M. Zachary Rosenthal, PhD

Originally developed and empirically supported as an outpatient treatmentfor borderline personality disorder (BPD) (Linehan,1993a, 1993b; Linehan et al., 1991), dialecticalbehavior therapy (DBT) recently has been adapted for adults with BPD and comorbid substance use disorders (SUDs)(Linehan et al., 2002, 1999). This modifiedtreatment, DBT-SUD, has shown promise in two small randomized controlled trialsand is currently being tested in a two-site study (University of Washington andDuke University Medical Center) funded by the National Institute of Drug Abuse(NIDA). The purpose of this paper is to provide a primer on the basics ofDBT-SUD. For more comprehensive descriptions of DBT-SUD, the interested readeris referred to the treatment manual (Linehan 1993b),treatment outcome studies (Linehan et al., 2002,1999), online resources for DBT-SUD training <www.behavioraltech.org> orbook chapters on DBT-SUD (Rosenthal et al., 2005).

Dialectical behavior therapy for adults with BPD and comorbidSUDs was developed, in part, out of recognition thatindividuals with BPD often have problems with substance abuse, and that up totwo-thirds of those diagnosed with SUD also meet diagnostic criteria for BPD (Dulit et al., 1990). In addition, there may be commonetiological and maintaining factors across BPD and SUD, such as difficultieswith the regulation of emotional experience and expression, as well asimpulsivity (Bornovalova et al., 2005; Trull et al., 2001). Clinicians are faced with an enormouschallenge when treating individuals with co-occurring BPD and SUD. Compared tothose with BPD only, those with BPD and SUDs may showmore severe psychopathology, including greater anxiety and suicide attempts(van den Bosch et al., 2001). It is unclear whether standard drug counselingapproaches common in the substance abuse treatment community (e.g., 12-step)are efficacious for these difficult-to-treat patients. However, guidelines forimplementing treatments for dually diagnosed patients have been articulated(Drake et al., 2001), and such treatments have been developed for individualswith both SUD and schizophrenia, antisocial personality disorder, and a historyof interpersonal victimization, for example (Barrowclough et al., 2001; Drakeet al., 1993; Messina et al., 1999; Najavits et al.,1998). In line with the hypothesis that a specifically tailoredtreatment may be appropriate for this population, and following NIDA guidelinesfor psychosocial treatment development, Linehan andcolleagues developed DBT-SUD (unpublished data).

Like standard DBT, the modified version of this outpatient treatment is ablend of change (e.g., behavior therapy) and acceptance (e.g., mindfulnesstraining) approaches woven together by a set of philosophical assumptions, abiosocial theory and multiple modes of treatment (e.g., individual therapy,group skills training, pharmacotherapy). On the one hand, as a behavioraltreatment, DBT-SUD relentlessly pursues changing a range of maladaptivebehaviors using standard behavioral principles and procedures (e.g.,contingency management, shaping, stimulus control). Onthe other hand, as an acceptance-based treatment, DBT-SUD provides anunwavering emphasis on patient validation, mindfulness skills, and anunderlying assumption, that, in some moments of life, efforts to change whatinherently cannot be changed may exacerbate problems, rather than solve them.

Instead of monochromatically being change- 

 acceptance-focused, the DBT-SUD therapist carefully integrates 

 acceptance throughout all aspects oftreatment. Indeed, the ubiquitous dialectic in DBT is that of acceptance andchange. Neither one alone is thought to be sufficient for all problems.Instead, the DBT-SUD therapist constantly is searching for ways to help anygiven problem using either, or both, change and acceptance strategies. Thepragmatic goal is to identify and implement an optimal solution to each problemthat arises in a fluid context, while being completely willing to let go of anysolution, as needed, in response to new problems or evidence that any onesolution does not appear to be helpful. A balance between acceptance and changeis important, but this does not always translate literally into an equaldistribution of acceptance and change. Like a skilled athlete adjusting to theweather conditions during a game, the relative proportion of acceptance andchange is a function of what appears useful in any given moment.

Two randomized trials examining DBT-SUD have been conducted. In the firststudy, 28 women diagnosed with BPD and/or SUD were randomly assigned to receiveone year of DBT-SUD or treatment as usual (TAU) in the community (Linehan et al., 1999). After treatment, patients receivingDBT-SUD attended significantly more individual psychotherapy sessions, droppedout of treatment less often and had significantly less substance use, asmeasured via structured interviews and urinary analyses. At 16-month follow-up,patients receiving DBT-SUD reported higher global and social adjustmentcompared to those receiving TAU.

In the second study, 23 adults with BPD and opioiddependence (all heroin) were randomly assigned to receive either one year ofDBT-SUD or a comprehensive treatment that included 12-step meetings (e.g.,Narcotics Anonymous/Alcoholics Anonymous) plus individual therapy sessionsusing a manualized approach based purely inacceptance without direct emphasis on behavioral change (comprehensivevalidation therapy) (Linehan et al., 2002). Allpatients concurrently received levomethadyl (Orlaam) as an opiate replacement medication. Patients inboth treatment conditions evidenced decreases in drug use and improvements insocial and general adjustment following treatment. However, in the last fourmonths of treatment, patients receiving DBT-SUD continued to maintain previoustreatment gains, whereas those receiving comprehensive validation had anincrease in opiate use. Although a larger follow-up study currently is beingconducted to replicate and extend these findings, these preliminary studiestaken together suggest that DBT-SUD holds promise as a treatment for substanceusers with BPD.

