Transcript The Thin Edge of the Wedge - California Society of

The Thin Edge of the Wedge
Acceptance, Change, and
Behavior Therapy in the Treatment of
Addiction
1
Dialectical Behavior Therapy
Originally developed to treat suicidal
behaviors in patients who meet criteria for
Borderline Personality Disorder.
Efficacy demonstrated in other difficult-totreat populations: dual diagnosis, eating
disorders, geriatric depression.
2
Cognitive-Behavioral Treatment
of Borderline Personality
Disorder
Marsha M. Linehan, Ph.D.
University of Seattle, Washington
Guilford Press, New York, NY, 1993
3
Overview of Today’s Workshop
1.
2.
3.
4.
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.
4
5.
6.
7.
8.
9.
Commitment Strategies
Change Strategies
Acceptance Strategies
Attachment Strategies
Take Home Tools
5
DBT Balances:
Standard behavior therapy techniques to
induce change
vs.
Acceptance strategies to promote the
therapeutic alliance and keep patients in
treatment
6
DBT Balances:
Skills Acquisition: teaching new behaviors
vs.
Validating and Reinforcing existing adaptive
behaviors
7
Biosocial Therapy of BPD
A.
Biological Vulnerability
Patients born with greater emotional
sensitivity.
B.
Environmental Vulnerability
Patients grow up in families that fail to
validate private experience.
8
C.
Biology interacts with Environment
and produces dysfunction
Emotional dysregulation
Cognitive dysregulation
Behavioral dysregulation
Interpersonal dysregulation
Identity dysregulation
9
Biosocial Theory of SUDs
A.
Biological Component
Drug intoxication changes brain neurochemistry acutely.
Prolonged drug use causes prolonged changes
in brain function.
B.
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.
10
C.
SUDs are brain disorders but not JUST
brain disorders
Physiological and neurochemical dysfunction
Emotional, cognitive, behavioral dysregulation
Interpersonal and occupational dysfunctional
11
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.
12
BPD and SUD Patients are
Difficult Customers
1.
2.
3.
4.
5.
Effective treatments are scarce
Non-collaborative, non-compliant
Often drop out of treatment
Disliked by caregivers and by the public
Associated with increased morality
13
Goals of DBT Treatment
1.
2.
3.
4.
5.
6.
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
14
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).
15
%Days Abstinent by Self-Report
and by Urine Drug Testing
DBT Tx
TAU Tx
Verbal
U/A
Verbal
U/A
Pre-treatment
.29
.43
.32
.55
8-12 mo.
.89
.50
.62
.36
12-16 mo.
(Post-treatment)
.94
.50
.60
.18
16
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%.
17
DBT Vs. CVT+12-Step for tx of
opiate addicts with BPD Linehan 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.

