IDD-DBT: Dialectical Behavior Therapy for Substance Use Disorders. Steve Girardeau, PsyD, LP, DBTC

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1 IDD-DBT: Dialectical Behavior Therapy for Substance Use Disorders Steve Girardeau, PsyD, LP, DBTC

2 Objectives Describe the Essential Philosophies, Interventions, and Features of IDD-DBT Summarize the Research that Supports IDD-DBT in Integrated Treatment Settings Choose Recommended Methods of Integrating IDD- DBT into Practice

Research that Supports IDD-DBT in Integrated Treatment

3 DBT Origins Begins with CBT: Linehan s Cognitive-Behavioral Treatment of Borderline Personality Disorder was published in 1993; focus on behavioral change not thought change Balanced with client centered therapy; self-acceptance, growth and change, unconditional positive regard, authentic and present focused DBT places greater emphasis on behavioral interventions compared to cognitive interventions, and is guided by a different theory than CBT DBT is directive and change-oriented

and change, unconditional positive regard, authentic and present focused DBT places greater emphasis on behavioral

4 Origin of DBT-S Linehan and Dimeff conducted a number of small trials of DBT with women with borderline personality and substance use disorders They used the standard researched model with some additions The limited findings showed that the approach was efficacious Linehan s plans for a DBT-S manual have been promised but left unfulfilled

researched model with some additions The limited findings showed that the approach

5 Essential 5 Functions of IDD-DBT Improve clients motivation for change (MI techniques) Enhance clients capabilities (Skills Training) Help clients generalize skills/behaviors to their natural environments (Behavioral Activation Plans) Enhance the motivation and skill of therapists (Consultation) Structure the treatment/program and environment The 5 functions can be applied in any and all treatment modalities

(Behavioral Activation Plans) Enhance the motivation and skill of therapists (Consultation) Structure

6 Integrated Treatment Guidelines Originate from SAMHSA (Substance Abuse and Mental Health Services Administration) Call for integrated (not serial) services Cross-trained providers Stage-oriented treatment Motivational interventions Cognitive-behavioral interventions Multiple formats Integrated medication services

services Cross-trained providers Stage-oriented treatment Motivational

7 Dialectical Philosophy No position is absolute; each position has its own wisdom or truth for the individual. The synthesis of opposites and seeking a workable balance, leads to change Change is continual, so dialectics require fluidity

The synthesis of opposites and seeking a workable balance,

8 Dialectic Synthesis in IDD-DBT Acceptance of self and working for change Validation and challenge The serenity prayer (acceptance and change) Emotion and reason (Wise Mind) Active client and active therapist (collaboration) Goals of others and goals of client

(acceptance and change) Emotion and reason (Wise Mind) Active

9 Dialectical Dilemmas with Dual Disorders Wanting yet resisting change Taking a minor lapse to an extreme relapse Having goals or values conflict with behaviors Using even when it actively causes harm Removing triggers AND dealing with triggers

Having goals or values conflict with behaviors Using even

10 Dialectical Abstinence This is not harm reduction 100% (undialectical) commitment to cease substance use (or another harmful behavior) When a setback happens, you get back on your horse and ride rather than compounding the mistake Use of acceptance and nonjudgment helps in learning

setback happens, you get back on your horse and ride rather than

11 IDD-DBT View of Abstinence Not all clients can be abstinent at the beginning of treatment, yet abstinence is an agreed upon goal Not all clients entering treatment have the skills to maintain abstinence Commitment to abstinence happens with realistic timeframes that can be re-upped Therapists take a nonjudgmental approach to lapse and relapse Clients with high comorbidity can only change so much, so fast Medications are an accepted part of the treatment protocol

happens with realistic timeframes that can be re-upped Therapists take a nonjudgmental approach to lapse and relapse

12 DBT Theory: The Biosocial Model Clients suffer from emotional vulnerabilities Emotional vulnerabilities can come from many sources (e.g., attachment issues, loss, trauma, biology) Chronic and consistent invalidation (by self or other) exacerbates emotional vulnerabilities An ongoing, reciprocal relationship exists between emotional vulnerabilities and environments

, attachment issues, loss, trauma, biology) Chronic and consistent invalidation (by self or

13 DBT Theory: The Biosocial Model Emotional vulnerabilities are characterized by: - Emotional sensitivity - Emotional reactivity - Slow return to emotional baseline Over time emotions get sensitized, leading to a kindling effect This emotionality (and associated invalidation) is associated with many problems (disorders) Emotionality leads to escape and avoidance behaviors

get sensitized, leading to a kindling effect This emotionality (and associated invalidation)

14 Biosocial Theory Coherently Guides Treatment Targets and Strategies Validation is a primary intervention to: Reduce acute emotionality Provide gentle exposure to emotions Provide a corrective validating environment (and new learning) Create a bridge to learning self-validation Open the client up to change interventions Emotion regulation is taught to: - Understand how emotion happen - Reduce vulnerability to intense emotions - Increase opportunities for positive emotions - Assist in stepping out of ineffective mood-congruent behaviors 26

self-validation Open the client up to change interventions Emotion regulation is taught to: - Understand how emotion happen - Reduce

