The Thin Edge of the Wedge

1. The Thin Edge of the Wedge Acceptance, Change, and Behavior Therapy in the Treatment of Addiction

2. Dialectical Behavior Therapy Originally developed to treat suicidal behaviors in patients who meet criteria for Borderline Personality Disorder. Efficacy demonstrated in other difficult-to-treat populations: dual diagnosis, eating disorders, geriatric depression.

3. Cognitive-Behavioral Treatment of Borderline Personality Disorder Marsha M. Linehan, Ph.D. University of Seattle, Washington Guilford Press, New York, NY, 1993

4. Overview of Today’s Workshop • Why DBT? Rationale for treatment model. • Demonstrated Efficacy: in treatment of dual dx. • Setting the Stage: DBT assumptions and mind-set. • Structure of DBT Treatment: modes and functions.

5. Commitment Strategies • Change Strategies • Acceptance Strategies • Attachment Strategies • Take Home Tools

6. DBT Balances: Standard behavior therapy techniques to induce change vs. Acceptance strategies to promote the therapeutic alliance and keep patients in treatment

7. DBT Balances: Skills Acquisition: teaching new behaviors vs. Validating and Reinforcing existing adaptive behaviors

8. Biosocial Therapy of BPD • Biological Vulnerability Patients born with greater emotional sensitivity. • Environmental Vulnerability Patients grow up in families that fail to validate private experience.

9. Biology interacts with Environment and produces dysfunction Emotional dysregulation Cognitive dysregulation Behavioral dysregulation Interpersonal dysregulation Identity dysregulation

10. Biosocial Theory of SUDs • Biological Component Drug intoxication changes brain neurochemistry acutely. Prolonged drug use causes prolonged changes in brain function. • Social and Environmental Component Developmental effects of growing up in substance abusing family. Prolonged drug use causes long-term changes in social and emotional functioning.

11. SUDs are brain disorders but not JUST brain disorders Physiological and neurochemical dysfunction Emotional, cognitive, behavioral dysregulation Interpersonal and occupational dysfunctional

12. As a result of chronic dysregulation in multiple areas of function, BPD and SUD patients exhibit maladaptive behaviors, poor problem-solving skills, little tolerance for physical and emotional distress, failure to trust one’s own intuitions, and impaired ability to see reality as it is.

13. BPD and SUD Patients are Difficult Customers • Effective treatments are scarce • Non-collaborative, non-compliant • Often drop out of treatment • Disliked by caregivers and by the public • Associated with increased morality

14. Goals of DBT Treatment • Stop using drugs and parasuicidal behaviors • Increase ability to self-regulate emotions • Replace maladaptive behaviors with skillful behaviors • Improve dysfunctional cognition: irrational beliefs, black and white thinking, unrealistic expectations of the world and of the self • Validate patient to strengthen identity • Teach how to live skillfully in the world as it is

15. Efficacy of DBT-S for Women with BPD and SUDs Linehan et. Al., 1999 • Randomized double-blind clinical trial • N=28 women • 12 months of DBT vs. Treatment-as-usual • 4 month follow-up assessment • 4 months of opiate or stimulant drug repalcement + 4 months of replacement drug taper + 8 months no drug replacement • Monitor drug use by self-report and urine testing q 4 months (1 planned, 1 random).

16. %Days Abstinent by Self-Report and by Urine Drug Testing

17. Linehan et. Al., 1999 (cont.) • Drop out rates over 12 mos. of treatment: • DBT: 4/11 + 1 accidental OD = 36% • TAU: 8/11 = 73% • Other DBT studies for tx of BPD alone show drop-out rates of 16%.

18. DBT Vs. CVT+12-Step for tx of opiate addicts with BPDLinehan et.al., 2002 • Randomized double-blind clinical trial • N = 24 women • 12 months of DBT-S vs. CVT + 12-step • 4 month follow-up • 12 months of high-dose LAMM tx for all (modal dose = 90/90/130 mg/d on MWF) • Monitor drug use by self-report and urine testing 3x per week.

