Dialectical behavior therapy versus comprehensive validation therapy plus 12-step for the treatment of opioid dependent women meeting criteria for borderline personality disorder

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Abstract

We conducted a randomized controlled trial to evaluate whether dialectical behavior therapy (DBT), a treatment that synthesizes behavioral change with radical acceptance strategies, would be more effective for heroin-dependent women with borderline personality disorder (N=23) than Comprehensive Validation Therapy with 12-Step (CVT+12S), a manualized approach that provided the major acceptance-based strategies used in DBT in combination with participation in 12-Step programs. In addition to psychosocial treatment, subjects also received concurrent opiate agonist therapy with adequate doses of LAAM (thrice weekly; modal dose 90/90/130 mg). Treatment lasted for 12 months. Drug use outcomes were measured via thrice-weekly urinalyses and self-report. Three major findings emerged. First, results of urinalyses indicated that both treatment conditions were effective in reducing opiate use relative to baseline. At 16 months post-randomization (4 months post-treatment), all participants had a low proportion of opiate-positive urinalyses (27% in DBT; 33% in CVT+12S). With regard to between-condition differences, participants assigned to DBT maintained reductions in mean opiate use through 12 months of active treatment while those assigned to CVT+12S significantly increased opiate use during the last 4 months of treatment. Second, CVT+12S retained all 12 participants for the entire year of treatment, compared to a 64% retention rate in DBT. Third, at both post-treatment and at the 16-month follow-up assessment, subjects in both treatment conditions showed significant overall reductions in level of psychopathology relative to baseline. A noteworthy secondary finding was that DBT participants were significantly more accurate in their self-report of opiate use than were those assigned to CVT+12S.

Introduction

Substance use disorders (SUDS), particularly opiate dependence, often co-exist with borderline personality disorder (BPD) (Trull et al., 2000). Prevalence of current SUDS among clients receiving treatment for BPD range from approximately 25 (Miller et al., 1993) to 57% when substance abuse was not used as a criterion for BPD (Dulit et al., 1990). Prevalence of current BPD among individuals receiving treatment for SUDS range from 5.2 (Brooner et al., 1997) to 17% (DeJong et al., 1993). Co-morbidity between BPD and SUDS is associated with greater severity than is found in either diagnostic group alone (Cacciola et al., 2001, Kosten et al., 1989, Skodol et al., 1999). For example, rates of suicide and suicide attempts, already high among both BPD individuals (Frances et al., 1986, Stone et al., 1987) and substance abusers (Beautrais et al., 1999, Rossow and Lauritzen, 1999, Farrell et al., 1996) are even higher for individuals with both disorders (Links et al., 1995).

Opiate addicts with Axis II disorders have poor treatment outcome (Hien et al., 2000, Rutherford et al., 1994, Kosten et al., 1989). These individuals are more likely to have higher rates of illicit drug use during treatment and are more likely to drop out of treatment or be administratively discharged because of ongoing behavioral problems. As such, specialized psychosocial treatment programs for severely personality-disordered opiate-addicted clients have been recommended (NIH Consensus Conference, 1998, Kosten et al., 1989). Relatively few studies have evaluated specialized treatments for personality-disordered, opiate dependent clients participating in concurrent opiate agonist treatment. The most consistent finding of the existing studies is that psychotherapy, when added to standard drug treatment for opiate addicts, improves outcomes on drug use and other measures of psychosocial functioning (Kidorf et al., 1998, McLellan et al., 1993, Rounsaville et al., 1983, Woody et al., 1983, Woody et al., 1985). BPD without opiate dependence is also typically characterized by poor treatment outcomes, including high treatment drop-out and rates of non-compliance (Kelly et al., 1992, Soloff, 1994, Waldinger and Frank, 1989).

Dialectical behavior therapy is a cognitive-behavioral treatment approach originally developed to treat chronically suicidal clients (Linehan et al., 1991, Linehan, 1993a, Linehan, 1993b) and subsequently adapted for substance abusers. As a whole, DBT attends to five functions of comprehensive treatment: capability enhancement (skills training), motivational enhancement (individual behavioral treatment plans), generalization (in vivo assignments, phone consultation), structuring of the environment (programmatic emphasis on reinforcement of sobriety and adaptive behaviors), and capability and motivational enhancement of therapists (therapist team consultation group). The treatment has two major characteristics: a behavioral, problem-solving focus blended with acceptance-based strategies, and an emphasis on dialectical processes. The term dialectical is meant to convey both the co-existing multiple tensions that must be dealt with in treating the multi-disordered patients, as well as the thought processes and behavioral styles employed and targeted in the treatment strategies. DBT is defined by its emphasis on behaviorally explicit targets and treatment strategy groups. The conduct of the therapist is guided by a detailed manual of procedures (Linehan, 1993a, Linehan et al., 1997).

