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Dialectical Behavior Therapy for Substance Abusers

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Dialectical behavior therapy (DBT) is a well-established treatment for individuals with multiple and severe psychosocial disorders, including those who are chronically suicidal. Because many such patients have substance use disorders (SUDs), the authors developed DBT for Substance Abusers, which incorporates concepts and modalities designed to promote abstinence and to reduce the length and adverse impact of relapses. Among these are dialectical abstinence, "clear mind," and attachment strategies that include off-site counseling as well as active attempts to find patients who miss sessions. Several randomized clinical trials have found that DBT for Substance Abusers decreased substance abuse in patients with borderline personality disorder. The treatment also may be helpful for patients who have other severe disorders co-occurring with SUDs or who have not responded to other evidence-based SUD therapies.
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SCIENCE AND PRACTICE IN ACTION—DIALECTCAL BEHAVIOR THERAPY • 39
Dialectical Behavior Therapy for Substance Abusers
Linda A. Dimeff, Ph.D.
1
Marsha M. Linehan, Ph.D.
2
1
Behavioral Tech Research, Inc.
Seattle, Washington
2
Department of Psychology, University of
Washington
Seattle, Washington
D
ialectical behavior therapy (DBT) is a well-established treatment for individuals with multiple and severe psychosocial dis-
orders, including those who are chronically suicidal. Because many such patients have substance use disorders (SUDs),
the authors developed DBT for Substance Abusers, which incorporates concepts and modalities designed to promote abstinence
and to reduce the length and adverse impact of relapses. Among these are dialectical abstinence, “clear mind,” and attachment
strategies that include off-site counseling as well as active attempts to find patients who miss sessions. Several randomized
clinical trials have found that DBT for Substance Abusers decreased substance abuse in patients with borderline personality dis-
order. The treatment also may be helpful for patients who have other severe disorders co-occurring with SUDs or who have not
responded to other evidence-based SUD therapies.
D
eveloped by coauthor Dr. Marsha M. Linehan, dialectical behavior ther-
apy (DBT) is a comprehensive treatment program whose ultimate goal
is to aid patients in their efforts to build a life worth living. When DBT
is successful, the patient learns to envision, articulate, pursue, and sustain goals that
are independent of his or her history of out-of-control behavior, including substance
abuse, and is better able to grapple with lifes ordinary problems. DBTs emphasis
on building a life worth living is a broader therapeutic goal than reduction in
problem behaviors, symptom management, or palliative care.
The word dialectic refers to the synthesis of two opposites. The fundamental prin-
ciple of DBT is to create a dynamic that promotes two opposed goals for patients:
change and acceptance. This conceptual framing evolved in response to a dilemma
that arose in the course of trying to develop an effective treatment for suicidal patients.
Dr. Linehans basic premise for DBT was that people who wanted to be dead
did not have the requisite skills to solve the problems that were causing their pro-
found suffering and build a life worth living. However, a sole emphasis on pro-
moting behavioral change quickly proved unworkable. Many patients were
exquisitely sensitive to criticism; when prompted to change, they responded by shut-
ting down emotionally or by exhibiting increased, sometimes overwhelming emo-
tional arousal—for example, storming out of sessions or, occasionally, even attack-
ing the therapist. At the same time, dropping the emphasis on change and instead
encouraging patients to accept and tolerate situations and feelings that distressed
them produced equally negative consequences. Patients then viewed their thera-
40 • ADDICTION SCIENCE & CLINICAL PRACTICE—JUNE 2008
pist as ignoring or minimizing their suffering and responded
with extreme rage or fell into a sea of hopelessness.
In short, patients experienced both promptings for
acceptance and promptings for change as invalidating
their needs and their experience as a whole, with pre-
dictable consequences of emotional and cognitive dys-
regulation and failure to process new information. To
surmount this dilemma—to keep the suicidal patient
in the room and working productively—DBT incor-
porates a dialectic that unites change and acceptance.
The treatment balances the patients desire to eliminate
all painful experiences (including life itself) with a
corresponding effort to accept lifes inevitable pain. With-
out this synthesis, the patient’s problems tended to con-
verge and overwhelm both patient and therapist; with
it, the patient can work on changing one set of prob-
lems while tolerating—at least temporarily—the pain
evoked by other problems.
The treatment of severe disorders requires the syn-
thesis of many dialectical polarities, but that of accept-
ance and change is the most fundamental. The simul-
taneous embrace of acceptance and change in DBT is
consistent with the philosophical approach found in
Twelve-Step programs, expressed in the Serenity Prayer:
“God, grant me the serenity to accept the things I can-
not change, the courage to change the things I can, and
the wisdom to know the difference.”
The spirit of a dialectical point of view is never to
accept a proposition as a final truth or indisputable fact.
In the context of therapeutic dialogue, dialectic refers to
bringing about change by persuasion and to making
strategic use of oppositions that emerge within therapy
and the therapeutic relationship. In the search for the
validity or truth contained within each contradictory
position, new meanings emerge, thus moving the patient
and therapist closer to the essence of the subject under
consideration. The patient and therapist regularly ask,
“What havent we considered?” or “What is the synthe-
sis between these two positions?”
