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Woven throughout the absolute abstinence pole of the dialectic is the clear message that the use of drugs would be disastrous and must be avoided. In studies published between and , reported rates of borderline personality disorder BPD among patients seeking treatment for substance use disorders SUDs ranged widely, from 5 to 65 percent Trull et al.

More recently, Darke and colleagues documented a 42 percent prevalence of BPD among heroin abusers in Sydney, Australia. That SUD and BPD should frequently co-occur stands to reason, because substance abuse is one of the potentially self-damaging impulsive behaviors that constitute diagnostic criteria for the personality disorder. However, this overlap in criteria cannot account for the full extent of the comorbidity. For example, Dulit and colleagues found that, among study participants with SUDs, 85 percent of those who also met the criteria for BPD would still have done so because of symptoms unrelated to substance abuse.

Individuals with SUD and BPD are among the most difficult patients to treat for either condition, and they have more problems than those with only one or the other Links et al. For example, rates of suicide and suicide attempts, already high among substance abusers Beautrais, Joyce, and Mulder, ; Links et al. Substance-abusing patients have significantly more behavioral, legal, and medical problems, including alcoholism and depression, and are more extensively involved in substance abuse if they also have a personality disorder Cacciola et al.

Results from one study suggest, further, that patients with BPD have more severe psychiatric problems than patients with other personality disorders Kosten, Kosten, and Rounsaville, In a 6-year study with BPD patients, Zanarini and colleagues found that the co-occurrence of an SUD was the factor most closely associated with poor treatment outcomes.

DBT treats a lapse into substance abuse as a problem to solve, rather than as evidence of patient inadequacy or treatment failure. When a patient does slip, the therapist shifts rapidly to helping the patient fail well —that is, the therapist guides the patient in making a behavioral analysis of the events that led to and followed drug use, and gleaning all that can be learned and applied to future situations.

Additionally, the therapist helps the patient make a quick recovery from the lapse. I might as well really go for it.

The idea of failing well also involves repairing the harm done to oneself and others during the lapse. Once the individual has resumed abstinence, the therapist moves back to the opposite absolute abstinence pole.

Failing well may be particularly important for individuals who have BPD as well as SUD, given their susceptibility to dysregulated emotion. The process of dialectical abstinence can be compared to the actions of a quarterback in football.

The quarterback focuses constantly on the ultimate goal of scoring a touchdown, even if only a few yards are gained in each play and even if ground is lost. The DBT therapist, likewise, always moves the patient toward the goal, stops only long enough to get the patient back on his or her feet after a fall, and is always ready with the next play that will eventually bring him or her to the goal line.

The conceptual basis of DBT is inconsistent with making the benefits of treatment e. Rather than punishing patients for the very problems that brought them into treatment, DBT assumes that patients are doing the best they can and must continue working to achieve their goals. A common misunderstanding involves the scope of abstinence required in DBT.

Many Twelve-Step programs require complete abstinence from all psychoactive substances—not only illicit and misused addictive substances or alcohol, but also prescribed medications. In DBT, the counselor determines the scope of abstinence appropriate for each patient based on a thorough assessment and three ruling principles:. Target other drugs that appear to reliably precipitate use of the primary drug of abuse—for example, some patients may not use marijuana frequently but may end up injecting their primary drug of abuse, heroin, every time they do.

With regard to the third principle, patients with SUD and BPD typically have myriad problem behaviors, including self-injurious and suicidal behaviors, in addition to those associated with drug abuse. Pragmatically, there is only so much that a severely disordered patient can be expected to change at one time. Drug-abusing individuals are often difficult to draw into treatment.

Common butterfly problems include episodic engagement in therapy, failure to return telephone calls or participate in sessions, and ultimately early termination from treatment. Additionally, the therapist has relatively little power to persuade butterfly patients to do things they prefer not to do. DBT employs a number of strategies to engage treatment butterflies.

Until an attachment is secured and the substance-dependent individual is out of significant danger of relapse, DBT therapists are active in finding lost patients and re-engaging them in treatment. Beginning in the first therapy session, the therapist orients the patient to the butterfly attachment problem, and the two discuss the likelihood that the patient may fall out of contact with the therapist during the course of treatment.

Other strategies include increasing contact with the patient during the first several months of treatment e. The adaptation was designed for a population of individuals with SUD that is largely heterogeneous across drugs of abuse and demographic variables. To date, nine published randomized controlled trials RCTs conducted across five research institutions have evaluated DBT. Pending clinical efficacy trials, we suggest considering a few basic principles in deciding whether to intervene with dialectical behavioral therapy DBT when substance-abusing patients do not have comorbid borderline personality disorder BPD.

