident in any single session, DBT-SUD includes a heavy emphasis on the use
of the telephone to communicate with patients. A primary function of telephone
consultation is to generalize previously acquired skills into the natural
environment and to help directly implement skills plans made during sessions.
As a behavioral treatment, this component of DBT-SUD is considered essential,
as cognitive and behavioral skills trained during group and individual sessions
may not easily generalize into all relevant contexts outside the therapy

Consultation team.
Individuals with co-occurring BPD and SUDs are
difficult to treat. When considering the common lapses, numerous treatment
targets and frequent therapy-interfering behavior (e.g., late or missed
appointments), clinicians can feel acutely frustrated, demoralized and
hopeless. As in standard DBT, in DBT-SUD a key component is a weekly clinician
consultation team. The primary purposes of these meetings are remoralization and prevention of clinician burnout.
Consultation team members help each other better
assess problem behavior, identify creative solutions to ongoing problems,
enhance phenomenological empathy and provide validation to each other to
reinforce hard work and effective clinician behavior. Although no component
studies have examined whether the consultation team is an essential element of
DBT, it is possible that consultation team meetings provide much of the impetus
for the necessary motivation to continue working with these patients for a long
period of time.

There are several principles that organize the management of psychotropic
medications in DBT-SUD. First, and most importantly, safe and nonlethal medications are prescribed after careful
assessment. For those with a history of medication abuse, the DBT-SUD pharmacotherapist may observe the medication being
ingested, but also may consider providing a small supply of take-home
medications. Second, simple medication regimens are used to mitigate problems
with side effects and drug interactions, both of which can interfere with
treatment. Third, specific symptoms are targeted first, rather than general
problems, such as impulsivity. Fourth, choice of medications is guided by
controlled efficacy studies. Finally, speed of improvement is important, with,
for example, opiate replacement rapidly induced to a maintenance dose.

DBT-SUD case
. Because substance users with BPD often have problems
maintaining adequate food, housing and employment, case management can be added
to DBT-SUD. Unlike standard case management that commonly intervenes in the
environment (e.g., making a phone call on behalf of a client), DBT-SUD case
management strongly emphasizes coaching patients to intervene on their own
behalf. The case manager is utilized, as needed, by the individual therapist as
a resource to the therapist for referrals or advice, to provide information or
referrals directly to the client, or to provide in vivo skills coaching in the
patient's natural environment.

Attachment Problems

Several new skills have been added to DBT-SUD that are
geared directly toward problems experienced by individuals with BPD and SUD
(unpublished data). One important adaptation is the inclusion of attachment
strategies. Because individuals with BPD and SUDs may
attend treatment sessions inconsistently, arrive late for session or not at
all, or more generally appear "nonattached" to the treatment or therapist, in
DBT-SUD there are a number of ways in which efforts are made to increase
patient attachment to the therapist and treatment. For example, to develop
rapport, the first several sessions include a large amount of therapist
validation, with less emphasis on immediate change and/or aversive
contingencies than in standard DBT. Other attachment strategies include
orienting the patient to this problem, increasing contact with patients toward
the beginning of treatment, frequent contacts with patients via voice mail, in
vivo therapy sessions, decreasing or increasing session length as needed,
family and friends network meetings, calling patients when they appear to be
avoiding treatment, and finding them when they repeatedly fail to show up for
appointments and do not respond to telephone calls.


Overall, DBT-SUD is a principle-driven and flexible treatment approach for
individuals with BPD and co-occurring SUD that is comprehensive, in that the
treatment modalities include: 1) individual therapy to enhance patient
motivation and develop strategies for targeting problem behavior; 2) group
skills training to enhance acquisition of behavioral and cognitive skills; 3)
telephone consultation to promote generalization of skills to the patient's
natural environment; 4) therapist consultation team to reduce therapist
burnout; 5) pharmacotherapy approaches; and 6) case management strategies.



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