By Cindy McGlynn
Winter 2003-04, Vol 7 No 2
Susan is what you’d call a straight shooter. She is a strong, smiling woman with salt and pepper hair, a frank manner and a throaty laugh that warms the chilly air. She easily offers instruction to her café staff – even on break, a manager is still a manager. You probably wouldn’t guess her nearly lifelong battle with a mental health disorder that was once considered virtually untreatable by mental health professionals.
Susan has borderline personality disorder (BPD), a severe psychiatric diagnosis characterized by disturbed relationships, life-threatening behaviour, mood swings and impulsivity. Like many people with BPD, Susan also had a substance use problem. Add to that her history of being abused as a child, and it’s clear that Susan’s life has been a roller coaster of highs and lows. Highs included a few years at medical school and a career as a carpenter. Lows involved staggering addiction, which included smoking cigarette-sized packages of marijuana joints daily, consuming “suicidal” amounts of alcohol and living in an abusive relationship that left her with a fractured skull and broken spirit.
After years of bouncing from therapist to therapist, Susan landed in the office of a therapist who practices dialectical behaviour therapy (DBT). DBT is the only therapy developed specifically for people with BPD. The therapy is now being modified to help people like Susan who also have an addiction problem. Susan says it has changed her life.
Originally developed in 1991 by Dr. Marsha Linehan, a professor of psychiatry and psychology at the University of Washington, DBT offers radical validation and acceptance of a client’s situation, while challenging the client to modify behaviour and learn new coping skills. Clients undergo individual and group therapy and skills training. They keep diary cards and have access to 24-hour phone consultation. Therapists themselves receive group peer support as part of the therapy. Results from Linehan’s 1991 study found that the condition of 47 severely dysfunctional women with BPD improved significantly with DBT. A review by Koerner and Linda Dimeff published in a 2000 issue of Clinical Psychology shows that DBT has weighed in with impressive results.
Modifying the treatment to address the needs of clients like Susan, who are dually diagnosed with BPD and a substance use problem, is long overdue: the DSM lists substance abuse as a diagnostic criterion for BPD.One key modification to treatment is the concept of dialectical abstinence, which recognizes that relapse prevention approaches to substance use problems reduce the frequency and intensity of drug relapse, while abstinence-based approaches lengthen the intervals between periods of use.
“The idea was to teach patients a way to have state-dependent goals,” says Linehan. “You teach a person to focus completely on abstinence when they are abstinent. And you also work with them so that if they fail, they are not criticized, but immediately focus on becoming abstinent again.”
The skills training module focuses on reducing drug use. For example, the skill of alternate rebellion was added, Linehan says, “to acknowledge that rebellion itself is not a problem, but to figure out a way to rebel that can have no lasting negative consequences.” Patients are encouraged to consider dying their hair, going bungee jumping or even shaving their head (rather than using drugs) to rebel against restrictions and deprivations of their lives.
The results are impressive. A study by Linehan published in a 2002 issue of Drug and Alcohol Dependence compared modified DBT to comprehensive validation therapy (CVT) plus 12-step programs for clients with BPD and substance use problems. Clients receiving DBT had greater success maintaining a reduction in drug use throughout one year of treatment, especially in the last four months, and also had lower rates of drug use 16 months after the trial began, compared with individuals in CVT and a 12-step program.
Similar results have come out of research at the Centre for Addiction and Mental Health (CAMH) in Toronto. Shelley McMain, head of the DBT Clinic at CAMH, along with Lorne Korman and colleagues, recently completed a trial comparing DBT versus community treatment-as-usual for people with BPD and substance use issues. The study found that DBT fared better than standard treatment in reducing parasuicidal behaviour and alcohol abuse across the one-year treatment.
“The real strength of DBT is that it attends to the problems patients have other than using drugs,” says Linehan. “They experience intense negative emotions and difficulties in living, so it’s very focussed on reaching them and giving them skills for everyday life. It validates their pain. And it treats drug use as a method they use to cope. It does not treat them as though going off drugs will make everything all right. They know it won’t.”
