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The Thin Edge of the Wedge. Acceptance, Change, and Behavior Therapy in the Treatment of Addiction. Dialectical Behavior Therapy. Originally developed to treat suicidal behaviors in patients who meet criteria for Borderline Personality Disorder.

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the thin edge of the wedge

The Thin Edge of the Wedge

Acceptance, Change, and

Behavior Therapy in the Treatment of Addiction

dialectical behavior therapy
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.

cognitive behavioral treatment of borderline personality disorder
Cognitive-Behavioral Treatment of Borderline Personality Disorder

Marsha M. Linehan, Ph.D.

University of Seattle, Washington

Guilford Press, New York, NY, 1993

overview of today s workshop
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.
Commitment Strategies
  • Change Strategies
  • Acceptance Strategies
  • Attachment Strategies
  • Take Home Tools
dbt balances
DBT Balances:

Standard behavior therapy techniques to induce change


Acceptance strategies to promote the therapeutic alliance and keep patients in treatment

dbt balances7
DBT Balances:

Skills Acquisition: teaching new behaviors


Validating and Reinforcing existing adaptive behaviors

biosocial therapy of bpd
Biosocial Therapy of BPD
  • Biological Vulnerability

Patients born with greater emotional


  • Environmental Vulnerability

Patients grow up in families that fail to

validate private experience.

Biology interacts with Environment and produces dysfunction

Emotional dysregulation

Cognitive dysregulation

Behavioral dysregulation

Interpersonal dysregulation

Identity dysregulation

biosocial theory of suds
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.

SUDs are brain disorders but not JUST brain disorders

Physiological and neurochemical dysfunction

Emotional, cognitive, behavioral dysregulation

Interpersonal and occupational dysfunctional

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.
bpd and sud patients are difficult customers
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
goals of dbt treatment
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
efficacy of dbt s for women with bpd and suds linehan et al 1999
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).
linehan et al 1999 cont
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%.
dbt vs cvt 12 step for tx of opiate addicts with bpd linehan et al 2002
DBT Vs. CVT+12-Step for tx of opiate addicts with BPDLinehan, 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.
cvt 12 step treatment
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
dbt vs cvt 12 step tx outcome data linehan et al 2002
DBT vs. CVT + 12 Step TxOutcome Data Linehan, 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%).
drop out rates for dbt vs cvt 12 step tx linehan et al 2002
Drop-Out Rates for DBT vs. CVT + 12 Step Tx Linehan, 2002
  • Over a 12-month treatment period:

36% of DBT group dropped out.

0% of CVT + 12-Step group dropped out.

  • 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.
more conclusions
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.
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.
dbt assumptions
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
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.
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.
targets for dbt treatment
Targets for DBT Treatment
  • Stop suicidal and parasuicidal behaviors
  • Address therapy-interfering behaviors
  • Address quality-of-life interfering behaviors: stop drug use
drug abuse targets for dbt treatment
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”
structure of dbt treatment modes
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
structure of dbt treatment functions
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
skills training curriculum
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
getting started in dbt treatment
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)
patient therapist agreements
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
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
Therapist will strive to be competent, ethical, respectful and accessible
  • Therapist will maintain confidentiality
  • Therapist will seek consultation when needed
commitment strategies
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
chain analysis
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
Problem behavior occurs: be sure problem is defined in specific behavioral terms
  • Consequences: what happened next? Helps to identify reinforcers for problem behavior.
behavioral formulation
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?
solution analysis new alternative behaviors to replace dysfunctional links
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
Make a commitment to try the solution
  • Strengthen the commitment using commitment strategies
  • Troubleshoot the solution
  • Rehearse the solution
contingency management requires no co operation from the patient
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
extinction procedures
Extinction Procedures:
  • Orient the patient: explain the procedure and the rationale
  • Withdraw reinforcement for the maladaptive behavior
  • Validate, soothe, cheerlead
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
response to unacceptable behaviors
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
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)
ultimate aversive sanction vacation from therapy
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)
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”)
dialectical dilemmas
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
focus on total abstinence prior to drug use
Focus on Total AbstinencePrior 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.
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.
focus on harm reduction after drug use
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


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.


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.

mindfulness skills what
Mindfulness Skills: WHAT




mindfulness how
Mindfulness: HOW




radical acceptance
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

WillingnessDoing just what is needed in the moment. Listening. Responding. Allowing.Effective. Unpretentious. Aware.


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.

attachment strategies
Attachment Strategies
  • 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
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
skills added to dbt for substance abusers
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
workshop choices
Workshop Choices
  • Commitment Strategy: Devil’s Advocate
  • Chain Analysis Demonstration: Talk it to death
  • Correction-Overcorrection Demonstration
  • Validation Exercises
  • Mindfulness: Events vs. Interpretations
Mindfulness: Non-judgmental Thinking
  • Distress Tolerance: Half-smile Technique
  • Emotion Regulation: Opposite Action Technique
  • Responding to Emotional Meltdowns