DBT OVERVIEW AND PROCEDURES
Dr. Linehan developed DBT as an application of the
standard behavioral therapy of the 1970s to treat chron-
ically suicidal individuals (Linehan, 1987, 1993a, 1993b).
Subsequently, it was adapted for use with individuals
with both severe substance use disorder (SUD) and bor-
derline personality disorder (BPD), one of the most com-
mon dual diagnoses in substance abuse and mental health
clinical practice. The co-occurrence of SUD and BPD
causes severe emotional dysregulation, increases the prob-
ability of poor treatment outcomes, and increases the
risk of suicide. DBT includes explicit strategies for over-
coming some of the most difficult problems that com-
plicate treatment of both conditions, including weak
treatment engagement and retention.
The patient’s individual therapist is the primary treat-
ment provider in DBT. He or she takes ultimate respon-
sibility for developing and maintaining the treatment
plan for the patient.
The treatment includes five essential functions:
improving patient motivation to change,
enhancing patient capabilities,
generalizing new behaviors,
structuring the environment, and
enhancing therapist capability and motivation.
In outpatient therapy, these functions are delivered
via four treatment modes: individual therapy, group
skills training, telephone consultation, and therapy for
the therapist.
Like other behavioral approaches, DBT classifies
behavioral targets hierarchically. The DBT target hier-
archy is to decrease behaviors that are imminently life-
threatening (e.g., suicidal or homicidal); reduce behav-
iors that interfere with therapy (e.g., arriving late or not
attending therapy, being inattentive or intoxicated dur-
ing the session, or dissociating during the session); reduce
behaviors with consequences that degrade the quality
of life (e.g., homelessness, probation, Axis I behavioral
problems, or domestic violence); and increase behav-
ioral skills. In any given session, a DBT therapist will
pursue a number of these targets but will place the great-
est emphasis on the highest order problem behavior man-
ifested by the patient during the past week.
For substance-dependent individuals, substance abuse
is the highest order DBT target within the category of
behaviors that interfere with quality of life. DBTs sub-
stance-abuse–specific behavioral targets include:
decreasing abuse of substances, including illicit drugs
and legally prescribed drugs taken in a manner not
prescribed;
alleviating physical discomfort associated with absti-
nence and/or withdrawal;
diminishing urges, cravings, and temptations to abuse;
avoiding opportunities and cues to abuse, for example
by burning bridges to persons, places, and things asso-
ciated with drug abuse and by destroying the telephone
numbers of drug contacts, getting a new telephone
number, and throwing away drug paraphernalia;
The spirit of a
dialectical
point of view
is never to
accept a
proposition as
a final truth or
indisputable
fact.
SCIENCE AND PRACTICE IN ACTION—DIALECTICAL BEHAVIOR THERAPY • 41
reducing behaviors conducive to drug abuse, such as
momentarily giving up the goal to get off drugs and
instead functioning as if the use of drugs cannot be
avoided; and
increasing community reinforcement of healthy behav-
iors, such as fostering the development of new friends,
rekindling old friendships, pursuing social/vocational
activities, and seeking environments that support absti-
nence and punish behaviors related to drug abuse.
THE DIALECTICAL APPROACH TO
ABSTINENCE
In the quest for abstinence, the DBT dialectic takes the
form of pushing for immediate and permanent cessa-
tion of drug abuse (i.e., change), while also inculcat-
ing the fact that a relapse, should it occur, does not mean
that the patient or the therapy cannot achieve the desired
result (i.e., acceptance). The dialectical approach there-
fore joins unrelenting insistence on total abstinence with
nonjudgmental, problem-solving responses to relapse
that include techniques to reduce the dangers of over-
dose, infection, and other adverse consequences.
Establishing Abstinence Through Promoting
Change
The therapist communicates the expectation of absti-
nence in the very first DBT session by asking the patient
to commit to stop using drugs immediately. Because a
lifetime of abstinence may seem out of reach, the ther-
apist encourages the patient to commit to a length of
abstinence that the patient feels certain is attainable—
a day, a month, or just 5 minutes. At the end of this
period, the patient renews the commitment, again for
a sure interval. Ultimately, he or she achieves long-term,
stable abstinence by piecing together successive delim-
ited drug-free periods. The Twelve Steps slogan, “Just
for Today,” invokes the same cognitive strategy to reach
the same goal—a lifetime of abstinence achieved moment
by moment.
A second absolute abstinence strategy teaches patients
to “cope ahead” (Linehan, in press). The patient learns
the behavioral skill of anticipating potential cues in the
coming moments, hours, and days, and then proactively
preparing responses to high-risk situations that other-
wise might imperil abstinence. Additionally, the ther-
apist presses the patient to burn the bridges to his or her
drug-abusing past—for example, to get a new telephone
number, tell drug-abusing friends that he or she is off
drugs, and throw out drug paraphernalia. Woven through-
out the absolute abstinence pole of the dialectic is the
clear message that the use of drugs would be disastrous
and must be avoided.
