DBT for Substance Use Disorders (Part 2)

June 19, 2022

This feature by Nick Salsman, PhD, ABPP is Part 2 of 2 in a series about DBT for substance use disorders. In the first part, Nick described how DBT-SUD utilizes the approach of dialectical abstinence in the assessment and treatment of SUDs and how DBT-SUD utilizes the hierarchy of targets in Pretreatment and Stage 1. In part two, Nick explains eight commonly used attachment strategies and seven skills often used by DBT-SUD providers.

Dialectical Behavior Therapy for Substance Use Disorder (DBT-SUD) is a treatment for individuals with co-occurring disorders, typically Borderline Personality Disorder (BPD) and SUD, which utilizes all of the strategies of standard DBT in combination with some special treatment strategies.

From the first session of individual therapy in DBT-SUD, the provider should be prepared to utilize the special strategies known as the attachment strategies. Eight commonly used attachment strategies in DBT-SUD include:  

  1. Orienting the client to problems that can arise with attachment due to SUD: This includes collaboratively working with the client to assess potential barriers to engaging in treatment and plan for how to overcome these barriers by identifying warning signs.
  2. Increasing Contact: Providers work with clients to have high levels of contact early in treatment to facilitate positive associations with therapy and provide more opportunities to reduce chaos in the clients’ lives.
  3. Providing in vivo therapy: At times, attachment may be increased by having the provider bring the treatment to the client (e.g., in the client’s home), versus have the client come to treatment.
  4. Building connections to the client’s network: The provider works with the client to gain permission to speak with the most important people to the client if the client “goes missing”.
  5. Providing longer or shorter sessions as needed: The provider varies the length (and potentially frequency) of sessions to maximize the clients’ benefits and attachment.
  6. Actively pursuing clients who are not attending: Providers utilize multiple channels of communication, including potentially physically searching for clients who have stopped attending sessions.
  7. Mobilizing the team when the DBT-SUD provider gets demoralized: The DBT team not only helps treat burnout and improve motivation of the provider, but team members also chip in to take steps to re-engage clients who are in danger of dropping out (i.e., even if they are not the individual therapist).
  8. Building the client’s connection to the network of providers: The more connections that a client has to treatment, the more likely these connections can be used to help the client stay attached to treatment.

Each of these strategies is utilized to help clients stay connected to treatment when their SUD may inhibit this connection.

The DBT-SUD provider will also utilize skills training to help clients avoid substance use, particularly the skills for when the crisis is addiction. These skills include dialectical abstinence, clear mind, community reinforcement, burning bridges, building new ones, alternate rebellion, adaptive denial. These skills are sometimes referred to as the DCBA skills, based on utilizing the first letter of each of the seven skills. Each of these skills are utilized to help the individual avoid engaging in addiction behaviors.

  1. Dialectical abstinence is a skill set used by clients to synthesize an abstinence-based approach with a harm-reduction approach.
  2. Clear mind is when clients utilize their inherent wisdom to navigate a middle path between dangers and pulls of both addict mind (i.e., a life centered on addiction) and clean mind (i.e., believing one is immune to addiction).
  3. Community reinforcement is a skill where individuals learn to alter their environments in a manner that facilitates shaping abstinence behaviors.
  4. Burning bridges is a skill that also helps the client alter the environment through making changes that increase the difficulty in accessing substances.
  5. Building new bridges involves clients utilizing images and smells to compete with drug cravings.
  6. Alternate rebellion is a skill where clients utilize less destructive ways to rebel, other than substance use.
  7. Adaptive denial involves clients using their thoughts to motivate further abstinence behaviors.

Additionally, the DBT-SUD provider teaches the client to utilize the skills of mindfulness, interpersonal effectiveness, distress tolerance, emotion regulation, and self-management to avoid addiction behaviors. The DBT-SUD provider engages in skills training to empower the client to use skills to regulate their emotions (as well as their actions, environment, physiology, and cognition) and thereby decrease the motivation to use substances.

The DBT-SUD provider also incorporates and can facilitate the utilization of ancillary treatments and assessments. Three that are particularly relevant are replacement medications and other pharmacotherapy, 12 step programs, and drug screens. As is true in standard DBT, empirically supported pharmacotherapy is encouraged for clients with problems that are effectively treated with medications. Certain SUDs have strong empirical support for the utilization of pharmacotherapy. For example, opiate replacement medications are an effective tool in the treatment of opiate-use disorders and are thus encouraged as a part of DBT-SUD for individuals with opiate problems. Additionally, 12 step and similar programs can be an important part of recovery for individuals with SUDs. DBT-SUD providers work with their clients to engage in these type of programs when they can enhance abstinence behaviors. DBT-SUD providers will also often incorporate drug and alcohol screening as a part of the ongoing assessment of SUDs through treatment. This data can be combined with data from other tools such as the diary card to enhance precision in assessment of targeted behaviors.

Overall, these special treatment strategies increase the tools available to the DBT-SUD therapist to target SUDs and related problems. Nonetheless, the DBT-SUD provider will also consistently use the same strategies used in standard DBT. Through this combination, providers can effectively help those who are suffering with co-occurring SUD and severe emotion dysregulation.

For more on DBT skills, read this blog about Using Skills in the Natural Environment.

Nick L. Salsman, PhD, ABPP is a professor of psychology at Xavier University where he is the director of the Xavier University Psychological Services Center and runs the Xavier University Dialectical Behavior Therapy (DBT) program. Dr. Salsman is a fellow of the American Psychological Association, Society for Clinical Psychology. Read his full bio here.


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