________________________________________________________________________ Behavioral Addictions
Dialectical Behavior Therapy Dialectical behavior therapy combines elements of CBT with mindfulness and other approaches into a structured treat- ment approach that emphasizes skills training in mindful- ness, distress tolerance, and emotion regulation. Dialectical behavior therapy provides an atmosphere of validation with psychoeducation and coping skills training—core competencies for interpersonal functioning that ordinarily would have been learned growing up in a healthy family environment. The four primary skill sets are mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness [76]. Mindfulness helps patients cultivate present-moment aware- ness, enabling them to observe and describe what is occurring without judgment. Mindfulness effectively counteracts viewing the present through the lens of distorted hopes, expectations, and past experiences of rejection and abandonment. Many patients believe they miss their childhood/family/lover, but they actually miss their idealized version of the past, not the reality. Effective emotion regulation helps patients to not over-react when facing emotions that threaten to overwhelm. Patients learn to become more aware of their feelings, the precursors to losing emotional control, and how to downregulate arousal states to relieve the pressure for impulsive behavior. Up-regula- tion is also taught, so patients do not ignore faintly recognized but painful reactions alerting them something is not right. Dialectical behavior therapy also helps patients learn mul- tiple methods of tolerating distress without resorting to self- defeating or self-destructive behavior. One method involves self-soothing by engaging the five senses when experiencing acute interpersonal anxiety or distress. This can involve listen- ing to or singing a favorite song; watching a travel video of a beautiful location; savoring the taste of a favorite food; lighting a candle with a favorite scent; and/or touching or rubbing soft material or a smooth stone. Interpersonal effectiveness is built by establishing a repertoire of skills that improve unstable relationship patterns. Patients learn skills related to self-respect, assertiveness, inhibition of emotions, and setting and maintaining personal limits and boundaries. Interpersonal effectiveness is the result of psy- choeducation about commonly held relationship myths that encourages patients to begin dismantling maladaptive beliefs by developing statements that challenge their narratives. Clinical psychologists administering dialectical behavior therapy are available after hours for support calls; during these contacts, patients are asked a series of standardized questions that encourage the best use of problem-solving strategies that apply dialectical behavior therapy principles. Typically, therapist-led dialectical behavior therapy consists of 2 intro- ductory psychoeducational sessions; 16 core skill-learning and skill-building sessions on mindfulness, emotion regulation, and distress tolerance; and 2 final review and relapse prevention sessions [81].
Motivational Interviewing The concept of motivational interviewing evolved from experience in the treatment of problem drinkers and was first described in 1983. Motivational interviewing is a systematic, evidence-based approach to complex behavior change. It is unique in eliciting and exploring patients’ own arguments for change, evoking intrinsic motivation, and helping patients to resolve their ambivalence about change [82]. It is a directive but nonconfrontational method to bypass unproductive struggles. The therapist engages the patient through empathic listening, open-ended questions, reflective statements, affirmations, and summary statements. By decreasing denial and enhancing motivation, motivational interviewing is a pragmatic, practical approach that focuses on actual change [76]. Motivational interviewing helps empower patients with respon- sibility for their behavior. By allowing patients to resolve their ambivalence using an approach that gently pushes them, they are more inclined to acknowledge the consequences of their behavior and engage in treatment. More aggressive strategies, sometimes guided by a desire to “confront denial,” can fail because they push patients to make changes for which they are not willing or ready [83].
Interpersonal Psychotherapies Interpersonal Psychotherapy
Interpersonal psychotherapy (IPT) was originally developed as a treatment for patients with depression, but it has been modi- fied for other clinical populations. It is a brief, focused therapy that targets problem resolution and symptom improvement within four social domains: grief, interpersonal role disputes, role transitions, and interpersonal deficits. Treatment occurs in three phases [81]: • Developing a thorough understanding of interpersonal contexts that contributed to the primary diagnosis and identifying interpersonal problem areas • Helping the patient make interpersonal changes in the identified problem areas • Reviewing progress and consolidating gains in treat- ment to prevent relapse Group Psychodynamic Interpersonal Psychotherapy Group psychodynamic interpersonal psychotherapy (PIPT) differs from IPT in its de-emphasis of social roles (e.g., role disputes), with greater emphasis placed on present interactions among group members and the therapist. Group PIPT uses cyclical relational patterns and circumplex models (versus social roles) to understand interpersonal patterns. It also applies specific models to elucidate patient attachment needs, negative affect, and behavioral addiction as a coping mechanism [81].
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