Supporting Abstinence by Encouraging Acceptance
DBT treats a lapse into substance abuse as a problem to
solve, rather than as evidence of patient inadequacy or
treatment failure. When a patient does slip, the thera-
pist shifts rapidly to helping the patient fail well—that
is, the therapist guides the patient in making a behav-
ioral analysis of the events that led to and followed drug
use, and gleaning all that can be learned and applied
PREVALENCE AND CONSEQUENCES OF SUD-BPD
COMORBIDITY
In studies published between 1986 and 1997, reported rates of border-
line personality disorder (BPD) among patients seeking treatment for
substance use disorders (SUDs) ranged widely, from 5 to 65 percent
(Trull et al., 2000). More recently, Darke and colleagues (2004) docu-
mented a 42 percent prevalence of BPD among 615 heroin abusers in
Sydney, Australia. Conversely, in Trull’s review, the prevalence of current
SUDs among patients receiving treatment for BPD ranged from approxi-
mately 26 to 84 percent.
That SUD and BPD should frequently co-occur stands to reason,
because substance abuse is one of the potentially self-damaging impul-
sive behaviors that constitute diagnostic criteria for the personality dis-
order. However, this overlap in criteria cannot account for the full extent
of the comorbidity. For example, Dulit and colleagues (1990) found that,
among study participants with SUDs, 85 percent of those who also met
the criteria for BPD would still have done so because of symptoms unre-
lated to substance abuse.
Individuals with SUD and BPD are among the most difficult patients to
treat for either condition, and they have more problems than those with
only one or the other (Links et al., 1995). For example, rates of suicide
and suicide attempts, already high among substance abusers (Beau-
trais, Joyce, and Mulder, 1999; Links et al., 1995; Rossow and Lauritzen,
1999) and individuals with BPD (Frances, Fyer, and Clarkin, 1986; Stone,
Hurt, and Stone, 1987), are even higher for those with both disorders
(Rossow and Lauritzen, 1999). Substance-abusing patients have signifi-
cantly more behavioral, legal, and medical problems, including alco-
holism and depression, and are more extensively involved in substance
abuse if they also have a personality disorder (Cacciola et al., 1995, 2001;
McKay et al., 2000; Nace, Davis, and Gaspari, 1991; Rutherford, Cacci-
ola, and Alterman, 1994). Results from one study suggest, further, that
patients with BPD have more severe psychiatric problems than patients
with other personality disorders (Kosten, Kosten, and Rounsaville,
1989). In a 6-year study with 290 BPD patients, Zanarini and colleagues
(2004) found that the co-occurrence of an SUD was the factor most
closely associated with poor treatment outcomes.
42 • ADDICTION SCIENCE & CLINICAL PRACTICE—JUNE 2008
to future situations. Additionally, the therapist helps the
patient make a quick recovery from the lapse. This stance
and procedure correspond to Marlatt’s paradigm of “pro-
lapse” to alleviate the abstinence violation effect (AVE;
Marlatt and Donovan, 2005) by mitigating the intense
negative emotions and thoughts that many patients feel
after a lapse and that can hinder reestablishing absti-
nence (“What’s the point? I’ve already blown it. I might
as well really go for it.”).
The idea of failing well also involves repairing the
harm done to oneself and others during the lapse.
This concept is similar to making amends in Steps Eight
and Nine of Twelve Steps (Alcoholics Anonymous, 2006)
and serves two functions:
increasing awareness and memory of the negative con-
sequences when the person uses drugs, and
directly treating a component of AVE, namely, justi-
fied guilt.
Once the individual has resumed abstinence, the
therapist moves back to the opposite (absolute absti-
nence) pole. Failing well may be particularly important
for individuals who have BPD as well as SUD, given
their susceptibility to dysregulated emotion.
Further Comments on Dialectical Abstinence
The process of dialectical abstinence can be compared
to the actions of a quarterback in football. The quar-
terback focuses constantly on the ultimate goal of scor-
ing a touchdown, even if only a few yards are gained
in each play and even if ground is lost.
The DBT therapist, likewise, always
moves the patient toward the goal,
stops only long enough to get the
patient back on his or her feet
after a fall, and is always ready
with the next play that will eventually
bring him or her to the goal line.
The conceptual basis of DBT is incon-
sistent with making the benefits of treat-
ment (e.g., receipt of prescribed anti-
craving medications, attendance at
sessions, continued participation in
treatment) contingent on abstinence.
Rather than punishing patients for
the very problems that brought them
into treatment, DBT assumes that
patients are doing the best they
can and must continue work-
ing to achieve their goals.
A common misunderstanding involves the scope of
abstinence required in DBT. Many Twelve-Step pro-
grams require complete abstinence from all psychoac-
tive substances—not only illicit and misused addictive
substances or alcohol, but also prescribed medica-
tions. In DBT, the counselor determines the scope of
abstinence appropriate for each patient based on a thor-
ough assessment and three ruling principles:
Target the primary drug(s) of abuse—that is, those
that are causing the most significant problems for the
patient, as determined by the patient’s history of abuse,
and diagnostic and behavioral assessments.
Target other drugs that appear to reliably precipitate
use of the primary drug of abuse—for example, some
patients may not use marijuana frequently but may
end up injecting their primary drug of abuse, heroin,
every time they do.
Make sure that the treatment goals are, in fact, attain-
able.
