The Dual Recovery Tools of Dialectical Behavior Therapy (DBT)

1. The Dual Recovery Tools of Dialectical Behavior Therapy (DBT) “How can DBT help those with personality disorders and addictive disorders?”

2. What is a Personality Disorder? • According to the American Psychiatric Association (APA), a personality disorder exists when an individual’s “personality traits are inflexible and maladaptive and cause either significant impairment in social or occupational functioning or subjective distress.”

3. What causes Personality Disorders? • There are various theories, but the leading ones hold that normal, healthy childhood development gets interrupted in some significant manner; • One type of scenario in which this occurs is that of abuse or neglect – including severe emotional, physical, or sexual abuse. • One re-framed perspective is that a personality disorder is like a “badge of courage” because it indicates that someone has survived much hurt.

4. Reframing the “problem” of Personality Disorders • One way to understand personality disorders is that the person coped in the best way they knew how, in response to difficult circumstances, and at that past time (typically during childhood), it helped them to survive. (i.e., ADAPTIVE)

5. Reframing the “problem” of Personality Disorders • However, those old coping mechanisms tend not to work very well in adulthood, and have become ineffective, or MALADAPTIVE.

6. Goods News / “Bad” News • Unlike many other disorders that are chronic or ongoing, personality disorders are resolvable / “curable” • The process of resolving a personality disorder usually involves hard work over an extended period of time

7. Antisocial Personality Disorder (3% males, 1% females) • “A pattern of disregard for, and violation of, the rights of others” • Over 30% prevalence in substance abuse treatment settings; most common with male alcoholics, “mean drunks”

8. Narcissistic Personality Disorder (<1%) • “a pattern of grandiosity, need for admiration, and lack of empathy”

9. Histrionic Personality Disorder (2-3%) • “a pattern of excessive emotionality and attention seeking”

10. Borderline Personality Disorder (2%) • “a pattern of instability in interpersonal relationships, self-image” • 30-60% of persons diagnosed with personality disorders end up with this diagnosis

11. Prevalence • In one sample of 2,462 in/out patients, 21% with BPD had a primary substance abuse diagnosis (Koenigsberg, et al, 1985) • 23% who met criteria for BPD also met lifetime criteria for substance abuse (Links, et al, 1988) • 66% of clients receiving outpatient drug treatment services met criteria for BPD (Vaglum & Vaglum, 1985)

12. Common Characteristics of Personality Disorders • Pattern of problematic relationships • Tendency to blame difficulties on others, or on “bad luck” • A lack of personal responsibility • Impaired ability to learn from previous experience

13. Personality Disorders and Addiction • Pattern of problematic relationships • In active addiction, a person’s primary relationship is with their substance of choice – all other relationships come second to that one.

14. Personality Disorders and Addiction • Tendency to blame difficulties on others, or on “bad luck” • Working through the symptom of “denial,” or working from a state of “precontemplation” to an “action” stage of change is one key to recovery success

15. Personality Disorders and Addiction • A lack of personal responsibility • Owning personal responsibility for actively participating in one’s own recovery is another key to recovery success (12-Step inventories & amends-making)

16. Personality Disorders and Addiction • Impaired ability to learn from previous experience • “Doing the same thing over and over again, and expecting a different result” description of addictive “insanity”

17. “What is DBT?” • Dialectical Behavior Therapy is a type of treatment that focuses on skill-building in the following areas: • Mindfulness • Interpersonal Effectiveness • Emotion Regulation • Distress Tolerance

18. Dialectical Behavior Therapy treatment leads to changes in . . . • Ways of thinking • Ways of managing emotions • Ways of relating to others • Ways of dealing with distress

19. Mindfulness • Sees “Wise Mind” as the optimal balance between the logical / analytical “Logical Mind,” and the sometimes volatile “Emotional Mind”

20. Mindfulness • Using a Star Trek analogy, Captain Kirk represents the “wise mind” balance of Dr.Spock’s “reasonable mind,” and (“Bones”)McCoy’s “emotional mind”

21. “Taking Hold of Your Mind . . .” • Focuses on skills found in many meditation practices; • Includes awareness, description, and participation skills re: ones own thought processes; • Stresses staying in the moment, focusing on what works, and avoiding judging oneself.