18
CVT + 12-Step Treatment

Individual tx 40-90 min/wk: focus on nondemanding, 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
19
DBT vs. CVT + 12 Step Tx
Outcome Data Linehan et.al., 2002
1.
2.
3.
4.
5.
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%).
20
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.
21
Conclusions
1.
DBT tx is more effective than TAU at keeping
patients in treatment and reducing drug use.
2.
Drop-out rates remain high (at least 30%) with
notable exception of CVT + 12-Step tx.
3.
Validation may be an important component of
maintaining patient engagement.
22
More Conclusions
4.
Drug use remains significant (30-50% in DBT groups vs.
45-80% in TAU group).
5.
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.
6.
Could tx outcomes improve if you start with addicts
already in early recovery? Avoids complications of drug
replacement, detox, selects for committed group.
23
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.
24
DBT Assumptions
1.
Difficult behaviors represent maladaptive solutions, not
the problem.
2.
Engaging reluctant patients is a therapeutic task, not a
pre-requisite for enrollment.
3.
Patients are doing the best they can.
4.
Patients need to do better and try harder to change.
5.
Patients want to have lives worth living
25
6.
When patients say their lives are unbearable, this
is a valid statement.
7.
Patients may not have caused their problems, but
they need to solve them.
8.
Patients need to demonstrate adaptive behaviors
in all relevant contexts.
26
9.
Safety and security in therapy is not necessarily
valued, in so far as it does not reflect the real
world.
10.
Patients cannot fail in treatment.
11.
Therapists who conduct DBT need consultation.
27
Targets for DBT Treatment
1.
Stop suicidal and parasuicidal behaviors
2.
Address therapy-interfering behaviors
3.
Address quality-of-life interfering
behaviors: stop drug use
28
Drug Abuse Targets for DBT Treatment
1.
Stop using illicit drugs
2.
Decrease urges and cravings
3.
Decrease physical discomfort
4.
Decrease apparently unimportant behaviors
5.
Decrease “Keeping options to use open”
29
Structure of DBT Treatment:
Modes
1.
2.
3.
4.
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
30
Structure of DBT Treatment:
Functions
1.
Enhance capabilities: skills acquisition,
pharmacotherapy
2.
Enhance motivation: validation and attachment
strategies
3.
Insure generalization of learning: in vivo
sessions, phone contact, rehearsal
4.
Enhance therapist motivation: team
consultation
5.
Structure the environment: case mgmt
31
Skills Training Curriculum
1.
Mindfulness: focusing the mind, observing and
describing
2.
Emotion Regulation: increase positive
emotions, decrease negative
3.
Interpersonal Effectiveness: assertion skills
4.
Distress Tolerance: crisis survival, accepting
reality as it is
32
Getting Started in DBT
Treatment
1.
2.
3.
4.
5.
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)
33
Patient-Therapist Agreements
1.
2.
3.
4.
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
34
5.
6.
7.
8.
9.
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
35
10.
11.
12.
Therapist will strive to be competent,
ethical, respectful and accessible
Therapist will maintain confidentiality
Therapist will seek consultation when
needed
36
Commitment Strategies
1.
2.
3.
4.
5.
6.
7.
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
37
Chain Analysis
1.
Pre-existing vulnerabilities:
2.
Precipitating event: what external event triggered
what conditions
make client more likely to engage in problem behavior?
the problem behavior? Where was the point of no
return?
3.
Links in the chain leading to problem
behavior: include bodily sensations, thoughts,
feelings, behaviors, events in the environment
38
4.
Problem behavior occurs: be sure problem is
defined in specific behavioral terms
5.
Consequences: what happened next?
Helps to
identify reinforcers for problem behavior.
39
Behavioral Formulation
1.
2.
3.
4.
5.
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?
40
Solution Analysis: new alternative
behaviors to replace dysfunctional links
1.
Brainstorm all possible solutions:
2.
Remember 4 Solutions to Any Problem:
1.
2.
3.
4.
3.
Solve the problem
Feel better about the problem
Tolerate the problem
Be miserable
Pick a solution to work on
41
4.
Make a commitment to try the solution
5.
Strengthen the commitment using
commitment strategies
6.
Troubleshoot the solution
7.
Rehearse the solution
42
Contingency Management:
Requires no co-operation from
the patient
1.
2.
3.
Reinforce desired behaviors (surprising
how we forget this)
Fail to reinforce maladaptive behaviors:
extinction
Punish maladaptive behaviors: will only
suppress behavior
43
Extinction Procedures:
1.
Orient the patient: explain the procedure
and the rationale
2.
Withdraw reinforcement for the
maladaptive behavior
3.
Validate, soothe, cheerlead
44
4.
5.
6.
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
45
Response to Unacceptable
Behaviors
1.
2.
3.
4.
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
46
5.
6.
7.
8.
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)
47
Ultimate Aversive Sanction:
Vacation from Therapy
1.
Describe the problem behavior to the
patient
2.
State that failure to stop this behavior is
leading to vacation
3.
Give patient a chance to escape the
vacation (by solving the problem)
48
4.
Place patient on vacation. Patient may
resume tx when problem is solved.
5.
Give appropriate referrals for continuity of
care
6.
Maintain non-demand contact with patient
(“pining for his/her return”)
49
Dialectical Dilemmas
1.
2.
3.
4.
5.
Change vs. Acceptance
Active-Passivity vs. Apparent competence
Unrelenting crisis vs. Inhibited grieving
Emotional vulnerability vs. Selfinvalidation
Absolute Abstinence vs. Harm Reduction
50
Focus on Total Abstinence
Prior to Drug Use

Drugs are completely out of the question:
Turning the Mind.

