The Dual Recovery Tools
of Dialectical Behavior
Therapy (DBT)
“How can DBT help those
with personality disorders
and addictive disorders?”
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.”
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.
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)
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.
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
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”
Narcissistic Personality
Disorder (<1%)

“a pattern of
grandiosity,
need for
admiration,
and lack of
empathy”
Histrionic Personality
Disorder (2-3%)

“a pattern of
excessive
emotionality
and attention
seeking”
Borderline Personality
Disorder (2%)

“a pattern of
instability in
interpersonal
relationships, selfimage”

30-60% of persons
diagnosed with
personality
disorders end up
with this diagnosis
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)
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
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.
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
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)
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”
“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
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
Mindfulness

Sees “Wise Mind”
as the optimal
balance between
the logical /
analytical “Logical
Mind,” and the
sometimes volatile
“Emotional Mind”
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”
“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.
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”)
“DBT Path to Clear Mind”



Life-threatening
behavior?
Therapyinterfering
behavior?
Quality-of-lifeinterfering
behavior?
“DBT Path to Clear Mind”
1.
Decreasing use of
substances
2.
Decreasing urges &
cravings
3.
Decreasing physical
discomfort of
withdrawal &
abstinence
“DBT Path to Clear Mind”
4.
Decreasing associated
behaviors initially viewed as
“unimportant”
•
5.
paraphernalia, dealing, slippery
places & people
Decreasing “keeping options
to using open”
•
lying about use, keeping
contact info, avoiding
healthier places & people
Interpersonal Effectiveness

The emphasis is
on learning and
practicing skills
that make
relationships with
others work
better.
“Interpersonal Effectiveness . . .”
. . . Situations
 . . . Goals
 . . . Factors
 . . . Myths

. . . Affirmations
 . . . Options
 . . . Suggestions
 . . . Guidelines

Interpersonal Effectiveness
Strategies

Including the
following:




Assertiveness
skills
Communication
skills
Refusal skills
Conflict
resolution skills
Emotion Regulation

The emphasis is on . . .

Understanding
emotions

Reducing emotional
vulnerability

Decreasing emotional
suffering
“Emotion Regulation . . .”






. . . Goals
. . . Myths
. . . Models
. . . Descriptions
. . . Value
. . . Risk
management



. . . Increasing
positive emotion
. . . Letting go of
emotional
suffering
. . . Strategies for
changing
emotional state
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.
Distress Tolerance

The emphasis is
on skills for
tolerating painful
events and
emotions when
you cannot make
things better right
away.
“Distress Tolerance . . .”

. . . Crisis survival
strategies

. . . Guidelines for
accepting reality

. . . Principles for
accepting reality
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
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
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.
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.
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.
“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)
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”
Behavioral Analysis

(see handout)
Seeks to understand the relationship
between . . .
Antecedent events
Behavior
Consequences
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.