The adaptation of DBT to patients with SUD and BPD represents a natural extension of the therapy, in light of the comorbidity’s frequent and often synergistic threat to life (see Prevalence and Consequences of SUD-BPD Comorbidity). 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. The results support DBT’s efficacy in reducing a number of behavioral problems, including suicide attempts and self-injurious behaviors (Koons et al., 2001
; Linehan et al., 1991
; Linehan, Heard, and Armstrong, 1993
; van den Bosch et al., 2005
; Verheul et al., 2003
), substance abuse (Linehan et al., 1999
), bulimia (Safer, Telch, and Agras, 2001
), binge eating (Telch, Agras, and Linehan, 2001
), and depression in the elderly (Lynch et al., 2003
). These and other studies have also demonstrated that DBT is more cost-effective than treatment as usual in reducing the medical severity of suicide attempts, hospitalization, emergency room visits, and utilization of crisis/respite beds (American Psychiatric Association, 1998
; Linehan and Heard, 1999
IS DBT APPROPRIATE FOR PATIENTS WITH SUD BUT NOT BPD?
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. Is there a treatment already proven for the patient’s particular problem or problems? 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. Third, consider the extent to which emotional dysregulation plays a role in the individual’s continued use of drugs. 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.
On the other hand, given that DBT was developed for a population of difficult-to-treat patients with multiple Axis I and Axis II problems, it may be a reasonable approach for the non-BPD multidiagnostic SUD patient who has failed on multiple occasions in other evidence-based SUD therapies. 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.
The case of “Lucy” illustrates the kind of non-BPD patient who may benefit from DBT. An opiate-dependent woman in her mid-30s, 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.
Two of the RCTs focused specifically on the application of DBT for individuals with SUD and BPD. Both were conducted by Dr. Linehan and colleagues at the University of Washington (Linehan et al., 1999
). 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 12-month course of treatment. In each trial, the assessment phase spanned a total of 24 months, from pretreatment through a year following treatment completion. The initial RCT compared DBT (n
= 12) with community-based treatment as usual (n
= 16) among polysubstance-dependent women with BPD (Linehan et al., 1999
). 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 16-month followup.
The second trial involved 23 opiate-dependent individuals with BPD and used a more rigorous control condition, comprehensive validation therapy with Twelve Steps (CVT+12). This CVT + Twelve Steps is a manualized approach that includes the major acceptance-based strategies used in DBT in combination with participation in a Twelve-Step program, such as that used in Narcotics Anonymous (NA). Therapists focused on validating the patient in a warm and supportive atmosphere—providing, of course, that the behavior was effective in terms of the patient’s long-term goals. Subjects in the CVT +12 arm of the study were required to attend at least one NA meeting weekly, conducted at the treatment clinic and facilitated by the therapists, both of whom were members of NA. 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. Second, both treatments retained subjects in treatment, but CVT + 12 was exceptionally effective in doing so (100 versus 64 percent in DBT). Finally, both post-treatment and at the 16-month followup assessment, subjects in both treatment conditions showed overall reductions in levels of psychopathology relative to baseline.
Clearly, further studies are required to confirm the efficacy of DBT for individuals with SUD and BPD. However, the data thus far are promising, and additional research/clinical trials are under way.
To date, no clinical trials have evaluated DBT for patients with SUD but not BPD. However, we believe that certain circumstances and considerations may justify its use for the treatment of SUD patients who have other severe co-occurring psychosocial problems and/or have failed to respond to other SUD therapies (see Is DBT Appropriate for Patients With SUD But Not BPD?).