Commit to total abstinence for a finite and
realistic period of time.

Slam the Door Shut: recommit again and
again.
51
Radical acceptance of the absence of drugs
and the difficulties in remaining sober.
 Inner deal with yourself: OK to use in future
or on deathbed.
 Adaptive denial: stop thinking about painful
aspects of abstaining. “I’ll deal with that
tomorrow”.
 Anticipate willfulness and hopelessness.

52
Focus on Harm Reduction
After Drug Use
Learn how to fail well
 Admit mistakes and learn from them
 Chain analysis (relapse dissection)
 Plan for the future (relapse prevention)
 Analyze and repair harm done by drug use
 Quick return to focus on Total Abstinance:
Turn the Mind and recommit

53
Validation
Acknowledging what is sane, true and
valid about a patient’s point of view.
Validation must be authentic and
genuine. Validation is not
synonymous with approval,
agreement, or sympathy.
54
Mindfulness
Techniques for focusing the mind are taught
and reinforced throughout DBT therapy.
Mindfulness is not meditation, nor is it
promoted as a path for spiritual growth. It
serves as a foundation for many other skills
including urge surfing, emotion regulation,
observing and describing reality, radical
acceptance, and non-judgmental thinking.
55
Mindfulness Skills: WHAT
Observing
Describing
Participating
56
Mindfulness: HOW
Non-judgmentally
One-mindfully
Effectively
57
Radical Acceptance






Acceptance of reality as is.
Acceptance is complete and comes from deep
within
Emotional/physical pain + nonacceptance =
suffering
Let go and stop fighting reality
Letting go transforms unbearable suffering into
more ordinary pain, which is part of life
Turning the Mind implies that acceptance is an
active choice and requires an inner commitment
58
Willingness
Doing just what is needed in the moment.
Listening. Responding. Allowing.
Effective. Unpretentious. Aware.
Willfulness
Refusing to do what is needed in the moment.
Refusal to tolerate what is happening in the moment.
Sitting on your hands. Giving up. Fixing.
Ineffective. Stubborn. Rigid.
59
Attachment Strategies
1.
2.
3.
4.
5.
6.
Educate Patient about butterfly problem
Increase session frequency initially
Use voicemail, e-mail, or greeting cards as
additional contacts
Conduct therapy in patient’s environment
Shorten or lengthen therapy sessions
Support meetings with family and friends
60
7.
8.
9.
10.
11.
12.
Treat therapists who are getting burnt-out
Phone patients who are avoiding therapy
Find lost clients
Send birthday and holiday cards
Give effective medications
Have multiple therapists coach client
about therapeutic relationships
61
Skills Added to DBT for
Substance Abusers
Urge Surfing (Observing Skill)
 Alternate rebellion (find a way to rebel that
does not harm you)
 Burning bridges: eliminate options to use
drugs and eliminate access to drugs
 Avoid and eliminate cues, reminders of drug
use
 Build a life worth living: Structure and
Mastery

62
Workshop Choices
1.
2.
3.
4.
5.
Commitment Strategy: Devil’s Advocate
Chain Analysis Demonstration: Talk it to
death
Correction-Overcorrection Demonstration
Validation Exercises
Mindfulness: Events vs. Interpretations
63
6.
7.
8.
9.
Mindfulness: Non-judgmental Thinking
Distress Tolerance: Half-smile Technique
Emotion Regulation: Opposite Action
Technique
Responding to Emotional Meltdowns
64