DBT for Substance Abuse: A New Approach to Helping Clients Struggling with BPD and Addictions October 28, 2015 Alina Gorgorian, Ph.D. Michael Roy, LCSW

DBT for Substance Abuse:

A New Approach to Helping Clients Struggling with BPD and Addictions

October 28, 2015

Alina Gorgorian, Ph.D.Michael Roy, LCSW

Clearview Women’s CenterLos Angeles, Calif.

© 2013 Clearview Treatment Programs. Not to be reprinted or reused without permission.

Why are we here?

More BPD and substance abuse than BPD or substance abuse

In substance abuse programs:

In studies between 1986 and 1997, among patients seeking treatment for substance abuse disorders, 5-65% have also had BPD dx (Trull et al., 2000)

Among 615 heroin users documented in Sydney Austrailia, 42% also had BPD (Drake et al., 2004)


Why are we here?

Among BPD samples:

In studies between 1986 and 1997, among pts receiving tx for BPD, SUDs ranged from 26-84% (Trull et. Al., 2000


Implications of Comorbidity

• Severe psychopathology predict poorer outcomes and early relapse among drug abusers

• Patients with severe psychopathology are screened out of tx outcome studies

• Suicide attempts are highest for individuals with both BPD and SUDs (Rossow and Lauritzen, 1999)

• Co-occurrence of an SUD and BPD was the factor most closely associated with poor tx outcomes (Zanarini et al. 2004)


Who Is DBT for?

• Severe, chronic, multi-diagnosed, “difficult to treat” patients• Axis I and II patients

– BPD– Substance Abuse– Eating Disorders


DBT vs. TAU

• With DBT– Fewer drop out– Less drug use– Greater global adjustment– Greater social adjustment– DBT gains continued at follow-up


Borderline Personality Disorder

• A pervasive disorder of the emotion regulation system• Criterion behaviors function to regulate emotions or are a

natural consequence of emotion dysregulation


DSM 5 Criteria for BPDAt least 5 . . .

1. Frantic efforts to avoid real or imagined abandonment2. A pattern of unstable and intense interpersonal relationships characterized

by alternating between extremes of idealization and devaluation3. Identity disturbance: markedly and persistently unstable self-image or sense of

self 4. Impulsivity in at least two areas that are potentially self-damaging5. Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior 6. Affective instability due to a marked reactivity of mood 7. Chronic feelings of emptiness 8. Inappropriate, intense anger or difficulty controlling anger 9. Transient, stress-related paranoid ideation or severe dissociative symptoms


Criteria Reorganized

• Emotional Dysregulation– Mood swings– Intense anger/rage

• Interpersonal Dysregulation– Interpersonal chaos– Fear of being abandoned

• Self Dysregulation– Struggle with identity and

sense of self– Feelings of emptiness

• Behavioral Dysregulation– Self-injury– Suicidality – Impulsivity

• Cognitive Dysregulation– Dissociation– Paranoia– Obsessions

Linehan, 1993

© 2013 Clearview Treatment Programs. Not to be reprinted or reused without permissi on.

Biosocial Model of BPD

Biological Dysfunction in Emotion Regulation System

Biological Dysfunction in Emotion Regulation System

Invalidating EnvironmentInvalidating Environment

Pervasive Emotion Dysregulation

Pervasive Emotion Dysregulation

10

INABILITY TO MODULATE EMOTIONS

EMOTION DYSREGULATIONEMOTION DYSREGULATION

EMOTIONAL VULNERABILITYEMOTIONAL VULNERABILITY

11

Emotional Vulnerability

• High sensitivity– Immediate reactions– Low threshold for emotional reaction

• High reactivity– Extreme reactions– High arousal dysregulates cognitive processing

• Slow return to baseline– Long-lasting reactions– Contributes to high sensitivity to next emotional stimulus


Linehan, 1993

The “Social” Part:Invalidating Environments

• Behaviors and communication of private experiences are pervasively rejected as invalid.

• Emotional displays are met by punishment; escalation is met by erratic, intermittent reinforcement.

• Problem-solving is oversimplified.


