DBT, Family Therapy, Substance Use, Videos

DBT for Substance Use Treatment

An Interview with Sandstone Care

On March 29th, 2016 Laura gave an interview with Sandstone Care, a treatment program in Rockville Maryland for teens and young adults with co-occuring substance use and mental health concerns. Below is a video as well as the full transcript. We talk about how DBT fits into substance use treatment as well as the basics of family therapy and the biosocial theory.



Luke Mattey:  Hello, everybody. This is Luke Mattey at Sandstone Care. I have with me today, Laura Goldstein. She has just wrapped up an amazing presentation here in the office in North Bethesda. So I wanted to grab her a little bit to do a quick video podcast for us to tell us a little bit about herself, her practice, and then share some unique parts of her practice with you. Welcome, Laura.

Laura Goldstein: Thank you so much for having me.

Luke Mattey: Yeah, thank you so much for coming in. Yeah, if you would like to tell us a little bit about your background and your practice, I’d really appreciate it. Thank you.

Laura Goldstein: Yeah, absolutely. So I am a marriage and family therapist. I graduated from Thomas Jefferson University in Philly with my MFT degree in 2012. And then I came back to the Rockville area shortly after graduation and began working as a family therapist on a DBT team, at which point I was trained in DBT, went through the intensive training process and now I combine DBT work with my family therapy work in my private practice. I’ve applied DBT to substance use populations. I’ve applied it working with adolescents and their parents. It’s not the only modality that I work with, but I lean really, really heavily into it. And I find it to be really valuable with working either with individuals or with families or even couples.

Luke Mattey: That’s great. That’s great. Thank you. So your presentation this morning was on DBT, specifically Dialectical Behavioral Therapy.

Laura Goldstein:  Behavioral Therapy.

Luke Mattey: Thank you. And how that relates to substance use disorders. So do you mind sharing a little bit about your experience there and maybe a little bit from the presentation?

DBT In Substance Use Treatment

Laura Goldstein:  Yeah, so the idea behind using DBT to treat substance use disorders is that really substance use is co-occurring with other presentations, specifically emotion dysregulation. And the substance use is just one of the many maladaptive coping behaviors people can choose to help regulate their emotions. And if you teach clients the skills to regulate those emotions, other than substance use or other maladaptive coping behaviors, then they can learn to engage in more effective ways of coping. So the idea behind DBT is to train them up with skills so that they can manage that. And then also, to help them have the skills so that they’re not just managing their crises, and their substance use urges, but also preventing them from happening by creating a more stable life surrounding them.

Luke Mattey: Okay. That’s great. Thank you so much for sharing that.

Laura Goldstein: It’s very basic DBT.

Luke Mattey:  No, no and that’s good. You dumb it down for me, which knows nothing about it, so that’s great. Thank you so much. So in the presentation, you also talked about how important the family unit, or the support structure is for potentially the client you’re working with. Can you tell us a little bit about why it’s important or in your experience, how that’s played out?

Biosocial Theory of DBT

Laura Goldstein: Absolutely. So in DBT, we talk about the bio-social theory, which is the theory that we work with of how behaviors and emotions can become so out of control. And the biological part of the theory is that people are born with a predisposition to intense emotions and then impulsivity around that. More sensitive to emotions, more reactive, slow return to baseline, and then not having the impulse of control to manage their behaviors when these emotions happen.

Then the social part of the theory is that their environment reacts with these vulnerabilities in a way that typically is unhelpful. So social invalidation from family, society, parents, teachers, friends. When you feel invalidated, it makes it harder to actually soothe yourself through these emotions. And then the other piece is the behavioral reinforcement. So a lot of times people are accidentally reinforcing the ineffective coping skills rather than the more effective coping skills.

And so what we know is that the biological vulnerabilities make it harder for the social environment to respond effectively and in a social environment that’s not responding effectively makes it harder for the individual to manage their own vulnerabilities. And so the idea in DBT treatment is you have to work with both. You need individual therapy to learn the skills to manage your vulnerabilities. You also need family therapy to help learn a more effective way of responding to these things. So, as a family therapist, my bias is very much leaning into that social environment piece and helping families learn skills like validation and what it means to be both empathic and holding accountability at the same time with appropriate behavioral limits and being consistent with behavioral expectations.

And the two go hand in hand. When you work with one, the other will get better. We work the biological vulnerabilities, the social piece will improve. When you work with the social piece, the vulnerabilities will improve and if you’re doing both at the same time, then you have the quickest, most effective likelihood for recovery and most sustainable change.