19. CVT + 12-Step Treatment • Individual tx 40-90 min/wk: focus on non-demanding, non-confrontational validation, no problem solving, no skills acquisition. • 12+12 NA Group Meeting 1x/week • Meeting w 12-Step sponsor encouraged • Case management services available • Phone consultation: local crisis hotline

20. DBT vs. CVT + 12 Step TxOutcome Data Linehan et.al., 2002 • Positive opiate urine tests decreased for both groups from 80% to 40% during first four months of tx. • In CVT tx group, positive opiate urine tests increased to 50% after 8 months of treatment. • In DBT tx group, positive opiate urine tests remained unchanged, about 40%, after 8 months of treatment. • The apparent decrease in opiate use was not accompanied by an increase in non-opiate drug use (about 57% of urines throughout the study). • Single U/A at 4 mo. follow-up showed low opiate use in both groups (DBT = 27%, CVT+12 Step = 33%).

21. Drop-Out Rates for DBT vs. CVT + 12 Step Tx Linehan et.al., 2002 • Over a 12-month treatment period: 36% of DBT group dropped out. 0% of CVT + 12-Step group dropped out.

22. Conclusions • DBT tx is more effective than TAU at keeping patients in treatment and reducing drug use. • Drop-out rates remain high (at least 30%) with notable exception of CVT + 12-Step tx. • Validation may be an important component of maintaining patient engagement.

23. More Conclusions • Drug use remains significant (30-50% in DBT groups vs. 45-80% in TAU group). • High drop-outs and significant drug use are particularly discouraging given that these studies conducted intensive long-term treatment free of charge and offered drug replacement therapy. • Could tx outcomes improve if you start with addicts already in early recovery? Avoids complications of drug replacement, detox, selects for committed group.

24. Dialectics is a branch of philosophy that proposes that every phenomenon contains its opposite within. Ambivalence is described as the inability to choose between white and black. Dialectical thinking challenges us to hold both black and white in our minds simultaneously, valuing each color equally. The resulting tension is a vehicle for change and transformation when we seek the SYNTHSIZE the opposing poles of the dialectic.

25. DBT Assumptions • Difficult behaviors represent maladaptive solutions, not the problem. • Engaging reluctant patients is a therapeutic task, not a pre-requisite for enrollment. • Patients are doing the best they can. • Patients need to do better and try harder to change. • Patients want to have lives worth living

26. When patients say their lives are unbearable, this is a valid statement. • Patients may not have caused their problems, but they need to solve them. • Patients need to demonstrate adaptive behaviors in all relevant contexts.

27. Safety and security in therapy is not necessarily valued, in so far as it does not reflect the real world. • Patients cannot fail in treatment. • Therapists who conduct DBT need consultation.

28. Targets for DBT Treatment • Stop suicidal and parasuicidal behaviors • Address therapy-interfering behaviors • Address quality-of-life interfering behaviors: stop drug use

29. Drug Abuse Targets for DBT Treatment • Stop using illicit drugs • Decrease urges and cravings • Decrease physical discomfort • Decrease apparently unimportant behaviors • Decrease “Keeping options to use open”

30. Structure of DBT Treatment: Modes • Group Skills Training: typically 2 hr. group per week • Individual Therapy: typically 1-2 sessions per week • Phone consultation for crisis management, skills coaching • Team consultation for therapists, typically 2 hrs/week

31. Structure of DBT Treatment: Functions • Enhance capabilities:skills acquisition, pharmacotherapy • Enhance motivation:validation and attachment strategies • Insure generalization of learning:invivo sessions, phone contact, rehearsal • Enhance therapist motivation:team consultation • Structure the environment: case mgmt

32. Skills Training Curriculum • Mindfulness:focusing the mind, observing and describing • Emotion Regulation:increase positive emotions, decrease negative • Interpersonal Effectiveness:assertion skills • Distress Tolerance:crisis survival, accepting reality as it is