With regard to the third principle, patients with
SUD and BPD typically have myriad problem behav-
iors, including self-injurious and suicidal behaviors, in
addition to those associated with drug abuse. Pragmat-
ically, there is only so much that a severely disordered
patient can be expected to change at one time. For exam-
ple, DBT may not target a patients drinking, even if
consumption of alcohol exceeds recommended guide-
lines, unless (i) the patient states an explicit interest in
stopping alcohol use; (ii) alcohol is the primary drug
causing the individual’s problems; or (iii) alcohol is reli-
ably associated with use of the primary drug of choice
or another higher order target—for example, if the patient
attempts suicide only when drunk.
Patients with SUD typically begin DBT in a men-
tal and behavioral state that we call “addict mind.” Their
thoughts, beliefs, actions, and emotions are under the
control of drugs. As they achieve increasingly lengthy
abstinence, they typically develop an outlook that we
call “clean mind.” In this state, they are off drugs but
seemingly feel immune from future problems—a lack
of vigilance that can set the stage for lapses. The alter-
nation between addict mind and clean mind constitutes
a dialectic that leads to the emergence, during the process
of dialectical abstinence seeking, of a third state called
clear mind.” Now, the individual enjoys abstinence
while remaining fully aware of the nearness and ten-
dencies of that addict mind; he or she is vigilant and
takes measures to avoid or cope with the circumstances
that can—in a moment—restore addict mind.
SCIENCE AND PRACTICE IN ACTION—DIALECTICAL BEHAVIOR THERAPY • 43
DBT STRATEGIES FOR ATTACHMENT
Drug-abusing individuals are often difficult to draw into
treatment. Although some attach easily to their treat-
ment providers, others behave like butterflies, flying fre-
quently into and out of the therapist’s hand and depart-
ing just at the very moment when the therapist believes
they have landed for good (Linehan, 1993a). Common
butterfly problems include episodic engagement in ther-
apy, failure to return telephone calls or participate in ses-
sions, and ultimately early termination from treatment.
Additionally, the therapist has relatively little power to
persuade butterfly patients to do things they prefer
not to do.
DBT employs a number of strategies to engage treat-
ment butterflies. These strategies increase the positive
valence of therapy and the therapist, re-engage “lost
patients, and prevent the deleterious consequences that
commonly occur during periods when patients fall
out of contact with their therapist. Until an attachment
is secured and the substance-dependent individual is out
of significant danger of relapse, DBT therapists are active
in finding lost patients and re-engaging them in treat-
ment.
Beginning in the first therapy session, the therapist
orients the patient to the butterfly attachment problem,
and the two discuss the likelihood that the patient
may fall out of contact with the therapist during the
course of treatment. A “just in case” plan is established:
The patient makes a list of all the places the therapist
might look should the patient become lost (e.g., addresses
and telephone numbers for drug-abusing friends, places
where the patient goes to abuse drugs), as well as sup-
portive family and friends who can be counted on to
help the therapist and patient in this event. Other strate-
gies include increasing contact with the patient during
the first several months of treatment (e.g., scheduling
check-in telephone calls between sessions, exchanging
voice mail or e-mail messages); bringing therapy to the
patient—that is, conducting sessions at his or her home,
in a park, in a car, or at a diner; and shortening or length-
ening therapy sessions.
CLINICAL TRIALS OF DBT
The adaptation of DBT to patients with SUD and BPD
represents a natural extension of the therapy, in light
of the comorbiditys frequent and often synergistic threat
to life (see Prevalence and Consequences of SUD-BPD
Comorbidity). The adaptation was designed for a popu-
lation of individuals with SUD that is largely heteroge-
neous across drugs of abuse and demographic variables.
To date, nine published randomized controlled
trials (RCTs) conducted across five research institutions
have evaluated DBT. The results support DBTs effi-
cacy in reducing a number of behavioral problems,
including suicide attempts and self-injurious behaviors
(Koons et al., 2001; Linehan et al., 1991, 2006; Line-
han, Heard, and Armstrong, 1993; van den Bosch et al.,
2005; Verheul et al., 2003), substance abuse (Linehan
et al., 1999, 2002), bulimia (Safer, Telch, and Agras,
2001), binge eating (Telch, Agras, and Linehan, 2001),
and depression in the elderly (Lynch et al., 2003). These
and other studies have also demonstrated that DBT is
44 • ADDICTION SCIENCE & CLINICAL PRACTICE—JUNE 2008
more cost-effective than treatment as usual in reducing
the medical severity of suicide attempts, hospitalization,
emergency room visits, and utilization of crisis/respite
beds (American Psychiatric Association, 1998; Linehan
and Heard, 1999).
Two of the RCTs focused specifically on the appli-
cation of DBT for individuals with SUD and BPD. Both
were conducted by Dr. Linehan and colleagues at the
University of Washington (Linehan et al., 1999, 2002).
The majority of participants were polysubstance-depend-
ent with extensive histories of substance abuse and unsuc-
cessful attempts at abstaining from drugs prior to begin-
ning DBT. Comprehensive DBT that included all modes
and functions was provided in both trials across a 12-
month course of treatment. In each trial, the assessment
phase spanned a total of 24 months, from pretreatment
through a year following treatment completion. The ini-
tial RCT compared DBT (n = 12) with community-
based treatment as usual (n = 16) among polysubstance-
dependent women with BPD (Linehan et al., 1999).