.Dialectics in DBT-SUD refers broadly to both a worldview and a process ofchange. Using a dialectical worldview, the disease, disorder and symptoms arenot treated. Instead, patients are considered as whole individuals whoseproblem behaviors occur in specific contexts. Accordingly, an ongoing and oftenmoving target for the DBT-SUD therapist is to understand the relevant contextin which drug use and other problem behavior occurs, in order to better predictand control these behaviors. As a process of change, dialectics refers to thepractice of arriving at a working truth for any given moment. For every point(thesis) that is made a counterpoint (antithesis) can be taken, until asynthesis between these oppositional positions emerges that appears to beeffective. The synthesis is then examined for what is left out, what may notactually be useful or for likely barriers to implementation.

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

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

.As is standard DBT, the theoretical model underpinning DBT-SUD includes threeprimary factors: temperamental emotional vulnerability, the history and/orpresence of an invalidating environment(s), and problems with emotional dysregulation. According to Linehan(1993a), individuals with BPD are hypothesized to suffer from biologicallymediated (e.g., temperament) problems with emotional vulnerability, wherebythese patients respond quickly to a wide range of stimuli (sensitivity). Themagnitude of such reactions is high (reactivity), and, once emotionallyaroused, it takes a long time to return to previous levels of emotional arousal(slow return to baseline). In addition, individuals with BPD frequently reportgrowing up in and/or currently living in social environments characterized byphysical and sexual abuse/neglect, as well as invalidation of internalexperiences, such as emotions and thoughts. The biosocial theoretical frameworkunderpinning DBT suggests that the reciprocal and transactional influence ofemotional vulnerability and environmental invalidation together give rise tothe pervasive problems with regulating emotions thought to underlie BPDcriterion behaviors (Linehan, 1993a).

.As a comprehensive treatment, there are multiple modes of DBT-SUD, each withcorresponding functions. Group skills training is a weekly meeting whereinpatients 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 regulationskills are designed to reduce vulnerability to emotions (e.g., improve sleep),increase positive emotions, accept emotions, and change specific emotionalstates using behavioral and cognitive skills. Distress tolerance skills areintended to assist patients in tolerating the ordinary pain of life withoutinadvertently engaging in behavior that leads to unnecessary suffering. Forexample, 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' abilityto ask for what they want or say no to others more effectively, to better developand maintain relationships, and to preserve their self-respect. Group meetingsresemble the classroom more than customary group psychotherapy. Patientsdescribe attempts to practice skills homework, and group co-leaders teach newskills each week.

. In addition to group skill training, DBT-SUD patientsattend weekly individual psychotherapy sessions. These meetings generally last50 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 arecomplying with treatment and responding well may find it rewarding to attendmore than one session per week. Daily diary cards are used to monitor targetbehaviors, such as drug use and relevant antecedents and consequences. Frequentanalyses are conducted to understand the variables that control problembehaviors, and skills are woven into planning for future contexts. Individualtherapy sessions emphasize validation of the patient's internal experiences andeffective behavior, coupled with ongoing problem solving, solution generation, analyses of solutions and iterative refinements ofsolutions. Using an ongoing balance of acceptance and change strategies, aprimary goal of individual therapy sessions is to increase or sustain patientmotivation to participate actively in treatment.

. Treatment once a week may be insufficient for patientswith BPD and SUDs. Because crises can be unrelentingbetween weekly appointments, and in light of the myriad treatment target thatare evident in any single session, DBT-SUD includes a heavy emphasis on the useof the telephone to communicate with patients. A primary function of telephoneconsultation is to generalize previously acquired skills into the naturalenvironment 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 sessionsmay not easily generalize into all relevant contexts outside the therapyoffice.

.Individuals with co-occurring BPD and SUDs aredifficult to treat. When considering the common lapses, numerous treatmenttargets and frequent therapy-interfering behavior (e.g., late or missedappointments), clinicians can feel acutely frustrated, demoralized andhopeless. As in standard DBT, in DBT-SUD a key component is a weekly clinicianconsultation team. The primary purposes of these meetings are remoralization and prevention of clinician burnout.Consultation team members help each other betterassess problem behavior, identify creative solutions to ongoing problems,enhance phenomenological empathy and provide validation to each other toreinforce hard work and effective clinician behavior. Although no componentstudies have examined whether the consultation team is an essential element ofDBT, it is possible that consultation team meetings provide much of the impetusfor the necessary motivation to continue working with these patients for a longperiod of time.

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

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

Several new skills have been added to DBT-SUD that aregeared directly toward problems experienced by individuals with BPD and SUD(unpublished data). One important adaptation is the inclusion of attachmentstrategies. Because individuals with BPD and SUDs mayattend treatment sessions inconsistently, arrive late for session or not atall, or more generally appear "nonattached" to the treatment or therapist, inDBT-SUD there are a number of ways in which efforts are made to increasepatient attachment to the therapist and treatment. For example, to developrapport, the first several sessions include a large amount of therapistvalidation, with less emphasis on immediate change and/or aversivecontingencies than in standard DBT. Other attachment strategies includeorienting the patient to this problem, increasing contact with patients towardthe beginning of treatment, frequent contacts with patients via voice mail, invivo therapy sessions, decreasing or increasing session length as needed,family and friends network meetings, calling patients when they appear to beavoiding treatment, and finding them when they repeatedly fail to show up forappointments and do not respond to telephone calls.

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

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Articles

With its focus on both behavior modification and mindfulness training, dialectical behavior therapy has proven quite effective in treating patients with borderline personality disorder. This article provides a primer on a modified version of this outpatient treatment for borderline patients with substance use disorders, a comorbid condition that may affect as many as two-thirds of patients with BPD.

M. Zachary Rosenthal, PhD

Articles

Dialectical Behavior Therapy for Patients Dually Diagnosed With Borderline Personality Disorder and Substance Use Disorders