Consequences of Chronic Invalidation

• Environment fails to teach individual to:– Effectively label private experiences – Effectively regulate emotions– Trust experiences as valid responses to events (gut

instinct)

• Instead, environment teaches individual to:– Self-invalidate and search environment for cues about

how to respond


DBT aims to modulate emotions by…

• Decreasing (or increasing) physiological arousalassociated with emotion

• Re-orienting attention• Inhibiting mood-dependent behaviors• Experiencing emotions without escalating or blunting• Organizing behavior in the service of non-mood dependent

goals (i.e., opposite action)


Linehan, 1993

Assumptions about the patient

• Patients are doing the best they can• Patients want to improve• Patients need to do better, try harder, and be more

motivated• Patients may not have caused all their own problems, but

they have to solve them anyway• The lives of suicidal, borderline individuals are unbearable as

they are currently being lived• Patients must learn new behaviors in all relevant contexts• Patients can not fail in DBT


Linehan, 1993

Assumptions about therapy

• The most caring thing a therapist can do is help patients change in ways that bring them closer to their own ultimate goals

• Clarity, precision, and compassion are of the utmost importance in the conduct of DBT

• The therapeutic relationship is a real relationship between equals

• Principles of behavior are universal, affecting therapists no less than patients

• Therapists treating borderline patients need support• DBT therapists can fail• DBT therapy can fail even when therapists do not


Linehan, 1993

Standard Modes of Therapy

• Outpatient Individual Session• Outpatient Skills Training Class• Phone Coaching• Consultation Team• Ancillary Treatments

– Pharmacotherapy– Acute inpatient psychiatric


Responsibilities of Individual Therapist

• Treatment planning• Integrating all modes of therapy• Consulting to client• Managing crises and life-threatening behaviors


But first… Pre-treatment

1. Agreement on Goalsa) To stop using drugs now. Get a verbal commitment.

2. Agreement to Recommended Treatmenta) Patient agreementb) Therapist agreements

3. Agreement to therapist-client relationship


First Four Sessions

• Get client’s goals– Orient to the overarching goals of DBT: Building a life

worth living• Get history of suicidal and substance use – assess current risk• Help client prepare for the difficulty of stopping problem

behaviors• Look for positives


First Four Sessions

• Orient to structure of program• Orient to protocols

– 24-hour rule– 4 miss rule

• Review– Diary card– Dialectics in DBT– Imminent Risk Assessment and Treatment Plan if needed– Biosocial Theory of BPD


First Session1. Assess client’s

– History– Current problems– Reason for coming to tx

2. Get their goals– Weave DBT targets into their goals

3. Get commitment to – Stop life-threatening behaviors– Participate in all sessions, UAs

4. Caution them about– Butterfly syndrome– Replacement meds and taper


Stage 1 Primary Targets:

Severe Behavioral Dyscontrol Behavioral Control•Decrease

– Life-threatening behaviors– Therapy-interfering behaviors– Quality of life-interfering behaviors

•Increase– Mindfulness– Distress tolerance– Interpersonal effectiveness– Emotion dysregulation– Self-management


Linehan, 1993

Core Theories in DBT

1. Behavioral Science2. Zen Practice3. Dialectical Philosophy

25

Behaviorism: Chain-Analysis

Excellent tool to identify key areas to be worked onIdentify…• Prompting Event• Vulnerabilities• Cognitions• Emotions• Behaviors• Body Sensations• Problem Behavior• Consequences


Chain Analysis VulnerabilityVulnerability

Prompting

Event

Prompting

Event LinksLinksLinksLinks

ProblemProblem

BehavioBehaviorr

ProblemProblem

BehavioBehaviorr

ConsequencesConsequences


Linehan, 1993

Solution Analysis

Identify what needs to be done at each point on the chain to prevent the problem behavior from recurring

• Prompting Event• Vulnerabilities• Cognitions• Emotions• Behaviors• Body Sensations• Problem Behavior• Consequences


Problem Solving

VulnerabilityVulnerability

PromptingPrompting

EventEvent

PromptingPrompting

EventEvent

LinksLinksLinksLinks

ProblemProblem

BehaviorBehavior

ProblemProblem

BehaviorBehavior

ConsequencesConsequencesConsequencesConsequences

ConsequencesConsequencesConsequencesConsequencesEffectiveEffective

BehaviorBehavior

EffectiveEffective

BehaviorBehavior


Linehan, 1993

Diary Cards

• Provides a general overview of client’s week• Reduces risk of overlooking target behaviors• Keeps more accurate record of client’s daily emotions and

behaviors • Enables client and therapist to perceive potential links

between emotions


Zen Practice

• Contemplative practice, not a religion• Mindfulness – acceptance of the moment

– Change requires acceptance– Acceptance of one set of problems to work on

identified problems– Radical acceptance of the pat and limitations of

the future

31

Dialectical Approach

Balancing change/problem-solving and acceptance/validation

Eliminating painful events with accepting painful events


Dialectics: Find Balance Between

• Skill enhancement vs. Self-acceptance• Problem solving vs. Problem acceptance• Affect regulation vs. Affect tolerance• Self-efficacy vs. Help-seeking


What Is Validation?