15 Biosocial Theory Coherently Guides Treatment Targets and Strategies Mindfulness (non-judgment and acceptance) is taught to: Reduce amplifying emotions Reduce escape and avoidance of emotions Create qualitatively different and effective experience of emotions Distress Tolerance is taught to: - Provide healthy ways of coping with emotions when needed Use the theory to conceptualize the purpose of the interventions used

qualitatively different and effective experience of emotions Distress Tolerance is taught to: - Provide

16 IDD-DBT and Other Approaches Motivational Interviewing is compatible with IDD-DBT (and called for by IDDT guidelines). Both have strong Rogerian aspects and use dialectical concepts. IDD-DBT is more directive, can be more protocol driven, and rests on skills training as essential IDD-DBT has substantial overlap with Relapse Prevention. Both embrace concepts of acceptance, learning from setbacks, and developing action plans to prevent future setbacks IDD-DBT has greatest contrasts with Traditional CD treatment and Twelve-step. However, aspects of both approaches can be thoughtfully combined IDD-DBT supports dialectical abstinence while not wavering from promoting total abstinence as a treatment goal

IDD-DBT is more directive, can be more protocol driven, and rests on skills training as essential IDD-DBT has substantial overlap with Relapse Prevention.

17 Importance of Treatment Structure Clear treatment framework (i.e., structure) is a common factor in empirically supported treatments for borderline personality disorder (BPD) (Weinburg et al., 2011) Research shows that more complex client presentations require greater treatment structure Structure creates predictability, safety, and success for clients and therapists

18 Examples of Treatment Structure Within the Service Delivery Clear informed consent and limits of confidentiality Describing the typical routines of therapy and/or each part of a program Detailed therapy agreements, rules, and expectations (of therapists too) Detailed protocols for dealing with safety issues Use of the treatment hierarchy Use of diary cards, homework, and written safety and skills plans Treatment plans with clear goals and objectives, created early in the therapy process Start and end on time!

too) Detailed protocols for dealing with safety issues Use of the treatment hierarchy Use of diary cards, homework, and written

19 IDDT Treatment Stages Engagement: primary goal is developing rapport and the beginning of the treatment alliance Persuasion: primary goal is building awareness of mental health and chemical health issues Active Treatment: primary goal is ever-increasing progress on both sets of symptoms Relapse Prevention: client is abstinent and primary goal is vigilance to avoid relapse and work on other recovery goals

health issues Active Treatment: primary goal is ever-increasing progress on both sets of symptoms

20 Dialectical Perspective on Stages of Change Find what client is willing to work on Remember that alliance rests on agreement on goals and methodology Consider starting with where the client is at (also remembering engagement stage)

on agreement on goals and methodology Consider starting

21 Commitment Strategies Foot in the Door Tying to Prior Commitments Freedom and Choice in the Absence of Alternatives Devil s Advocate Commitment strategies are HUGE with this population due to butterfly attachment: more frequent contact at the start, revisit commitment often

22 Orienting Strategies Involves educating and socializing the client to treatment Showing how skills, interventions, homework, etc. help clients reach their stated wants, needs, and goals

23 Other Dialectical Change Strategies Metaphor and Teaching Stories Playing Devil s Advocate Extending (aikido self-defense) (can be used with resistance) Activating Wise Mind Making Lemonade Out of Lemons Allowing Natural Change Dialectic Assessment: What s Missing?

24 Best Ways to Change Behaviors Reinforce anything and everything that is not a problem behavior (clients emit positive behaviors nearly continuously) Train a new behavior (skill) to reinforce Make a high probability behavior contingent on a low probability behavior (i.e., Premack Principle) Put a problem behavior on cue (i.e., bring it under stimulus control) Understand the motivation for the behavior and use it to leverage change Aim For Behaviors That Push But Do Not Exceed Client s Capabilities

25 Behavioral Contingencies The consequences of behavior influence what we learn A temporally close relationship between behavior and consequence influences what will happen the next time we are in a similar situation with similar context Highlighting contingencies (e.g., structure, expectations, safety, immediate feedback, etc.) helps clients learn and be more effective

26 IDD-DBT in Inpatient/Residential Settings Train all staff on philosophy: acceptance, non-judgmental stance, and validation balanced with skills and change strategies Train all staff on skills and adopt skills language Develop milieu both with clients and in consultation with each other Decide what targets or goals are realistic given timeframes/length of stay and structure accordingly (inpatient) Decide level of experience of staff and ability to implement difference aspects (residential) Decide if there is a go-to or assigned staff for each client or if a true team approach is used Be thoughtful and consistent in the approach

27 IDD-DBT with Case Management IDD-DBT philosophy and milieu with clients and case management team Close communication with therapist and team (can be part of team rather than ancillary) Balance validation with accomplishing case management tasks Interweave skills with case management tasks Offers naturalistic opportunities to generalize skills

28 IDD-DBT in Private Practice Integrate individual therapy mode and skill training mode creatively Apply to wide-ranging diagnoses Avoid common therapist interfering behaviors Arrange for formal consultation. Does not need to be other IDD-DBT therapists

USING DIALECTICAL BEHAVIOR THERAPY WITH SUBSTANCE ABUSE DISORDERS

USING DIALECTICAL BEHAVIOR THERAPY WITH SUBSTANCE ABUSE DISORDERS PRESENTERS: GEOFF WECKEL, PSYD MARK FOSTER, MA, LPC 550 BAILEY AVE, SUITE 302, FORT WORTH, TEXAS WWW.RESTORATIONCEC.COM Dialectical Behavior