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

27. Dialectical Behavior Therapy 631pist providing a warm, genuine, and compassionate interpersonal style. In manycases, these clients were raised in invalidating family environments (e.g., physical,sexual, or emotional abuse), continue to be surrounded by invalidating peopleassociated with drug using, and describe their previous mental healthtreatments as invalidating. The DBT-SUD therapist attempts to create a relationshipthat is different from past relationships. The deep pain and sufferingexperienced by these clients is attended to and validated in an authentic andcompassionate way.Importantly, however, therapist validation of client behavior is targetedspecifically to that which makes sense, is legitimate, or is effective. DBT-SUDtherapists attempt to validate what is valid, and, at times, invalidate what isinvalid. This requires the DBT therapist to discern carefully what is valid, andto apply validation in accordance with the conceptualization of each client’sproblem behaviors. For example, after a relapse, the therapist might warmly andcompassionately validate how and why it makes sense that the client used drugsto reduce short-term misery, but would not validate drug use as an effective,long-term solution to reducing pain. In DBT-SUD, validation is essential,because clients often come and go from treatment, and may not be as attachedto therapists compared to standard DBT clients with BPD and no substance useproblems. Consequently, aversive interpersonal contingencies are held to aminimum, unless, of course, such contingencies assist in reducing problembehaviors.Dialectical StrategiesIn DBT, dialectical strategies are fundamentally based around acceptance (e.g.,validation) and change (e.g., problem solving). Dialectical reasoning is pursuedwith the client, whereby the therapist helps the client move from a polarizedposition of “either–or” to a dialectical synthesis of “both–and.” Any therapiststrategy that challenges the client’s position (thesis), and instead involvesactively searching for what might be missing (antithesis), can be considered adialectical strategy if the tension between the thesis and antithesis produces asynthesis, or solution, that is ultimately useful for therapeutic change. There isno assumption that a single synthesis is the “correct” solution to a problem.Instead, the therapeutic process is one that continually works dialectically,yielding a number of possible solutions to a given problem; that is, the underlyingprinciple of dialectical strategies is a focus on the process of change within afluid context. Specifically, however, there are a number of dialectical strategiesused with clients (see Table 27.5; for descriptions, see Linehan, 1993b). Inorder to be effective, these strategies must be used in a manner that is genuine,and not as simple mechanical techniques. In addition, from a dialectical perspective,the therapist must be willing to let go of the truth or rightness of anydialectical strategy, and instead continually search for ways to help clients