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

27. Dialectical Behavior Therapy 623Next, “apparently unimportant behaviors” are targeted. Patterned afterMarlatt’s work on apparently irrelevant decisions (Marlatt & Gordon, 1985),in DBT-SUD, behaviors (both observable events and privately experiencedevents, such as thoughts) that are links on the chain toward drug use are targeted.Examples range from obvious (e.g., selling drugs) to less obvious (e.g.,going into an environment with many cues associated with drug use). Finally,on the path to clear mind, DBT-SUD targets closing options to use drugs,including, for example, ending contacts and throwing away contact informationwith those who sell and use drugs, getting rid of all drug paraphernalia, andnot lying about drug use.Dialectical AbstinenceThe goal of DBT-SUD is to stop using drugs, with the ideal outcome of treatmentbeing complete and indefinite abstinence. However, the cold reality suggestedby clinical observation and supported by treatment outcome studies isthat even in the best treatments for substance use, abstinence may not lastindefinitely. Harm reduction approaches take into account the likelihood oflapse following treatment (e.g., Marlatt & Gordon, 1985), aiming to reduce theimpact of substance use rather than focus exclusively on abstinence. In DBT-SUD, abstinence is the goal, not harm reduction. However, the synthesisbetween complete abstinence and a harm reduction approach is struck. Theresulting perspective, called “dialectical abstinence,” refers to the position oftargeting complete abstinence on the one hand, while being prepared for andresponding effectively to drug lapse on the other hand; that is, dialectical abstinenceis achieved through the therapist targeting 100% abstinence with theclient, while also planning for the possibility of relapse by developing a relapsemanagement plan.Attachment StrategiesAlthough similar to BPD clients without substance use problems, thosewith co-occurring BPD–SUD disorders appear to have important differences.Linehan (1993a) characterizes individuals with BPD as either “attached” or as“butterflies.” Whereas attached BPD clients communicate often with therapists,rarely miss appointments, and appear closely affiliated to their therapists,butterfly clients do the opposite. Substance-abusing BPD clients are often butterflies,possibly because their drug use has become more reinforcing than socialinteractions, and this clinical observation has led to the addition of a set ofattachment strategies in DBT-SUD. For example, to develop rapport, the firstseveral sessions include a large amount of therapist validation, with less emphasison immediate change and/or interpersonal aversive contingencies than in