Those who received DBT were significantly more likely
to remain in treatment (64 versus 27 percent), achieved
greater reductions in drug abuse as measured by struc-
tured interviews and urinalyses throughout the treat-
ment year, and attended more individual therapy
sessions than subjects receiving treatment as usual. Addi-
tionally, although trial participants in both conditions
improved in social and global adjustment during the
treatment year, only DBT subjects sustained these improve-
ments at the 16-month followup.
The second trial involved 23 opiate-dependent indi-
viduals with BPD and used a more rigorous control con-
dition, comprehensive validation therapy with Twelve
Steps (CVT+12). This CVT + Twelve Steps is a manu-
alized approach that includes the major acceptance-based
strategies used in DBT in combination with participa-
tion in a Twelve -Step program, such as that used in Nar-
cotics Anonymous (NA). Therapists focused on vali-
dating the patient in a warm and supportive
atmosphere—providing, of course, that the behavior
was effective in terms of the patient’s long-term goals.
Subjects in the CVT +12 arm of the study were required
to attend at least one NA meeting weekly, conducted at
the treatment clinic and facilitated by the therapists,
both of whom were members of NA. All subjects took
levomethadyl (ORLAAM, which is no longer avail-
able in Europe or the United States), an opiate replace-
ment medication, throughout the treatment year and
continued to receive it post-treatment.
Three major findings emerged from this study. First,
although both treatments were associated with urinal-
ysis-confirmed reductions in opiate abuse, only DBT
subjects maintained these reductions during the last 4
months of treatment. Second, both treatments retained
subjects in treatment, but CVT + 12 was exceptionally
effective in doing so (100 versus 64 percent in DBT).
Finally, both post-treatment and at the 16-month fol-
lowup assessment, subjects in both treatment conditions
IS DBT APPROPRIATE FOR PATIENTS WITH SUD BUT
NOT BPD?
Pending clinical efficacy trials, we suggest considering a few basic prin-
ciples in deciding whether to intervene with dialectical behavioral ther-
apy (DBT) when substance-abusing patients do not have comorbid bor-
derline personality disorder (BPD). First, be guided by what is known
from the empirical literature. Is there a treatment already proven for the
patient’s particular problem or problems? Second, be parsimonious. All
things being equal, consider beginning with a less complex and compre-
hensive treatment than DBT. Although DBT contains elements that
doubtless will be therapeutic for most patients, it is also likely to be con-
siderably more extensive than most patients with a substance use disor-
der (SUD) require. Third, consider the extent to which emotional dysreg-
ulation plays a role in the individual’s continued use of drugs. As DBT
was developed specifically for individuals with pervasive emotional dys-
regulation, DBT may be a good fit for people whose use of drugs is asso-
ciated with affective dyscontrol. DBT may be ineffective for individuals
with whom emotions play little, if any, role in their sustained use of
drugs.
On the other hand, given that DBT was developed for a population of
difficult-to-treat patients with multiple Axis I and Axis II problems, it
may be a reasonable approach for the non-BPD multidiagnostic SUD
patient who has failed on multiple occasions in other evidence-based
SUD therapies. DBT may also be a reasonable first-line treatment for
individuals who are substance dependent and chronically suicidal but
do not meet criteria for BPD.
The case of “Lucy” illustrates the kind of non-BPD patient who may ben-
efit from DBT. An opiate-dependent woman in her mid-30s, Lucy has
been repeatedly discharged from a community methadone maintenance
program because of drug-positive urinalyses and problems with atten-
dance. In addition to meeting criteria for opiate dependence, Lucy has
had multiple episodes of major depression and is currently living with
an abusive partner who is not interested in quitting his own use of
drugs. A careful behavioral analysis highlights the central role of emo-
tional dyscontrol resulting in her frequent use of drugs (often before
having sex with her boyfriend; after an argument with him; or as a way to
escape negative emotions, including sadness). Although Lucy does not
meet the full criteria for treatment with BPD, the intervention may still
be warranted because many of her problems are rooted in emotional
dyscontrol.
SCIENCE AND PRACTICE IN ACTION—DIALECTICAL BEHAVIOR THERAPY • 45
showed overall reductions in levels of psychopathol-
ogy relative to baseline.
Clearly, further studies are required to confirm the
efficacy of DBT for individuals with SUD and BPD.
However, the data thus far are promising, and additional
research/clinical trials are under way.
To date, no clinical trials have evaluated DBT for
patients with SUD but not BPD. However, we believe
that certain circumstances and considerations may
justify its use for the treatment of SUD patients who
have other severe co-occurring psychosocial problems
and/or have failed to respond to other SUD therapies
(see Is DBT Appropriate for Patients With SUD But Not
BPD?).
TREATMENT FIDELITY AND CLINICAL
OUTCOMES
To date, two published studies have evaluated the rela-
tionship of DBT fidelity to treatment outcome; both
confirm the importance of program fidelity and clini-
cal adherence to the treatment manual. The first study
(Linehan, 1993a) was an RCT designed to address the
question: Can DBT skills training, when separated from
the other modes and functions of DBT, be beneficial?
