Dialectical Behavior Therapy for Substance Use Disorders

Following the initial evidence supporting DBT for suicide and non-suicidal self-injury (NSSI) in the early 1990s, Marsha Linehan and colleagues introduced modifications to target substance use disorders (SUD) as one of the greatest risk factors for fatal outcomes. DBT-SUD developed by adding new principles, strategies, protocols, and modalities to address common problems and complications of addiction, while maintaining all of those from the original model for NSSI. For example, individuals with BPD and SUDs tend to demonstrate “butterfly attachment,” characterized by limited treatment inclination, fleeting commitment, and minimal attachment to providers; whereas those with BPD without SUDS more often show an opposite attachment-seeking pattern. Therefore, a number of Attachment Strategies were added, such as assigning regular phone check-ins to build connection, orienting social networks to help reconnect with “lost” clients, and reinforcement of treatment participation. Some added DBT-SUD modalities include social networking meetings supporting attachment, urine toxicology screening, and pharmacotherapy to provide replacement medication for opioid addiction given its empirical support.

Is DBT-SUD really that different from standard DBT?

Before reviewing some of the specific modifications (for a more thorough review see McMain et al., 2007), it’s important to note that the general strategies of DBT-SUD for helping individuals with addictions are much the same as the standard DBT approach to orientation and commitment, behavioral targeting, validation, and problem solving. As with NSSI and suicide, substance-related targets are understood as efforts to emotionally regulate in the face of challenging circumstances and experiences, with similar learning histories related to benefits such as emotional relief, numbness, or pleasant emotions — at least in the short term. As with standard DBT, clients are oriented to the option of developing new capabilities through DBT for responding to problems in ways that are consistent with their values and with moving towards lives that they would experience as worth living. Substance-related targets are monitored on diary cards, prioritized as the top quality of life-interfering behavior, explored through behavioral chain analysis, problem-solved using solution analysis, and coached with phone consultation (even after using if it is deemed that skills might be generalized).

The Dialectic of SUD Treatment

In dialectical fashion, DBT-SUD synthesizes the two polarized and dominant SUD treatment approaches, including abstinence models such as 12-step programs and harm-reduction models such as cognitive-behavioral relapse prevention. The middle position of dialectical abstinence recognizes the wisdom and strengths of each by establishing a solid commitment to abstinence that cuts off all known paths to use (the Burning Bridges skill), with a total acceptance of slips as part of learning to establish more secure pathways toward abstinence. This synthesis leaves out the main limitations of the two approaches, namely the shame and resignation that typically transform lapses into full relapses within the abstinence approach (i.e., the abstinence violation effect), and the continuing substance use (i.e., non-abstinence) that tends to match the treatment expectation communicated by the harm avoidance approach. While initially articulated for treating addictions, dialectical abstinence was already fully present in standard DBT in its approach to treating suicide and NSSI. With those examples in mind, its practice would likely already be quite familiar to DBT providers.

The Dialectic of Kicking the Habit

A dialectic of common substance use states of mind is also included among the DBT-SUD skills with an Addict Mind consumed by the rationales, physical cravings, and emotional benefits of using (e.g., “no one will know,” “I deserve to,” etc.), which often vacillates with a Clean Mind that pushes away from the physical, cognitive, and emotional consequences of using. Unfortunately, Clean Mind tends to push so hard against Addict Mind that it inevitably lands on overly simplistic solutions for remaining abstinent (e.g., “I’ve learned my lesson,” “never again,” etc.), setting the stage for further repetition. The Clear Mind synthesis is fully open to both sides, fully pursuing abstinence while accounting for the draw of using. For example, the Alternate Rebellion skill involves practicing new expressions of rebellious pleasures that do not harm oneself, goals, or others, such as wearing outrageous T-shirts or “going commando.” Additional DBT-SUD skills include Community Reinforcement of abstinent behaviors, Building Bridges to new stimuli to condition abstinence, and Adaptive Denial of unbearable expectations of remaining abstinent. Over time, Linehan observed that the DBT-SUD skills are also very well-suited and relevant for targeting any habitual problematic behavior such as “addictions” to food, NSSI, social media, work, etc. (Linehan, 2014).

DBT-SUD Research Support

With five randomized controlled trials (RCTs) supporting it, DBT is the recognized treatment of choice for co-occurring BPD and SUD (Lee, Cameron, & Jenner, 2015). Three RCTs supported DBT-SUD for reducing substance use relative to treatment as usual (TAU; Linehan et al., 1999) or for reducing use over time in a way that was comparable to somewhat stronger than comparison manualized SUD treatments (Linehan et al., 2002; Linehan et al., 2009). Two RCTs found that standard DBT without SUD modifications outperformed TAU and treatment by experts in substance use outcomes (Harned et al., 2008; van den Bosch et al., 2002). Harned and colleagues (2008) found that 87.5% of those with substance dependence who received DBT achieved full remission for at least 4 weeks, as compared to only 33.3% of those who received comparison treatment by experts. DBT-SUD findings were recently generalized in three important ways within a large pre-post effectiveness trial of primary SUD (i.e., no BPD inclusion criterion), Native-American clients, and adolescents (Beckstead et al., 2015).

