Philosophy. 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 topics.
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.
Individual psychotherapy. 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.
Telephone consultation. 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 office.
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.
Pharmacotherapy. 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 management. 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.Summary
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.