Data suggest that in the treatment of suicidal women with BPD, DBT is more effective than treatment-as-usual (TAU) for reducing the frequency and medical severity of suicide attempts and self-injury, the frequency and duration of inpatient psychiatric days, treatment drop-out, social adjustment ratings, and self-reported anger (see Koerner and Linehan, 2000 for a review). Similarly, in a randomized controlled trial conducted by Linehan et al. (1999), women meeting criteria for BPD and polysubstance use disorder or substance use disorder for amphetamines, anxiolytics, cocaine, cannabis, hypnotics, opiates, or sedatives had significantly greater reductions in drug use throughout the treatment year and at follow up than did TAU subjects. Further, those assigned to DBT had significantly better treatment retention (64% retention in DBT; 27% retention in TAU). In social and global adjustment, there were no significant between-group differences during treatment or at 12-month follow-up, but DBT subjects did show significantly greater gains on these variables at the 16-month follow-up. These results are encouraging, but the TAU comparison design provides insufficient experimental control to draw firm conclusions. That is, whether the treatment gains were due to DBT per se, or simply the provision of a well-organized psychotherapy remains unclear.

The present study had two primary goals: first, to increase internal validity by evaluating the efficacy of DBT for substance abusers against a more rigorous control condition; second, to determine whether the findings of Linehan et al. (1999) generalize to a sample of opiate-addicted women with BPD. All participants received 1 year of treatment that included opiate agonist treatment and their randomly assigned psychotherapy condition. Opiate agonist therapy was provided to all subjects because the support for such a regime in treating heroin addicts is overwhelming (NIH Consensus Conference, 1998).

Given the absence of another data-based psychosocial intervention for the treatment of substance abusers with BPD, we used a constructive approach to treatment evaluation to develop a suitable control condition (Borkovec, 1990, Borkovec, 1993). The control condition, Comprehensive Validation Therapy with 12-Step (CVT+12S), is a manualized approach that provides the major acceptance-based strategies employed in DBT (such as therapeutic warmth, responsiveness, and empathy) in combination with participation in 12-Step programs. This design will maximize internal validity by holding the following factors constant across treatment condition: use of a manualized psychotherapy, access to treatment (including individual psychotherapy and crisis intervention), academic treatment setting, therapist experience and commitment, and general treatment factors common to standard non-behavioral treatments for opiate addicts. The provision of opiate agonist treatment is also held constant across condition. The primary hypothesis examined in this study was that DBT would be superior to CVT+12S in reducing behaviors targeted for reduction in DBT, including drug use and treatment drop-out. We further hypothesized DBT would be superior to CVT+12S in maintaining treatment effects over a 4-month follow-up.

Section snippets

Subjects

Individuals were recruited from mental health clinics, needle exchange programs, substance abuse clinics, methadone maintenance clinics, and non-profit HIV/AIDS prevention organizations treating under-served minority populations. For inclusion in the study, subjects were required to be females between the ages of 18 and 45 who met the following criteria: (1) diagnosis of BPD according to two structured interviews: the Personality Disorders Exam (PDE; Loranger, 1988) and the Structured Clinical

Data analysis

All analyses were two-tailed and were conducted on the modified intent-to-treat sample of 23. Baseline characteristics of the DBT and CVT+12S subjects were compared using t-tests for continuous measurements and Pearson's chi-square test or Fisher's exact test as appropriate for categorical measurements. Weekly urinalysis results were analyzed using hierarchical logistic regression models that allowed random subject-specific intercepts and subject-specific time slopes (Diggle et al., 1996).

Discussion

This comparison of DBT to Comprehensive Validation Therapy+12-Step among clients receiving opiate agonist medication had three primary results. First, both treatments when combined with LAAM were effective in reducing opiate use and in maintaining the reduction during the 4-month follow-up period. Participants assigned to DBT, however, showed better maintenance of treatment gains (i.e. reduced opiate use) through 12 months of active treatment while those assigned to CVT+12S increased opiate use

Acknowledgements

This research was supported by grant DA08674 from the National Institute of Drug Abuse, National Institute of Health, awarded to Marsha M. Linehan, PhD, Principal Investigator. The authors would like to thank the following individuals and organizations for their significant contribution to this project: Kris Adams, Audra Adelberger, Mary Ellen Fowler, Rebecca Gangloff, Angela Murray Gregory, Catherine Hynes, Ron Jackson, Eric Levensky, Joshua McDavid, Melissa McGee, Sheree Miller, Ellen Naden,

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