Some practice tips for responding to Lying:

A common obstacle in treating clients with SUD is patterns of lying about their use, which may be particularly challenging for DBT providers committed to acceptance and validation. The following are DBT-consistent recommendations for managing this.

• Be mindful of the Active-Passivity/Apparent Competence dialectical dilemma and the accompanying secondary target of inaccurate communication. These are individuals doing the best they can who learned that others are unavailable, uninterested, uncaring, and/or punitive of failings. As such, they’ve learned to protect themselves from disappointment or attack.
• Be ready to validate lying based on the wisdom from past learning and expectations (level-4 validation).
• If you find yourself feeling hurt or angry, seek the support of your team for getting back to a phenomenologically empathic formulation where “lying” can be descriptive and without judgment.
• State your desire to develop a different, supportive, honest, and collaborative relationship.
• Assess and validate any concerns that there could be actual consequences to their honesty with you (level-5 validation), such as information that could negatively affect legal decisions if shared including probation, disability status, child protective services, divorce proceedings, etc. Balance your commitment to being “on their side” with openness about the limitations of confidentiality.
• Remain committed to acceptance regardless of their honesty, as well as committed to following the data including tox-screen results as part of addictions best-practices.
• Be clear that although dishonesty may keep you at a distance and prevent treatment from working (and could ultimately necessitate a vacation from therapy if not surmounted), this is a shared problem you have together and it will not affect your experience of them as a person.
• Listen to your gut. If the self-report is superficially plausible but doesn’t feel right, use level-three-validation mindreading such as, “As much as I would love to believe that what you’re telling me is true, and perhaps it is, I’d like you to know that I’m also completely open to the possibility that you’re not able to tell me what’s really going on right now. In fact, given the way things have gone before, you have to admit that it would be foolish of me to act as if I assumed what you’re saying is true.”
• Continue to express availability, interest in understanding, regret for lost opportunities, and the desire to work together when possible.
• Do not ask if they are telling the truth, and avoid outright accusations of lying. Such actions will only serve to back them further away from the truth.
• The use of non-demanding mindreading opens the door toward more honest communication, if not in the moment, then over time.

References

• Beckstead, D. J., Lambert, M. J., DuBose, A. P., & Linehan, M. (2015). Dialectical behavior therapy with American Indian/Alaska Native adolescents diagnosed with substance use disorders: Combining an evidence based treatment with cultural, traditional, and spiritual beliefs. Addictive behaviors, 51, 84-87.
• Harned, M. S., Chapman, A. L., Dexter-Mazza, E. T., Murray, A., Comtois, K. A., & Linehan, M. M. (2008). Treating co-occurring Axis I disorders in recurrently suicidal women with borderline personality disorder: A 2-year randomized trial of dialectical behavior therapy versus community treatment by experts. Journal of Consulting and Clinical Psychology, 76(6), 1068.
• Linehan, M. M., Lynch, T. R., Harned, M. S., Korslund, K. E., & Rosenthal, Z. M. (November, 2009). Preliminary outcomes of a randomized controlled trial of DBT vs. drug counseling for opiate-dependent BPD men and women. Presented at the 43rd Annual Convention of the Association for Behavior and Cognitive Therapies, New York, NY.
• Linehan, M. M. (2014). DBT skill training manual (2nd ed.). New York: Guilford.
• Lee, N. K., Cameron, J., & Jenner, L. (2015). A systematic review of interventions for co-occurring substance use and borderline personality disorders. Drug and alcohol review, 34(6), 663-672.
• McMain, S., Sayrs, J. H., Dimeff, L. A., & Linehan, M. M. (2007). Dialectical behavior therapy for individuals with borderline personality disorder and substance dependence. Dialectical behavior therapy in clinical practice: Applications across disorders and settings, 145-173.
• van den Bosch, L. M., Verheul, R., Schippers, G. M., & van den Brink, W. (2002). Dialectical behavior therapy of borderline patients with and without substance use problems: Implementation and long-term effects. Addictive Behaviors, 27(6), 911-923.

Seth Axelrod, PhD, is a clinical psychologist and Associate Professor of Psychiatry at the Yale University School of Medicine, where he leads DBT and DBT for Substance Use Disorder teams for Yale-New Haven Psychiatric Hospital’s Adult Intensive Outpatient Program. He received his doctorate from the University of Kentucky, completed his internship with the Connecticut Department of Mental Health and Addiction Services, and did personality disorders postdoctoral training at the Yale School of Medicine. He co-founded the annual Yale NEA-BPD Conference, founded the Connecticut DBT Network, and is a member of Marsha Linehan’s annual DBT Strategic Planning Meeting. Dr. Axelrod’s research and publications are in the areas of borderline personality disorder and DBT adaptations.

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