22. Mindfulness Strategies • Alternate Rebellion • Encourages addicted individuals to find alternate ways to rebel against the restrictions and deprivations of their lives without needlessly complicating or destroying their lives • Observing Urges • Using this skill as a management technique for urges / cravings to use (“this too shall pass”)

23. “DBT Path to Clear Mind” • Life-threatening behavior? • Therapy-interfering behavior? • Quality-of-life-interfering behavior?

24. “DBT Path to Clear Mind” • Decreasing use of substances • Decreasing urges & cravings • Decreasing physical discomfort of withdrawal & abstinence

25. “DBT Path to Clear Mind” • Decreasing associated behaviors initially viewed as “unimportant” • paraphernalia, dealing, slippery places & people • Decreasing “keeping options to using open” • lying about use, keeping contact info, avoiding healthier places & people

26. Interpersonal Effectiveness • The emphasis is on learning and practicing skills that make relationships with others work better.

27. “Interpersonal Effectiveness . . .” • . . . Situations • . . . Goals • . . . Factors • . . . Myths • . . . Affirmations • . . . Options • . . . Suggestions • . . . Guidelines

28. Interpersonal Effectiveness Strategies • Including the following: • Assertiveness skills • Communication skills • Refusal skills • Conflict resolution skills

29. Emotion Regulation • The emphasis is on . . . • Understanding emotions • Reducing emotional vulnerability • Decreasing emotional suffering

30. “Emotion Regulation . . .” • . . . Goals • . . . Myths • . . . Models • . . . Descriptions • . . . Value • . . . Risk management • . . . Increasing positive emotion • . . . Letting go of emotional suffering • . . . Strategies for changing emotional state

31. Emotion Regulation Strategies • Building a Life Worth Living • Based on the idea that restored or increased functioning is one of the most effective ways to prevent relapse; • Encourages behaviors compatible with a higher-functioning life, and incompatible with a using lifestyle; • Involves building structure and constructive activity into one’s lifestyle.

32. Distress Tolerance • The emphasis is on skills for tolerating painful events and emotions when you cannot make things better right away.

33. “Distress Tolerance . . .” • . . . Crisis survival strategies • . . . Guidelines for accepting reality • . . . Principles for accepting reality

34. Distress Tolerance Strategies • Adaptive Denial • The skill of actively blocking or pushing away thoughts or aspects of reality that would be harmful or difficult to endure if attended to

35. Distress Tolerance Strategies • Burning Your Bridges • RADICAL acceptance that one is not going to use again, along with taking action to cut off any / all using options

36. Distress Tolerance Strategies • Avoiding and Eliminating “Cues to Use” • A “stimulus-control” strategy by which the individual intentionally and planfully avoids or eliminates from their life “people, places, and things” that are associated with past using patterns and behaviors.

37. Tools for the “Recovery Toolbox” • The DBT model of treatment offers some additional, or specialized tools for folks with personality disorders to be able to use in support of their ongoing dual recovery.

38. The DBT view on Substance Abuse • The DBT model views substance abuse as “impulsive dysfunctional behavior” that serves to regulate emotions during times of intense affective dysregulation.

39. “Dialectical Abstinence” = (a) Unrelenting insistence upon total abstinence before any slip/relapse + (b) Radical acceptance, non-judgmental problem-solving, and effective relapse prevention after any use, followed by return to (a)

40. Relapse: Endpoint or Process? • Endpoint?(all or nothing) • “the recurrence of a disease after a period of improvement” • Process?(nonfatal slip intended to teach) • “the act or instance of backsliding, or worsening”

41. Behavioral Analysis (see handout) • Seeks to understand the relationship between . . . • Antecedent events • Behavior • Consequences

42. DBT: Attachment Strategies • DBT treatment attempts to engage with the “Butterfly Client” (those who “fly in and out” of treatment) in ways that support effective, active participation in recovery.