Luke Mattey: Great. Great. Thanks for sharing that. So I know you mentioned during the presentation as well, how important that is. Do you work with the client and the family concurrently or would you involve another therapist?

Laura Goldstein: Yeah, great question. So in my practice, I see individuals and I work with individuals. I also see families and I work with families. I love working with families. But I won’t see the individual within the same family and that family for rapport issues. So I am happy to work with a family. It’s actually my preference. I don’t know if I want to say it out loud.

Luke Mattey: You’re allowed.

Family Therapy and Validation

Laura Goldstein: Yea, I love working with families. I would sooner work with a family and then refer them to another individual therapist. There are also a ton of individual therapists out there that can work with this type of population. There aren’t a ton of family therapists out there who are DBT trained. So my options for referrals are a little bit more limited.

But if I am working with an individual, and this happens often, I’ll get a call from a parent of an adolescent who will want me to do individual work, and I’ll pose to them the offer that we could start with family work, and it might be just as effective, and they’ll say, “No, no, no, no. My kid, really, let’s focus on the individual work.” And that means that three, four months into treatment when I’m making the recommendation that they really need to be doing family therapy, I’ll refer out. And now that I’ve hired my first associate, I can keep that in-house, and the hope is to be able to continue to grow so that we can offer all of that with in-house with different therapists in the hopefully near future.

Luke Mattey: Yeah, absolutely. That’s awesome. So thank you so much. And then one thing I would like for you to share with everybody is maybe something that’s either a little unique to your practice or something that you found has had the most impact with the clients, or the families that you’ve worked with. For example, I know you talked about the daily activity log?

Laura Goldstein: Diary Card.

Luke Mattey: Diary, thank you so much.

Laura Goldstein: The diary card is a tool that I use specifically with individual therapy for individual clients and it’s asking them to track their emotions and their behaviors. It’s classic for DBT therapy. I take no credit for it being something that I’ve personally created. And it works really well so that you can start to get data on how their emotions, your client’s emotions and behaviors are impacting one another. I don’t use that as much in family therapy.

There have been conversations that I’ve had about like, “How do we create a diary card for family therapy?” And I think that’s something that would be really interesting to figure out. I think one of the things that I really, really enjoy doing is working with parents on teaching validation skills. Actually, I wouldn’t say parents, I work with the whole family because it’s just as important as it is for the parents to be able to validate their kid’s emotions. It’s equally important for a kid to be able to validate their parent’s perspective. It is not a one-directional validation train.

So I often start there with families and because of that bio-social theory, we see that there’s just a deficit in the skills for that. And it’s always, oh no, I shouldn’t say always, but most of the time with the best intention is that a parent just wants to help. They don’t want their kids to be suffering, they don’t want them to be struggling. And so it’s kind of this idea of like, “Hurry up and feel differently. Don’t worry about it. It’ll get better. It’s not as big of a deal,” or, “Have you tried X, Y, and Z?”

All of those phrases just accidentally dismiss the core of the emotion. And sometimes somebody just needs to be understood for the emotion that it is what it is. And so teaching families how to do the validation instead of the accidental dismissing, I think is often a place where I start when I have families who come in my door.

Luke Mattey: That’s awesome. That’s very helpful. Thank you so much. So once again, I just like to thank Laura so much for the presentation today.

Laura Goldstein: My pleasure. Absolutely.

Luke Mattey: As well as sitting down here with me. So just to kind of wrap up, if you can let folks know the best way to find out more information about you, where you’re located, your services that would be awesome.

Laura Goldstein: Sure, absolutely. So Montgomery County Counseling Center is the name of my practice. Right now, it’s a small two-woman show, but like I said, hopefully, we’ll be growing. I am in Rockville, North Bethesda. My website https://mccounselingcenter.com and my email address is lauragoldsteinmft, which stands for marriage and family therapist. So lauragoldsteinmft@gmail.com and my phone number. Do you want my phone number?

Luke Mattey: It’s up to you. It’s up to you.

Laura Goldstein: I’m not a, “You can follow me on Instagram.” But my phone number is 240-772-1555.

Luke Mattey: Awesome. Thank you so much again, Laura, and I look forward to connecting you with folks that want to learn more about you. So thanks again.

Laura Goldstein: Awesome. Thanks so much for having me.

Luke Mattey:  Yep.

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