Still, therapists say that even with modifications to DBT, treating concurrent BPD and substance use is a challenge. McMain says that adding a substance use problem to BPD complicates an already complex situation. “When you’ve got substance abuse on board, it increases the risk of suicide, and that risk is already high,” she explains. Dropout and failure rates are also higher among clients with both BPD and substance use problems. Linehan says her biggest difficulty is helping clients find a new peer support group. “Drug users already have a supportive community, but that community is other drug addicts,” she explains. “It’s a challenge to find them a new community to fit into if they feel lonely or abandoned. We try 12-step communities where they get a reinforcement approach.”
Modified DBT is also breaking new ground simply by gathering data about treatment for people with DBT and substance use problems. Dr. George Davis, clinical director for the Center for Dialectical and Cognitive Behavioral Therapy in New Haven, Connecticut, says it’s difficult to know about other treatment models because most research has excluded people with BPD and addictions. “Traditionally, effectiveness studies for substance abuse have had BPD as part of exclusion criterion,” says Davis. “And when looking at BPD, they’ve listed substance abuse as an exclusion criterion. It has made it challenging to look at trials and try to compare results for a dually diagnosed population.”
Davis says therapists know anecdotally that 12-step addiction treatment models have had some success with this population, but little else is clear. But with more clinical trials in the works (Linehan’s team is working with Duke University in Durham, North Carolina, to compare modified DBT to standard drug counselling) and an invigorated therapeutic community, the future looks promising for people with BPD and substance use problems.
After decades of struggle and addiction, Susan says she has been clean for 14 months and that DBT gave her a life worth living. “I am a new person. I have a new life,” she says. “I actually experience moments of serenity and happiness now, and that didn’t happen before. I’ve been looking for this therapy for 25 years.”
Diagnosing personality disorders among people with substance use issues is a challenge. Samuel A. Ball, an associate professor in the Department of Psychiatry at the Yale University School of Medicine, indicates certain behaviours that should be excluded as a personality disorder symptom, including:
behaviours when intoxicated or withdrawing
behaviours only engaged in when seeking substances or concealing use
behaviours that began after substance onset and are inconsistent with prior personality
behaviours that cease after a couple of months of abstinence
DBT incorporates treatment ideas that are considered radical by some therapists, for example, the notion of dialectical abstinence, which balances an insistence on total abstinence with a policy of total acceptance upon relapse to reduce the intensity and frequency of recurrent substance abuse.
Louisa Van den Bosch, head researcher with the DBT Project for the Amsterdam Institute for Addiction Research, says that what is really radical is that DBT challenges therapists themselves to expand their own methodology to become more effective therapists.
“I think DBT is not only about therapy; it’s about changing attitudes and taking patients seriously: asking them how they feel and helping them change the behaviour that they want to change,” says Van den Bosch. “It reflects changes in other parts of our society where consumers have more rights.”
Van den Bosch says DBT allows therapists to be creative and respond to individual needs. Therapists must use their own judgement, for example, if a client has relapsed to substance abuse prior to a skills training meeting but still wishes to join the group for the session. This can be threatening to therapists who would prefer “by the book” instruction about whether the client should stay for the meeting or be sent home.
“Some psychiatrists think this is something that crosses limits and that you should treat by guidelines all the time,” says Van den Bosch. “Our project is adding to this discussion.”
In a 2002 study published in the Journal of Addictive Behaviours, Van den Bosch and colleagues compared results of DBT for people with borderline personality disorder with and without substance use problems. Therapists initially refused to offer 24-hour phone consultation, thinking clients would abuse the privilege. The clients insisted on full access to DBT prescribed treatment, including phone access. Van den Bosch says the results were surprising. “Most therapists find they enjoy doing this kind of phone consultation,” she says. “They know patients will call if something is happening to them, so if they don’t call, they also know things are OK.”
After nine years as a DBT therapist and trainer, Van den Bosch says she has seen the popularity of DBT ebb and flow, but nowadays she says clients are asking for it.
“At first, these patients may have the attitude that there’s nothing left for them in this world,” says Van den Bosch. “It’s amazing to see these patients after a year.”