Vulnerabilities and Relapse Prevention in Substance Use Treatment.

I'm sure many of you have been exposed to Dialectical Behavioral Therapy. As clinicians and clients many of us have seen a rise in the use of DBT on hospital units, in partial care programs, and in outpatient settings. When Marsha Linehan created this theory, she had clients who struggled with borderline behaviors in mind. Since then, many have used the skills from DBT to assist in treating an array of clients across multiple diagnostic criteria. Although I am not a strict DBT clinician, although I have worked on a comprehensive team in the past, I find that when using DBT to c

ase formulate and/or in treatment, it is best to evaluate each intervention tool that DBT provides.

Recently I have found that many clinicians and programs that are “DBT informed” use skills but have often passed on the opportunity to use diary cards and behavioral chain analysis. This appears to be in an effort to reduce clutter designed by Linehan to target a specific population, however, my contention is that using the chain analysis with someone with a substance use disorder can be exceptionally helpful. The following is a brief explanation of why I think the chain analysis can be helpful and how you can use the idea of vulnerabilities in the DBT chain analysis to help clients with a substance use disorder even if you're unfamiliar with DBT.

The traditional chain analysis consists of vulnerabilities, prompting events, links, behavior, and consequences. At surface value, this may look like discussions we have regarding relapses in substance use treatment. Often, we refer to prompting events in the substance use field as triggers. The linking events become the actions we take between the trigger and the client's use of a substance. The term behavior in DBT represents the use of a substance. And the consequences remain just that the consequences of our substance use. This part of the DBT chain analysis appears to correlate very strongly with the work we do in evaluating relapse with clients regarding their substance use.

However, the introduction to the idea of vulnerabilities is a slight differentiation from our classical understanding of relapse. How many times have we been presented with a client who's abstaining from their substance of choice only to be “blindsided” by a trigger they've experienced repeatedly without relapse? We often trace things back to the trigger; the fight with the spouse, a song on the radio or driving by a familiar liquor store, or hanging out. Often, our clinical attention is steered towards reevaluating our plan to deal with that trigger. However, we fail to recognize that our client has coped with that trigger once, twice, or even a dozen times prior to that relapse. I believe the answer to this problem lies within vulnerabilities. By helping our clients understand their vulnerabilities they become more aware of why that trigger had a particular impact on that day.

This can be particularly helpful for clients who have put together a significant amount of time of abstinence. It's often recommended in recovery to avoid people, places, and things, essentially avoiding triggers until you have enough skills to cope with them. However, avoiding all triggers forever is nearly impossible and potentially not desirable for our clients. Controlling triggers in our environment is very difficult as we have little to no control over aspects of our environment. For example, a client who needs to go grocery shopping cannot always control the music in the grocery store, or the music blasting from cars passing by.

Clients may learn their vulnerabilities and take action to care for and plan for them. This is already recognized in substance use treatment through the acronym halt as it relates to substance use, hungry, anger, lonely, and tired. Recognizing the importance of these 4 vulnerabilities is essential but understanding the relationship between all vulnerabilities and abstinence may be the goal!

So, what do I do in my practice? I will start with a discussion of vulnerabilities. I try to provide as much relevant psychoeducation as possible and work to assist my client in recognizing their ability to cope with triggers in relation to vulnerabilities and their emotional state. Whether anxiety, depression, or anger, we look to identify how certain vulnerabilities affect where they are on their own mental health continuum. Then we plan how to manage vulnerabilities that are most likely to make us susceptible to triggers.

If you use DBT in your practice with clients let me know how and if you use it with clients struggling with substance use let me know if you have found success!