2022 California Council of Community Behavioral Health Agencies (CBHA) Conference

Integrating Dialectical Behavioral Therapy (DBT) and Co-Occurring Disorder Treatment at Four Winds Hospital

Four Winds continues to be a leader in mental health care as we are now well into our fifth year of applying Dialectical Behavior Therapy to our Co-Occurring Disorder treatment. The Co-Occurring Track, one of two treatment tracks in our Adult Inpatient Program, offers a structured program for patients with co-occurring psychiatric and substance abuse disorders. It is designed to meet the mental, emotional, and spiritual needs of our patients by focusing on the dignity and strengths of each person as they struggle with the symptoms and behaviors that have led them to hospitalization.

Patients with co-occurring disorders (formerly known as dual diagnosis) are affected by both psychiatric disorders (mood, anxiety, traumatic stress and psychotic disorders) plus substance abuse (alcohol, opiates, cocaine/stimulants, benzodiazepines, etc.). Many of these patients may try to recover from one problem and unknowingly neglect the other. Often one disorder is “blamed” for the other. These patients present specific diagnostic and treatment challenges since symptoms of both problems can overlap and/or mask one another. Proper treatment requires that both disorders be addressed simultaneously in an integrated process.

Our program consists of two substance-abuse groups daily that are led by masters-level CASAC’s and licensed therapists. These groups are both educational and therapeutic and include CBT, relapse prevention, coping skills, information about co-occurring disorders, and other relevant topics. An in-hospital twelve-step (Alcoholics Anonymous) meeting is held seven days a week. Patients also participate in DBT skills groups to enhance their ability to use skills instead of substances to cope with emotional discomfort. The skills groups include Mindfulness, Distress Tolerance, Emotion Regulation, and Interpersonal Effective.

A fifth skill, Walking the Middle Path, is integrated into the teaching that occurs in these groups. This skill is particularly useful in counteracting the black and white, either/or thinking that can make recovery, and life, so difficult. Walking the Middle Path requires becoming mindful of when thinking has become dichotomous and learning to appreciate the kernel of “truth” in seemingly contradictory points of view. Patients with co-occurring disorders, as well as mental health practitioners, can sometimes get hung up on whether they have either a mental disorder or a substance use disorder, and whether one or the other should be treated first. Walking the Middle Path replaces the “chicken or the egg” question with the “chicken and the egg.” A common example of this is patients with bipolar disorder and substance abuse. Both disorders need to be treated simultaneously in an integrated fashion if treatment is to be successful.

Adult inpatient team members do many of the same skill-strengthening assignments given to our patients. This helps staff with the important task of accepting and validating the challenge of behavioral change, and understanding that given their circumstances, patients couldn’t be any other way. It also helps staff be better able to help our patients define “target behaviors” and the skills necessary to deal with them. Target behaviors may include substance abuse, intentional self-harm, suicide attempts, dangerously risky behavior, binging, purging, promiscuity, gambling, avoiding treatment, stopping medications, etc.

Patients learn to identify the target behavior(s) that led them to come into the hospital, along with the triggers and circumstances that resulted in the target behaviors. The process by which this chain of events is identified is called a Behavioral Chain Analysis. Helping patients identify the links in the chain and learn alternate behaviors (skills) to manage the progression of events more skillfully is essential to helping them improve their lives one day at a time. The transformative power of the program lies in the dance, of sorts, between acceptance and change, the central dialectic in Dialectical Behavior Therapy. Accepting that our patients are doing the best they can, while also recognizing that they must change in order to have a life worth living, enhances self-acceptance and motivation.

Medication management is a vital part of treatment for patients with co-occurring disorders. Abuse of substances can interfere with prescribed medications, increasing the risk of relapse of the psychiatric condition, which may further increase the abuse of substances. Our team of experienced psychiatrists practices state-of-the-art psychopharmacology to address co-occurring psychiatric problems, such as depression, panic disorder, PTSD, bipolar disorder, and psychotic disorders. If necessary, careful medical monitoring helps patients withdraw from substances. Medical staff members are versed in helping patients walk the “middle path” between accepting the need for medication while also accepting personal responsibility for working on skills to create a life worth living.

As we live through ongoing change in our healthcare environment, there is one thing that we believe is certain: incorporating DBT has strengthened Four Winds Adult Inpatient Co-Occurring Program and makes the program transformational experience for our patients.

Dr. Bauman is Assistant Professor of Psychiatry and Behavioral Sciences at the Albert Einstein College of Medicine.

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