Response: Innovations and Implementation

Abstract

Mardell Gavriel: At Walden House, we use dialectical behavior therapy (DBT) skills training and strategies with a wide range of clients, although we don’t implement the whole package. As we practice it, embracing a dialectic way of thinking means avoiding rigid notions, understanding that it’s all right to feel more than one way about something, and being cognitively fluid and creative in one’s thinking. The clinician may help the patient connect to both poles of his ambivalence about drugs. On one hand, the client wants recovery and recognizes that drugs have been problematic in his life, and on the other, he has real urges to use because drugs have been his survival strategy for a long time. Both of those rationales are equally true; what the dialectic recognizes is that both can yield useful insights. Helen Sackler: The authors’ football analogy illustrating the dialectic (Dimeff and Linehan, 2008) is similar to the way we routinely talk to substance abusers. In the analogy, the quarterback always has the goal of scoring, but he knows he can’t score on every play. On most plays, he just has to try to push the ball downfield. To our patients, we say, “What’s going to make your life worth living a year, 2 years, 5 years down the road? Keep your eyes on the prize, but work a day at a time.” Gavriel: One reason the DBT model has been fairly easy to implement in substance abuse treatment is that, philosophically, it integrates well with other existing models. To a great extent, the DBT skills are the same ones that underlie many of the curricula that are traditionally taught in substance abuse treatment—stress tolerance, emotional regulation, relapse prevention, and so on. Staffers find that DBT training reinforces and promotes their ability to do what they are already aiming for, which is to try to maintain a balance between accepting each client where he or she is and pushing for change. Suzette Glasner-Edwards: DBT overlaps greatly with other cognitive-behavioral and relapse prevention therapeutic approaches. Where it stands out and is innovative is in its conceptual framing and the emphasis it puts on some issues. DBT’s handling of engagement issues and treatment dropouts seems fairly intuitive, for example, but it is distinctive because it is so direct and up front. The counselor acknowledges right at the start that dropouts happen and problem-solves with patients to prevent it, in part by planning with patients to contact them if they don’t show up for a session. The DBT focus on teaching patients to tolerate pain and discomfort is similar to conventional coaching of clients to ride out their urges to use drugs, but it goes further. I think this could be very helpful with engagement and retention, particularly in early abstinence. Among stimulant abusers, for example, overwhelming psychological discomfort is among the problems that lead to high dropout rates. The terms “addict mind,” “clean mind,” and “clear mind” are consistent with traditional concepts in recovery and could be particularly useful in helping clients to understand their stages of recovery. I would like to see the authors articulate these terms further, with a list of changes and behaviors that clients can use to assess their progress. Clients could then say, “Well, I see that I am feeling so-and-so, and that tells me I’m in clean mind” or “I just did such and such, so I know I’m in clear mind.” Gavriel: The central concept of dialectical abstinence is another good example of DBT putting a new spin on treatment issues and practices. Although it is not earth-shatteringly new, it merges the concept of abstinence-based therapy and the attitude of learning from relapse in a novel, useful way. Similarly, getting client locator information up front and seeking out no-show patients is not unique to DBT. However, it has not become embedded in practice, and the emphasis that DBT puts on it is unique. Sackler: There is one valuable innovation in DBT that I think is brand new. It’s the idea that patients should immediately make amends for the harm they have done, rather than—as in Alcoholics Anonymous—waiting until Step 8. Gavriel: For all its compatibility with current practices, DBT does challenge some common ideas in the field. For example, we tend to say, when clients engage in inconsistent help-seeking, that they are not yet motivated enough for treatment and need to bottom out and come back. DBT says, instead, that we should try to maintain therapeutic relationships—and go find them. Sackler: I think this is a great direction for substance abuse treatment to take. Glasner-Edwards: Yes, so do I, particularly for its approaches to overcoming some of the problems of treatment engagement and retention.