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

622 V. TREATMENTS FOR ADDICTIONSment. Although standard DBT often uses a variety of commitment strategiesduring pretreatment sessions, in DBT-SUD, clients must, at a minimum, agreeto work toward abstinence from all drugs. Because commitment to treatmentoften ebbs and flows, it is necessary to monitor ongoing changes in committedbehavior throughout treatment.Treatment TargetsClients with BPD often present for treatment with severe behavioral dyscontrol(e.g., self-injurious behavior), treatment-interfering behaviors (e.g., not showingup to treatment), and problems affecting physical (e.g., sleep problems),emotional (e.g., excessive emotionality), and cognitive (e.g., hopelessness)functioning. To treat this range of therapeutic targets consistently, a hierarchyfor problem behaviors is used in DBT-SUD: (1) Reduce acute life-threateningand intentional self-injurious behaviors; (2) reduce treatment-interfering behaviors;and (3) reduce quality-of-life interfering behaviors, beginning withdrug use, and including such problems as eating disorders, anxiety, depression,and physical health problems. The complete and total cessation of all drug useis the primary target in the quality-of-life interfering behaviors.Within this larger treatment hierarchy, DBT-SUD outlines the “path toclear mind” in order to provide specific treatment targets addressing substanceuse. The overarching, and, accordingly, first SUD-specific target is the reductionof all substance abuse, including illicit and licit drug abuse. In accomplishingthis, the next target in the path to clear mind is to maintain an adequatedose of drug replacement medications, when relevant, and more generally todecrease the physical discomfort associated with abstinence. Physical pain andpsychological distress are targeted for change when possible. However, acceptanceskills are used to tolerate pain that cannot be reduced directly.Clients also learn how to monitor cravings, to evaluate the intensity ofcravings, to identify when cravings are particularly likely to increase drug use,to reduce cravings, and to avoid using drugs once cravings occur. On the onehand, clients learn that cravings should be expected to occur; on the otherhand, they learn how to actively problem-solve ways to cope with cravingswithout using. Unlike standard DBT, in which clients are frequently encouragedto turn their attention toward the experience of aversive emotions, DBT-SUD clients are encouraged to use skills to turn their attention away from cravingsand urges to use. As coping skills are acquired and generalized, DBT-SUDemphasizes community reinforcement of “nonaddict wise-mind” behaviors; thatis, clients increase activities associated with a decreased likelihood for drug use,such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA) meetings,gaining steady and legitimate employment, and socializing whenever possiblewith nonaddicts in mainstream settings.