USING DIALECTICAL BEHAVIOR THERAPY WITH SUBSTANCE ABUSE DISORDERS

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1 USING DIALECTICAL BEHAVIOR THERAPY WITH SUBSTANCE ABUSE DISORDERS PRESENTERS: GEOFF WECKEL, PSYD MARK FOSTER, MA, LPC 550 BAILEY AVE, SUITE 302, FORT WORTH, TEXAS

2 Dialectical Behavior Therapy (DBT): Was originally developed to treat chronically suicidal individuals diagnosed with borderline personality disorder (BPD) Is now recognized as a viable treatment option for a wide range of other disorders such as substance dependence, depression, post-traumatic stress disorder (PTSD), and eating disorders

3 DBT is on SAMHSA s National Registry of Evidence- Based Programs and Practices (October 2006) as a treatment option for: Suicide Attempts, Nonsuicidal Self-Injury (parasuicidal history), Psychosocial Adjustment, Treatment Retention, Drug Use, and Symptoms of Eating Disorders

4 Adaptations of DBT have been developed for: Suicidal adolescents Individuals with substance use disorders Individuals with eating disorders Individuals with comorbid HIV and substance use disorders Developmentally delayed individuals Older adults with depression and one or more personality disorders Individuals with schizophrenia Families of patients Women experiencing domestic violence Violent intimate partners Inpatient and partial hospitalization settings for adolescents and adults Forensic settings for juveniles and adults

5 Five Essential Functions of DBT: 1) Capability Enhancement (skills training); 2) Motivational Enhancement (individual behavioral treatment plans); 3) Generalization (access to therapist outside clinical setting, homework, and inclusion of family in treatment); 4) Structuring of the environment (programmatic emphasis on reinforcement of adaptive behaviors); and 5) Capability and Motivational Enhancement of Therapists (therapist team consultation group).

6 DBT s Basic Assumptions : People are doing the best they can. People want to improve. People need to do better, try harder and be more motivated to change. People may not have caused all of their own problems but they have to solve them anyway. People must learn new behaviors in all relevant contexts. All behaviors (actions, thoughts, emotions) are caused. Figuring out and changing the causes of behavior works better than judging and blaming.

7 DBT is Based on Three Philosophical Positions: 1) Dialectical Synthesis 2) Behaviorism 3) Mindfulness

8 Dialectical Synthesis Life is filled with dialectical tension. The term "dialectical" means an integration of two opposites. The primary dialectical tension found in DBT is acceptance and change. The concatenation between acceptance and change is called the Middle Path. Change Acceptance

9 Common Dialectical Dilemmas for BPDs: Emotional Vulnerability and Self-Invalidation Active Passivity and Apparent Competence Unrelenting Crisis and Uninhibited Grieving

10 Invalidating Environment Biological Vulnerability to Emotions Chronic Emotional Dysregulation High Sensitivity High Reactivity Slow Return to Baseline Believe Thoughts, Feelingss, or Actions are Invalid Leads to Self- Invalidation Biosocial Theory Transactional Model Biological Vulnerabilities Invalidating Environment Validation Mindful of Dialect Empathically Communicating Dialect Chain Analysis

11 Chain Analysis Step 1: Describe the problem behavior. Step 2: Describe the prompting event that started the chain of events leading to the problem behavior. Step 3: Describe the factors happening before the event that made onevulnerable to starting down the chain of events toward the problem behavior. Step 4: Describe in details the chain of events that led to the problem behaviors. Step 5: Describe the consequences of the problem behaviors.

12 To Change Behaviors: Step 6: Describe skillful behaviors to replace problem links in the chain of events. Step 7: Develop prevention plans to reduce vulnerability to stressful events. Step 8: Repair important or significant consequences of the problem behavior.

13 Attentional Control (Focused Mind) Full Awareness (Opened Mind) Mindfulness is: Awareness and accepting dialectical tension, Reducing emotinal suffering while increasing well-being, Improves decision making abilities, Increases effectiveness, Increases compassion for others, and Lessons pain, suffering, and stress.

