1. EXPERIENTIAL AVOIDANCE AND EMOTIONAL DYSREGULATION
AS THERAPEUTIC DIMENSIONS
IN ALCOHOL USE DISORDER TREATMENT:
findings based on 3-months
Dialectical Behavior Therapy Skills Training
Marco Cavicchioli (1-2), Mariagrazia Movalli (1-2), Francesco Massa (2), Pietro Ramella (2),
Cesare Maffei (1-2)
University Vita-Salute San Raffaele, Milan;
Department of Clinical Psychology, San Raffaele Hospital, Milan

2. why focusing on ea
It was postulated and proved that EA represents a functional dimensional in several psychopathological disorders (for a review see: Chawla & Ostafin, 2007; Hayes et al., 1996), including Substance Use Disorders (SUDs).
In clinical and experimental research, there is a working in progress discussion about the relation between EA and emotion regulation:
EA REPRESENTS
A SPECIFIC FORM
OF EMOTION REGULATION
(Hoffman & Asmundson, 2008)
EA IS A COMMON PATHOLOGICAL FUNCTION
OF PARTICULAR EMOTIONAL
REGULATION STRATEGIES
(Boulanger, Hayes & Pistorello, 2010)

3. why focusing on ea and difficulties in emotion regulation in suds
Empirical research showed how EA was:
related to some clinical aspects of SUDs
(Baker et al., 2004; Levin et al., 2012; Stewart, Zvolensky & Eifert, 2002)
a mediator of relationship between
some different forms of psychological distress and substance use
(Bordieri et al., 2014; Levin et al., 2012; Stewart, Zvolensky & Eifert, 2002)
Specific difficulties in emotion regulation were found in several SUDs:
deficits in tolerating and accepting emotions (e.g. Berking et al., 2011; Bonn-Miller et al., 2008;)
difficulty in impulse control when experiencing negative emotions (e.g. Fox et al., 2007; 2008)
believes there is little to do when one experiences negative emotions (Wilcox & Adinoff, 2015)

4. why dbt skills training in treatment of alcohol use disorder
Dialectical Behavior Therapy (DBT)
is a manualized psychological treatment originally developed
to reduce maladaptive behaviors related to emotional dysregulation
in Borderline Personality Disorder (BPD)
(Linehan, 1993)
Several randomized controlled trials (RCTs) have demonstrated that
DBT is an effective treatment for BPD
(for a review see: Leichsenring et al., 2011; Panos et al., 2013)
Research on DBT efficacy supports the hypothesis that this treatment can be useful
in other mental disorders related to emotional dysregulation (Linehan et al., 2007),
including SUDs
(Axlerod et al., 2011; Harned et al., 2008; Linehan et al., 1999, 2002; van den Bosch et al., 2002, 2005; Linehan & Dimeff, 2008)

5. why considering ea in dbt
Even though EA is not considered the primary hypothesized pathological process in DBT model, some studies investigated the role of this dimension in DBT outcomes and it was considered as a secondary outcome of DBT programs.
Specifically:
EA represented
a therapeutic interference factor in DBT programs
(Berking et al., 2009; Rüsch et al., 2008)
DBT showed a specific effect, compared with CBT,
in improving emotional expression and in reducing EA in BPD treatment
(Neacsiu et al., 2014)

6. ON DBT-ST TREATMENT OUTCOMES FOR AUD HAS NOT BEEN PREVIOUSLY REPORTED
THE ROLE OF EA
ON DBT-ST TREATMENT OUTCOMES FOR AUD
HAS NOT BEEN PREVIOUSLY REPORTED

7. aims of the study 1 2 3 4 This study aims to:
show primary treatment outcomes
abstinence maintenance
consecutive days of abstinence (CDA)
alcohol addiction severity
assess the improvement of EA and SUDs-related domains of emotional dysregulation during the treatment
test the predictive role of EA on alcohol/substance use outcome
evaluate the mediating effect of EA on relationship existing between SUDs-related difficulties in emotional regulation and abstinence maintenance 1 2 3 4

8. results: sample intensive phase post-intensive phase
110 AUD patients were consecutively admitted to 3-month DBT-ST program as stand-alone treatment
86 (78.2%) patients completed the program.
4 (3.6%) subjects did not conclude the intensive phase.
20 (18.2%) subjects did not conclude the post-intensive phase.
Abstinence maintenance was assessed by random weekly toxicological screening (e.g. alcohol and other drugs)
intensive phase
4 weeks (5 times a week)
post-intensive phase
8 weeks (twice a week) 1 2 3 4 5 6 7 8 9 10 11 12
110
patients 86
patients 4 20