Chronically suicidal individuals with BPD receiving
outpatient non-DBT individual therapy were randomly
assigned to receive either DBT skills training (n = 11)
or a wait list control (n = 8). After 12 months of treat-
ment, while subjects in both conditions improved
over time, no significant differences between conditions
were detected in any outcome variables, including sui-
cidal and nonsuicidal self-injurious behavior, lethality
of suicide attempts, emergency room visits, and inpa-
tient hospital admissions. Additionally, the analysis did
not suggest that the failure to detect a difference between
conditions was due to the small sample size.
Although subjects from this sample were not sub-
stance-dependent, there is no reason to expect the find-
ings would differ among those who are. This study clearly
indicates that providing pieces of DBT separated from
the comprehensive model does not improve clinical out-
comes for chronically suicidal BPD patients already
engaged in non-DBT therapy. What is not known is
whether DBT skills training alone, when compared with
no treatment or less treatment (e.g., periodic case man-
agement), would be of benefit. Given the strength of
current data on comprehensive DBT for patients with
severe BPD, the absence of data supporting a “lighter
version of DBT, and the high-risk nature of the patient
population, it is advisable to preserve the treatments
integrity.
A second RCT by Dr. Linehan and colleagues (2002)
examined the relationship of DBT treatment adherence
to a key clinical outcome—drug-free urinalyses—in sub-
stance-dependent individuals with BPD. In compari-
son with patients assigned to non-DBT-adherent ther-
apists (n = 3), patients of therapists who adhered to
the treatment manual (n = 4) had significantly more
drug-free urinalyses throughout the treatment year (F
= 5.71; P > 0.038) and at the 12-month post-treatment
assessment (F = 9.6; P > 0.018). In other words, stick-
ing to the manual (adhering to the treatment at all turns)
improves clinical outcomes.
COST-EFFECTIVENESS OF DBT
The highest health care costs associated with BPD are
the result of lengthy and repeated psychiatric hospital-
izations (Linehan and Heard, 1999). Two studies have
been published to date demonstrating that outpatient
DBT can yield considerable cost savings for public sec-
tor systems (American Psychiatric Association, 1998).
In the first RCT of DBT for chronically suicidal patients
with BPD, Dr. Linehan and Dr. Heard (1999) found
that the treatment saved $9,000 per patient during the
initial treatment year over the cost of treatment as usual.
Data from the Mental Health Center of Greater Man-
chester in New Hampshire also demonstrated signifi-
cant cost savings and improvements in clinical outcomes
in chronically suicidal individuals with BPD (American
Psychiatric Association, 1998). Comparison of the psy-
chiatric services used in the year before therapy with
those used in the year following therapy by patients (n
= 14) who completed a year of DBT showed significant
decreases in psychiatric service utilization: 77 percent
in hospitalization days, 76 percent in partial hospital-
ization days, 56 percent in crisis beds, and 80 percent
in emergency room contacts. Total service costs also fell
dramatically: from $645,000 to $273,000. We know of
no separate studies to date that evaluate cost savings of
DBT for a comorbid SUD and BPD patient popula-
tion.
DBT MANUALS AND TRAINING
Dr. Linehans (1993a) Cognitive-Behavioral Treatment
of Borderline Personality Disorder provides a compre-
hensive description of the treatment. Skills Training
Manual for Treating Borderline Personality Disorder (Line-
han, 1993b) describes the skills, strategies for teaching
Data on the
efficacy of
dialectical
behavior
therapy for
individuals
with substance
use disorders
and borderline
personality
disorder are
promising.
46 • ADDICTION SCIENCE & CLINICAL PRACTICE—JUNE 2008
REFERENCES
Alcoholics Anonymous, 2006. “Twelve Steps” (electronic version), http://www.alcoholics-anonymous.org/en_information_aa.cfm?PageID=17&SubPage=68. See also A.A. Fact File:
http://www.alcoholics-anonymous.org/en_pdfs/m-24_aafactfile.pdf.
American Psychiatric Association, 1998. Gold Award: Integrating dialectical behavior therapy into a community mental health program. Psychiatric Services 49(10):1338-1340.
Beautrais, A.L.; Joyce, P.R.; and Mulder, R.T., 1999. Cannabis abuse and serious suicide attempts. Addiction 94(8):1155-1164.
Cacciola, J.S., et al., 1995. Treatment response of antisocial substance abusers. Journal of Nervous and Mental Disease 183(3):166-171.
Cacciola, J.S., et al., 2001. The relationship of psychiatric comorbidity to treatment outcomes in methadone maintained patients. Drug and Alcohol Dependence 61(3):271-280.
Darke, S., et al., 2004. Borderline personality disorder, antisocial personality disorder and risk-taking among heroin users: Findings from the Australian Treatment Outcome Study
(ATOS). Drug and Alcohol Dependence 74(1):77-83.
Dulit, R.A., et al., 1990. Substance use in borderline personality disorder. American Journal of Psychiatry 147(8):1002-1007.
Frances, A.; Fyer, M.R.; and Clarkin, J.F., 1986. Personality and suicide. In: J.J. Mann and M. Stanley (Eds.), Psychobiology of Suicidal Behavior (Vol. 487). New York: Annals of the New York
Academy of Sciences, pp. 281-293.