14 Mindfulness What Skills: Observe Describe Participate Mindfulness How Skills: Don t Judge Stay Focused Do What Works

15 Emotional Mind Wise Mind Rational Mind

16 Behavioral Skills: Acceptance-Oriented 1) Mindfulness being aware and accepting of one s moment-tomoment experiences 2) Distress Tolerance effectively managing pain Change-Oriented 3) Interpersonal Effectiveness fostering effective relationships 4) Emotion Regulation effectively managing feelings

17 DBT Wheel

18 There are Four Modalities in DBT: 1) DBT Skills Training Group 2) DBT Individual Therapy 3) DBT Phone Coaching 4) DBT Therapist(s) Consultation Team

19 Stages of DBT treatment: Stage 1 clients are miserable and their behavior is out of control. The goal of Stage 1 is for the client to move from being out of control to achieving behavioral control. Stage 2 clients are living a life of quiet desperation: behavior is under control but they continue to suffer, often due to past trauma and invalidation. Their emotional experience is out of control. The goal of Stage 2 is to help the client move from a state of quiet desperation to one of full emotional experiencing. Stage 3 clients are challenged to learn to live: to define life goals, build self-respect, and find peace and happiness. The goal of Stage 3 is that the client leads a life of ordinary happiness and unhappiness. Stage 4 clients are encoruaged to find spiritual purpose. The goal of treatment is for clients to move from a sense of incompleteness towards a life that involves an ongoing capacity for experiences of joy and freedom.

20 DBT uses a hierarchy of treatment targets to help the therapist determine the order in which problems should be addressed. The treatment targets in order of priority are: 1) Life-threatening Behaviors 2) Therapy-interfering Behaviors 3) Quality of Life Behaviors 4) Skills Acquisition

21 DBT applied to Substance Abuse Disorder Substance Abuse is addressed in the behaviors that interfere with quality of life. Target Behaviors of Substance Use Include: Decreasing Abuse of Substances, Alleviating Physical Discomfort Associated with Abstinence and/or Withdrawal, Diminishing Urges, Craving, and Temptations to Abuse, Avoiding Opportunities and Cues to Abuse, Reducing Behaviors Conducive to Drug Abuse, and Increasing Community Reinforcement of Healthy Behaviors.

22 Dialectical tension in Regard to Substance Abuse calls for the: immediate and permanent cessation of drug abuse (i.e. Change), while also inculcating the fact that a relapse, should it occur, does not mean that the patient cannot achieved the desired result (i.e. Acceptance). Relapse No Drugs

23 Dialectical Synthesis is found in the Serenity Prayer God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.

24 Emotional Mind experiencing raw emotions and emotional driven thoughts Rational Mind thinking rationally and logically about the facts Wise Mind the synthesis of the emotional and rational mind, which allows one to make wise decisions when problem solving Addict Mind thoughts, beliefs, action, and emotions that are under the influence of drugs Clean Mind feeling immune to problems related to drug use Clear Mind the synthesis of the addict and clean mind allows one to remain abstinence while being fully aware of the possibilities of relapse

25 DBT Skills for Substance Use Disorders Mindfulness Urge Suffering observe and describe without judgment Alternate Rebellion find alternative ways to express oneself Addict Mind Clear Mind Clean Mind

26 DBT Skills for Substance Use Disorders Distress Tolerance Burning Bridges cut off activities that increase possibilities of drug use Just for Today stay clean one day at a time Adaptive Denial seek legit activities that are pleasurable TIPP Temperature Intense Exercise Paced breating Progressively relaxing your muscles Pros and Cons

27 DBT Skills for Substance Use Disorders Emotion Regulation Opposite Action toemotions ABC Accumulating positive experiences Build mastery Cope ahead PLEASE PhysicaL Eating Avoid mood altering drugs Sleep Exercise

28 DBT Skills for Substance Use Disorders Interpersonal Effectiveness Abstinence Violation Effect Making Amends Steps 8 & 9 Butterfly Attachment GIVE DEAR MAN Interpersonal Effectiveness FAST

29 Chaining Fail Well = Prolapse

30 Strategies to Enhance Attachment to Treatment Orient the Patient to the Problem Increase Contact Provide Therapy in vivo Build Connections to the Social Network Provide Shorter or Longer Sessions as Necessary Actively Pursue Patients When They get Lost Mobilize the Team When the Therapist gets Demoralized Build the Patient s Connection to the Treatment Network

31 References Dimeff, L., & Linehan, M. (2008). Dialectical Behavior Therpay for Substance Abusers. Addiction Science Clinical Practice: 4(2) Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. McMain, S., Sayrs, J., Dimeff, L., & Linehan, M. (2007). Dialectical behavior therapy for individuals with borderline personality disorder and substance dependence. In L, Dimeff and K, Koerner (Eds.), Dialectical behavior therapy in clinical practice (pp ). New York: Guilford Press. National Register of Evidence-Based Programs and Practices. (2006). Retrieved from

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