9. The 83.7% completers maintained abstinence at the end of program
results:
primary treatment outcomes
The 83.7% completers maintained abstinence at the end of program
CDA mean was (SD = 38.19) among subjects who completed the treatment
Perceived alcohol addiction severity (SPQ alcohol ) significantly decrease
during the treatment independently of baseline levels [t(84) = ; p < .001]
d = ( )
ITT analysis supported the previous findings [t(108) = ; p < .001]
d = ( )

10. results:
ea and sud-related dimensions of ed

11. AAQ-II at the beginning of treatment
results:
predictive role of ea on cda
ITT results (N=110)
R2 Lineare = 0,040
CDA
y=1,14E2+-0,75*x
AAQ-II at the beginning of treatment
В = -.20, p < .05; R2 = .04

12. results: the mediating role of ea on primary outcomes
ITT results (N=110) *

13. results: the mediating role of ea on primary outcomes
pre-post change of EA explained different trends in DERS Impulse [F(1,106) = 2,16; ns] and DERS Strategies [F(1,106) = 2,72; ns] between lapsed and abstinent patients
the improvement in ability to accept and tolerate negative emotions remained the unique emotion regulation domain that was significantly related to abstinent maintenance

14. results: the mediating role of ea on primary outcomes
pre-post change of EA explained different trends in DERS Impulse [F(1,106) = 2,16; ns] and DERS Strategies [F(1,106) = 2,72; ns] between lapsed and abstinent patients
the improvement in ability to accept and tolerate negative emotions remained the unique emotion regulation domain that was significantly related to abstinent maintenance

15. results: the mediating role of ea on primary outcomes
pre-post change of EA explained different trends in DERS Impulse [F(1,106) = 2,16; ns] and DERS Strategies [F(1,106) = 2,72; ns] between lapsed and abstinent patients
the improvement in ability to accept and tolerate negative emotions remained the unique emotion regulation domain that was significantly related to abstinent maintenance

16. discussion
DBT-ST for AUD showed promising results in relation to primary outcomes such as treatment retention, abstinence maintenance and alcohol addiction severity
large improvements in EA and specific SUD-related difficulties in emotion regulation were observed during the treatment
These results are consistent with DBT’s emphasis on reducing emotional suppression/avoidance as well as on improvement emotional modulation using skills taught during the DBT-ST:
DISTRESS
TOLERANCE
SKILLS
OPPOSITE
ACTION
SKILLS
PROBLEM
SOLVING
SKILLS
MINDFULNESS
SKILLS
ACCEPTANCE
SKILLS

17. discussion
EA represented an early predictor of primary treatment outcome
greater improvement in EA and in SUD-related emotional dysregulation dimensions were related to abstinence maintenance during the treatment
changes in EA explained the relationship existing between improvements in impulse control when experiencing negative emotions and learning of flexible emotion regulation strategies with abstinence maintenance
LAPSE IN SUBSTANCE USE REPRESENTS A DYSFUNCTIONAL EMOTION REGULATION STRATEGY, WHICH HAS THE FUNCTION TO AVOID OR ALTER AVERSIVE EXPERIENCES

18. THE ABILITY TO ACCEPT AND TOLERATE NEGATIVE EMOTIONS
discussion
THE ABILITY TO ACCEPT AND TOLERATE NEGATIVE EMOTIONS
IN ADDITION TO THE DEVELOPMENT
OF A WILLINGNESS STANCE TOWARD UNWANTED EXPERIENCES
MIGHT REPRESENT CORE THERAPEUTIC DIMENSIONS
IN AUD TREATMENT

19. limitations
The absence of a control treatment condition (e.g. other treatments, waiting list):
we can not definitely attribute the improvement of EA/SUD-related ER strategies to a specific effect of DBT-ST program
the reduction of EA and difficulties in emotion regulation might be explained by factors that are shared with other third wave cognitive therapies, that showed promising results in SUDs treatment, such as ACT and MBRP

20. future perspectives
Additional clinical controlled trials are recommended to prove the specificity of DBT in reducing EA, as well as further process-outcome studies are necessary in order to understand which aspects of DBT intervention might have a better effect on EA decrease.
Follow-up studies should be carried out to evaluate the stability of EA and emotional dysregulation levels reached at the end of treatment and their role in long-term relapse prevention.

21. THANK YOU FOR YOUR ATTENTION!
Any questions?