Koons, C.R., et al., 2001. Efficacy of dialectical behavior therapy in women veterans with borderline personality disorder. Behavior Therapy 32(2):371-390.
Kosten, T.A.; Kosten, T.R.; and Rounsaville, B.J., 1989. Personality disorders in opiate addicts show prognostic specificity. Journal of Substance Abuse and Treatment 6(3):163-168.
Linehan, M.M., 1987. Dialectical behavior therapy: A cognitive behavioral approach to parasuicide. Journal of Personality Disorders 1:328-333.
Linehan, M.M., 1993a. Cognitive-Behavioral Treatment of Borderline Personality Disorder. New York: Guilford Press.
Linehan, M.M., 1993b. Skills Training Manual for Treating Borderline Personality Disorder. New York: Guilford Press.
Linehan, M.M., in press. Skills Training Manual for Disordered Emotion Regulation. New York: Guilford Press.
CONCLUSION
The co-occurrence of substance dependence in patients
with BPD poses a unique set of risks and challenges
for patients and their clinicians. DBT, a treatment orig-
inally developed by Dr. Linehan that is efficacious for
chronically suicidal patients with BPD, has been adapted
for this patient population. Features of the adapted inter-
vention include drug-specific behavioral targets for treat-
ment of problem drug use, a set of attachment strategies
for fostering and building a strong therapeutic rela-
tionship, and dialectical abstinence—a synthesis of two
polar opposite methods for addressing drug abuse. DBT
and its adaptation may also be effective for SUD patients
with multiple, complex problems rooted in emotional
dyscontrol who have not responded to other evidence-
based approaches.
ACKNOWLEDGMENTS
This research was supported by grant number R01
DA014997, awarded to Dr. Linehan, and grant num-
bers 2 R44 DA16493-03 and 2 R44 DA018049-03,
awarded to Dr. Dimeff, by the National Institute on
Drug Abuse. The authors thank Andrew Paves who
served invaluably as a research assistant in the prepara-
tion of this article.
CORRESPONDENCE
Linda A. Dimeff, Ph.D., Behavioral Tech Research, Inc.,
Seattle, WA 98105; e-mail: ldimeff@btechresearch.com.
them, and topics to discuss in DBT skills training groups.
It includes extensive handouts and homework sheets to
reproduce for use in the DBT skills training. A forth-
coming third manual focuses specifically on the modi-
fications of DBT for substance-dependent individuals
with BPD (Linehan, Dimeff, and Sayrs, in press).
An array of DBT educational products and instruc-
tor-led training programs are available for the beginner,
intermediate, and advanced levels. The trainings range
from 2-day introductory workshops to a team-based 10-
day intensive program that is conducted in two parts,
each 5 days in length, over 6 to 9 months. Developed
by Dr. Linehan, the DBT intensive training format pro-
vides in-depth knowledge of the content in the first 5
days. Extensive individual and team homework is assigned
upon completion of Part I and is intended to guide DBT
teams in applying and building a DBT program within
their unique settings. During Part II, teams present their
DBT program, provide a thorough case presentation,
and conduct a role play of work with the patient. Pre-
sentations are then critiqued by the trainers for clinical
adherence and program fidelity.
A number of self-training methods have been gen-
erated to date by Dr. Linehan, Dr. Linda A. Dimeff, and
their colleagues. These include five videos/DVDs fea-
turing Dr. Linehan teaching DBT skills to patients, as
well as more than 25 hours of in-depth online training
in the core DBT curriculum, including DBT skills,
behavioral chain analysis, and validation. Information
about workshops, intensive training, online training,
and other educational products for patients and thera-
pists can be obtained through Behavioral Tech, LLC
(www.behavioraltech.org).
Trainings
range from
a 2-day
introductory
workshop
to a 10-day
intensive
program.
SCIENCE AND PRACTICE IN ACTION—DIALECTICAL BEHAVIOR THERAPY • 47
Linehan, M.M., et al., 1991. Cognitive-behavioral treatment of chronically parasuicidal borderline patients. Archives of General Psychiatry 48(12):1060-1064.
Linehan, M.M., et al., 1999. Dialectical behavior therapy for patients with borderline personality disorder and drug-dependence. American Journal on Addictions 8(4):279-292.
Linehan, M.M., et al., 2002. Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for border-
line personality disorder. Drug and Alcohol Dependence 67(1):13-26.
Linehan, M.M., et al., 2006. Two-year randomized controlled trial and follow-up of dialectical behavior therapy vs therapy by experts for suicidal behaviors and borderline personality dis-
order. Archives of General Psychiatry 63(7):757-766.
Linehan, M.M.; Dimeff, L.A.; and Sayrs, J.H.R., in press. Dialectical Behavior Therapy for Substance Use Disorder.
New York: Guilford Press.
Linehan, M.M., and Heard, H.L., 1999. Borderline personality disorder: Costs, course, and treatment outcomes. In: N. Miller and K. Magruder (Eds.), The Cost Effectiveness of Psychother-
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Links, P.S., et al., 1995. Borderline personality disorder and substance abuse: Consequences of comorbidity. Canadian Journal of Psychiatry
40(1):9-14.
Lynch, T.R., et al., 2003. Dialectical behavior therapy for depressed older adults: A randomized pilot study. American Journal of Geriatric Psychiatry 11(1):33-45.
