Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

618 V. TREATMENTS FOR ADDICTIONSdialectical perspective, the therapist and client could jointly create a synthesisby discussing how substance use is both understandable as a means of reducingbordeom and simultaneously a cause of much long-term suffering. Workingtogether, the therapist and client would look for ways to feel better temporarilywithout creating long-term suffering.There are many dialectical tensions in DBT-SUD. However, the centraldialectic is that of acceptance and change. For the therapist, this entails balancingan acceptance of clients as they are in the present moment with an explicit,long-term goal of meaningful change. For clients, changing behaviors must bebalanced by accepting unpleasant thoughts, emotions, or the reality thatunpleasant events have occurred. As an example in DBT-SUD, clients areencouraged to accept the reality that painful emotions will occur, while concurrentlyworking to prevent unnecessary emotional suffering caused by dysfunctionalbehavior. A compromise between acceptance and change is not necessarilythe goal. Instead, a synthesis of polarities may be more acceptance-basedin one moment and more change-focused in another, depending on the contextand what is likely to be effective. This is similar to how a golfer might hit theball toward one side of the fairway or the other, depending on the direction andstrength of the wind in the present moment, the shape of the fairway, and theobstacles that lie to the side. The target is to hit the ball as close to the puttinggreen or cup as possible, without the ball going out of play, not to hit the balldown the exact middle of the fairway.BIOSOCIAL MODELLinehan (1993a, 1993b) suggests that BPD is fundamentally a disorder of theemotion regulation system and results from a reciprocal transaction between anemotional vulnerability, an invalidating environment, and emotional dysregulation(see Figure 27.1). Emotional vulnerability is considered to be the keyFIGURE 27.1. Components of the biosocial theory of borderline personality disorder.