First, be guided by what is known from the empirical literature. Second, be parsimonious. All things being equal, consider beginning with a less complex and comprehensive treatment than DBT. Although DBT contains elements that doubtless will be therapeutic for most patients, it is also likely to be considerably more extensive than most patients with a substance use disorder SUD require.

As DBT was developed specifically for individuals with pervasive emotional dysregulation, DBT may be a good fit for people whose use of drugs is associated with affective dyscontrol. DBT may be ineffective for individuals with whom emotions play little, if any, role in their sustained use of drugs. DBT may also be a reasonable first-line treatment for individuals who are substance dependent and chronically suicidal but do not meet criteria for BPD.

An opiate-dependent woman in her mids, Lucy has been repeatedly discharged from a community methadone maintenance program because of drug-positive urinalyses and problems with attendance. In addition to meeting criteria for opiate dependence, Lucy has had multiple episodes of major depression and is currently living with an abusive partner who is not interested in quitting his own use of drugs.

A careful behavioral analysis highlights the central role of emotional dyscontrol resulting in her frequent use of drugs often before having sex with her boyfriend; after an argument with him; or as a way to escape negative emotions, including sadness.

Although Lucy does not meet the full criteria for treatment with BPD, the intervention may still be warranted because many of her problems are rooted in emotional dyscontrol. Both were conducted by Dr. Linehan and colleagues at the University of Washington Linehan et al. The majority of participants were polysubstance-dependent with extensive histories of substance abuse and unsuccessful attempts at abstaining from drugs prior to beginning DBT. Comprehensive DBT that included all modes and functions was provided in both trials across a month course of treatment.

In each trial, the assessment phase spanned a total of 24 months, from pretreatment through a year following treatment completion. Those who received DBT were significantly more likely to remain in treatment 64 versus 27 percent , achieved greater reductions in drug abuse as measured by structured interviews and urinalyses throughout the treatment year, and attended more individual therapy sessions than subjects receiving treatment as usual.

Additionally, although trial participants in both conditions improved in social and global adjustment during the treatment year, only DBT subjects sustained these improvements at the month followup.

All subjects took levomethadyl ORLAAM, which is no longer available in Europe or the United States , an opiate replacement medication, throughout the treatment year and continued to receive it post-treatment. Three major findings emerged from this study. First, although both treatments were associated with urinalysis-confirmed reductions in opiate abuse, only DBT subjects maintained these reductions during the last 4 months of treatment.

Finally, both post-treatment and at the month followup assessment, subjects in both treatment conditions showed overall reductions in levels of psychopathology relative to baseline.

To date, two published studies have evaluated the relationship of DBT fidelity to treatment outcome; both confirm the importance of program fidelity and clinical adherence to the treatment manual. After 12 months of treatment, while subjects in both conditions improved over time, no significant differences between conditions were detected in any outcome variables, including suicidal and nonsuicidal self-injurious behavior, lethality of suicide attempts, emergency room visits, and inpatient hospital admissions.

Additionally, the analysis did not suggest that the failure to detect a difference between conditions was due to the small sample size. Although subjects from this sample were not substance-dependent, there is no reason to expect the findings would differ among those who are.

This study clearly indicates that providing pieces of DBT separated from the comprehensive model does not improve clinical outcomes for chronically suicidal BPD patients already engaged in non-DBT therapy. What is not known is whether DBT skills training alone, when compared with no treatment or less treatment e.

A second RCT by Dr. Linehan and colleagues examined the relationship of DBT treatment adherence to a key clinical outcome—drug-free urinalyses—in substance-dependent individuals with BPD. Steven C. Norton is a Rochester, Minnesota based psychologist who is specialized in Clinical Psychology. Patients can reach him at Norton is PH. Norton is a mental health professional with highly specialized training in the diagnosis and psychological treatment of mental, behavioral and emotional illnesses, including obsessive-compulsive disorder OCD.

His main focus is on diagnosing and treating mental, emotional, and behavioral disorders. Effective tools and strategies help clinicians recognize the physiologic and behavioral red flags of addiction and elicit a substance use history in a nonjudgmental manner, so you can make the appropriate diagnosis and develop a patient-specific plan for treatment and referral.

This educational module on the clinical assessment of substance abuse disorders presents written text and instructional videos that provide the knowledge, skills, and attitudes needed in the screening, evaluation, and referral of patients with substance abuse disorders.

Key words: Drug abuse; drug addiction; substance abuse; patient interviews; stage of addiction. Evaluation: Efficacy of an internet-based learning module and small-group debriefing on trainees' attitudes and communication skills toward patients with substance use disorders: results of a cluster randomized controlled trial.

National Institutes of Health. Drug Topics. More Drug Topics.