“The action of validating or making valid…a strengthening reinforcement, confirming; establishing or ratifying as valid”

• To Confirm• To Authenticate• To Corroborate• To Substantiate• To Verify


Why Add Validation?

Self-Verification Theory: people want to be known and understood by others according to their firmly held beliefs and feelings about themselves, that is self-views

• Validation = Self-verification• Invalidation Arousal; sense of out-of-control• Arousal + Out-of-control Inability to process new

information• Failure to process new info = no new learning


What Should we Validate?

• Importance of a problem• Emotional pain• Difficulty of change• Sense of out-of-control• Dysregulation• Inner strength and capabilities• Behavior

– Emotions, pain, and suffering– Physiological responses– Cognitive appraisals, thoughts, beliefs, and values– Actions


Phone Coaching

• If patient calls individual therapist:

– Decrease crisis behaviors– Increase generalization of DBT behavioral skills– Decrease sense of conflict, alienation, distance with

therapist


Polarities in Substance Abuse Tx

Abstinence only model

Vs.

Harm-reduction model


EmotionalEmotional

MindMind

EmotionalEmotional

MindMindReasonable

Mind

Reasonable

MindWise

Mind

Wise

Mind

Zen Practice: States of Mind


Linehan, 1993

Clean Clean MindMindClean Clean MindMind

Addict

Mind

Addict

Mind

Clear

Mind

Clear

Mind

DBT-SUD Path to Clear Mind


Linehan, 1993

Path to Clear Mind

Decrease substance use Decrease physical discomfort from abstaining Decrease urges and cravings to use drugs Decrease options, contacts, and cues to use drugs Decrease capitulation to use drugs Increase community reinforcement of clear mind behaviors


Decrease Physical Discomfort: Pain Management

• Rationale:• Reduce risk of early termination• Prevent drug use

• How:• Replacement meds • DBT skills, including distress tolerance,

mindfulness, and PLEASE skills


Decrease Urges and Cravings

• Mindfully self-monitor urges (diary cards)• Normalize presence of urges (didactic strategy)• Label urges and detach from them (observe &

describe skills)• Develop and use imagery

• Urge surfing


Didactic on Urges

• Urges are episodic and not constant; they come and go

• Urges may fluctuate in intensity during an episode and do not, by themselves, predict lapse

• Urges do not decrease dramatically upon cessation, but gradually decrease over time (so long as they’re not reinforced)


Decrease the options, contacts, and cues to use drugs

• Target all overt and covert behaviors that maintain possibilities for drug use• Change phone numbers• Get rid of drugs, paraphernalia, and drug contacts• Move away• No stealing, lying, selling drugs• Making public commitment not to use


Increase Community Reinforcement “Clear Mind” Behaviors

• Working for pay• Socializing with non-drug addicts• Joining groups where non-addicts go• Becoming involved in and participating in AA/NA


Finding your patients when they’re lost: Attachment Strategies

1. Orient client to attachment problem2. Increase contact during initial trimester3. Contact using VM4. Conduct therapy in vivo5. Shorten or lengthen sessions6. Conduct supportive family and friends network meetings7. Phone to break avoidance8. Find clients when they’re lost – utilize worksheet9. Give replacement medications


Family Work

• Utilize families as agents of change– Skills– Contingency management

• Utilize families as agents of validation• Families striking dialectical balance


Additional Skills

BEHAVIORS TO INCREASE BEHAVIORS TO DECREASEMindfulness Skills • Identity confusion

• Emptiness• Cognitive dysregulation

Interpersonal Skills • Interpersonal chaos• Fears of abandonment

Emotion Regulation Skills • Labile affect• Excessive anger

Distress Tolerance Skills • Impulsive behaviors• Suicidal threats• Self-harm


Recommended Readings

Dimeff, L. (n.d.). Dialectical behavior therapy in clinical practice: Applications across disorders and settings.

Koerner, K. (2012). Doing dialectical behavior therapy: A practical guide. New York: Guilford Press.

Linehan, M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.

Linehan, M. (2014). DBT Skills Training Manual (2nd ed.). Guilford Press.Linehan, M. (1993). Skills training manual for treating borderline personality disorder. New York: Guilford Press.


Documents

DBT for Substance Abuse: A New Approach to Helping Clients Struggling with BPD and Addictions October 28, 2015 Alina Gorgorian, Ph.D. Michael Roy, LCSW