Marlatt, G.A., and Donovan, D.M., 2005. Relapse Prevention: Maintenance Strategies in the T
reatment of Relapse Prevention.
New York: Guilford Press.
McKay, J.R., et al., 2000. Prognostic significance of antisocial personality disorder in cocaine-dependent patients entering continuing care. Journal of Nervous and Mental Disease
188(5):287-296.
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161(11):2108-2114.
RESPONSE: INNOVATIONS AND IMPLEMENTATION
Mardell Gavriel, Psy.D.; Suzette Glasner-Edwards, Ph.D.; and Helen Sackler, Ph.D.
Mardell Gavriel: At Walden House, we use
dialectical behavior therapy (DBT) skills
training and strategies with a wide range of
clients, although we dont implement the
whole package. As we practice it, embrac-
ing a dialectic way of thinking means avoid-
ing rigid notions, understanding that it’s all
right to feel more than one way about some-
thing, and being cognitively fluid and cre-
ative in ones thinking. The clinician may
help the patient connect to both poles of his
ambivalence about drugs. On one hand, the
client wants recovery and recognizes that
drugs have been problematic in his life, and
on the other, he has real urges to use because
drugs have been his survival strategy for a
long time. Both of those rationales are equally
true; what the dialectic recognizes is that
both can yield useful insights.
Helen Sackler: The authors’ football anal-
ogy illustrating the dialectic (Dimeff and
Linehan, 2008) is similar to the way we rou-
tinely talk to substance abusers. In the anal-
ogy, the quarterback always has the goal
of scoring, but he knows he cant score on
every play. On most plays, he just has to try
to push the ball downfield. To our patients,
we say, “Whats going to make your life
worth living a year, 2 years, 5 years down
the road? Keep your eyes on the prize, but
work a day at a time.”
Gavriel: One reason the DBT model has
been fairly easy to implement in substance
abuse tr
eatment is that, philosophically, it
integrates well with other existing models.
To a great extent, the DBT skills are the
same ones that underlie many of the cur-
ricula that are traditionally taught in sub-
stance abuse treatment—str
ess tolerance,
emotional regulation, relapse prevention,
and so on. Staffers find that DBT training
reinforces and promotes their ability to do
what they are already aiming for, which is
to try to maintain a balance between accept-
ing each client where he or she is and push-
ing for change.
Suzette Glasner-Edwards: DBT overlaps
greatly with other cognitive-behavioral and
relapse prevention therapeutic approaches.
Where it stands out and is innovative is in
its conceptual framing and the emphasis
it puts on some issues. DBTs handling of
engagement issues and treatment dropouts
seems fairly intuitive, for example, but it
is distinctive because it is so direct and up
... DBT is deliverable as a group-based skills training therapy (Ritschel et al., 2015). Empirically, DBT has been demonstrated to improve outcomes in patients with substance use disorder (SUD) and other impulsive or compulsive disorders (Dimeff and Linehan, 2008;Ritschel et al., 2015). Internet-based DBT has also been demonstrated to be applicable and effective (Wilks et al., 2018). ...
... During the pandemic, psychiatric services, especially those for addiction, were shifted and negatively impacted worldwide (Radfar et al., 2021), including in our affiliated centers. Online and group-based DBT therapy is a practical solution to operate during physical lockdown, maintain therapy adherence, and reduce the overall cost of therapy (Dimeff and Linehan, 2008). ...
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The pathological use of the Internet has surged during the pandemic, even though service provisions were negatively impacted. Telepsychiatry can be used as a solution to maintain psychiatric addiction services. This study examined the efficacy of online group dialectical behavioral therapy (DBT) for Internet addiction (IA), compared to cognitive behavioral therapy (CBT). Participants were divided into two arms for 8 weeks: the experimental arm received eight sessions of online DBT skill group training (n = 20), and the control arm received four sessions of online individual CBT (n = 20). All participants were required to complete a sociodemographic and Internet use survey, the Internet Addiction Test (IAT), and the University of Rhode Island Change Assessment (URICA). All participants completed the therapy. Of the 40 participants, six (15%) perceived the need for therapy and one (2.5%) participant had a history of seeking IA therapy. In the pre-post comparison, significant improvements were noted in the IAT and URICA scores as well as Internet use duration for both arms. No significant differences were observed across the arms and in the time-by-arm interaction. Online group DBT is a viable alternative to online CBT in an acute constrained setting, although further studies are required to scrutinize its long-term efficacy. Trial Registration: ISRCTN17273762
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... Wyniki badań sugerują skuteczność treningu redukcji stresu opartego na koncepcji mindfulness w przypadku klientów cierpiących na chroniczny ból, jak również używających substancji psychoaktywnych, uzależnionych od tytoniu czy od alkoholu (Brewer i in., 2011). Włączenie technik opartych na koncepcji mindfulness do podstawowej terapii przynosi także efekty w postaci redukcji konsumpcji środków psychoaktywnych u pacjentów z zaburzeniami osobowości typu borderline (Dimeff i Linehan, 2008). Włączenie treningów mindfulness do terapii klientów z zaburzeniami zachowania (uzależnieniami behawioralnymi) stanowi obiecujący obszar praktyki i badań. ...
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