33. Getting Started in DBT Treatment • Identify patient goals • Identify problems that currently interfere with goals • Define problems behaviorally • Patient and therapist make a list of target behaviors • Patient and therapist agree to work on targets for limited time (one year)

34. Patient-Therapist Agreements • Time-limited renewable contract for therapy • Miss 4 sessions in a row = termination • Agree to attend therapy, skills groups, and complete homework • Agree to work on self-destructive behaviors and therapy-interfering behaviors

35. Get off drugs • Don’t sell drugs to other clients in the program • Be capable of acting sober in clinic groups and sessions • Take meds as prescribed • Urine testing 3x/week

36. Therapist will strive to be competent, ethical, respectful and accessible • Therapist will maintain confidentiality • Therapist will seek consultation when needed

37. Commitment Strategies • Obtain a verbal commitment • Review pros and cons • Link present and prior commitments • Devil’s advocate • Foot-in-the-door, Door-in-the-face • Lack of desire for change is expression of helplessness/hopelessness • Freedom of choice in absence of alternatives

38. Chain Analysis • Pre-existing vulnerabilities: what conditions make client more likely to engage in problem behavior? • Precipitating event: what external event triggered the problem behavior? Where was the point of no return? • Links in the chain leading to problem behavior: include bodily sensations, thoughts, feelings, behaviors, events in the environment

39. Problem behavior occurs: be sure problem is defined in specific behavioral terms • Consequences: what happened next? Helps to identify reinforcers for problem behavior.

40. Behavioral Formulation • Summarize the story • Add any insights you have • Identify which links in the chain are dysfunctional • Identify reinforcers: what keeps this problem behavior going? • Identify function: how does this target behavior serve the patient?

41. Solution Analysis: new alternative behaviors to replace dysfunctional links • Brainstorm all possible solutions: • Remember 4 Solutions to Any Problem: • Solve the problem • Feel better about the problem • Tolerate the problem • Be miserable • Pick a solution to work on

42. Make a commitment to try the solution • Strengthen the commitment using commitment strategies • Troubleshoot the solution • Rehearse the solution

43. Contingency Management: Requires no co-operation from the patient • Reinforce desired behaviors (surprising how we forget this) • Fail to reinforce maladaptive behaviors: extinction • Punish maladaptive behaviors: will only suppress behavior

44. Extinction Procedures: • Orient the patient: explain the procedure and the rationale • Withdraw reinforcement for the maladaptive behavior • Validate, soothe, cheerlead

45. Remind patient of rationale and his/her prior commitments. • Find an alternative behavior to reinforce • DO NOT give in halfway through the extinction procedure: intermittent reinforcement will make the problem behavior very durable

46. Response to Unacceptable Behaviors • Describe the problem behavior to the patient • Patient performs chain analysis on the problem behavior • Patient reviews chain analysis with therapist for behavioral formulation • Patient presents chain analysis to community, gets feedback

47. Patient and therapist identify damage done by problem behavior • Correction: make amends for damage done by returning the situation back to baseline • Overcorrection: the amend actually improves the situation (“makes is better than it was to start with”) • Correction-overcorrection procedure is strengthened by therapist withholding some goody (warmth) until patient successfully completes the overcorrection (then warmth is restored)

48. Ultimate Aversive Sanction: Vacation from Therapy • Describe the problem behavior to the patient • State that failure to stop this behavior is leading to vacation • Give patient a chance to escape the vacation (by solving the problem)

49. Place patient on vacation. Patient may resume tx when problem is solved. • Give appropriate referrals for continuity of care • Maintain non-demand contact with patient (“pining for his/her return”)

50. Dialectical Dilemmas • Change vs. Acceptance • Active-Passivity vs. Apparent competence • Unrelenting crisis vs. Inhibited grieving • Emotional vulnerability vs. Self-invalidation • Absolute Abstinence vs. Harm Reduction