Initial RCT of a distress tolerance treatment for individuals with substance use disorders

“Finally, we examined if the changes in distress tolerance were clinically significant (as indexed by the reliable change index (RCI; Jacobson and Truax, 1991)).”

“…in depression symptoms (consistent with research suggesting the clinical utility of non-specific treatment factors and the simple provision of support; see Horvath and Symonds, 1991; Klein et al., 2003), they evidenced a significant decline in distress tolerance over the course of the intervention.”

“At the posttreatment assessment, participants in SIDI and SC completed the CEQ and CALPAS to control for nonspecific therapy effects.”

“To this end, SIDI draws on skills from DBT (Linehan, 1993; Linehan et al., 2002; Linehan et al., 1999) and Acceptance and Commitment Therapy (Hayes et al.”

“For both SIDI and SC, specific therapist behaviors were considered “prescribed” and “proscribed” (Waltz et al., 1993) to assure that the treatment delivered in each was distinct.”

“To this end, SIDI draws on skills from DBT (Linehan, 1993; Linehan et al., 2002; Linehan et al., 1999) and Acceptance and Commitment Therapy (Hayes et al.”

“…intolerance negatively affects drug and alcohol outcomes, with individuals low in distress tolerance more likely to drop out of substance use treatment (Daughters et al., 2005a) and subsequently relapse (Brandon et al., 2003; Brown et al., 2002; Daughters et al., 2005b; Quinn and Copeland, 1996).”

“…and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al., 2009; Daughters et al., 2008; Ellis et al., 2010; Howell et al., 2010; Keough et al., 2010; Nock and Mendes, 2008; Zvolensky et al., 2009).”

“This is particularly concerning given evidence for a positive association between both treatment dropout and relapse and a variety of other negative outcomes, including arrest and imprisonment, suicide, and lethal drug overdose (Britton et al., 2010; Simpson et al., 1997).”

“…intolerance negatively affects drug and alcohol outcomes, with individuals low in distress tolerance more likely to drop out of substance use treatment (Daughters et al., 2005a) and subsequently relapse (Brandon et al., 2003; Brown et al., 2002; Daughters et al., 2005b; Quinn and Copeland, 1996).”

“, 2003) is inversely related to a range of maladaptive behaviors, including antisocial behavior, maladaptive gambling, deliberate self-harm, binge/purge behavior, and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al.,…”

“The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et…”

“…and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al., 2009; Daughters et al., 2008; Ellis et al., 2010; Howell et al., 2010; Keough et al., 2010; Nock and Mendes, 2008; Zvolensky et al., 2009).”

“The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et…”

“…behaviors, including antisocial behavior, maladaptive gambling, deliberate self-harm, binge/purge behavior, and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al., 2009; Daughters et al., 2008;…”

“Interestingly, although the SC group showed significant improvements in depression symptoms (consistent with research suggesting the clinical utility of non-specific treatment factors and the simple provision of support; see Horvath and Symonds, 1991; Klein et al., 2003), they evidenced a significant decline in distre…”

“Finally, providing evidence that latency to termination scores on these tasks are not simply a measure of skill level or distress in response to the task, neither emotional distress in response to the tasks nor task performance have been found to be significantly associated with latency to task termination (Bornovalov…”

“To control for nonspecific therapeutic factors, participants in the SIDI and SC conditions completed the California Psychotherapy Alliance Scale (CALPAS) and the Treatment Expectancy and Credibility Scales (CEQ) (Devilly and Borkovec, 2000; Gaston, 1991).”

“The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et…”

“…behavior, and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al., 2009; Daughters et al., 2008; Ellis et al., 2010; Howell et al., 2010; Keough et al., 2010; Nock and Mendes, 2008; Zvolensky et…”

“…intolerance negatively affects drug and alcohol outcomes, with individuals low in distress tolerance more likely to drop out of substance use treatment (Daughters et al., 2005a) and subsequently relapse (Brandon et al., 2003; Brown et al., 2002; Daughters et al., 2005b; Quinn and Copeland, 1996).”

“…but still in residential substance abuse treatment) participants completed two behavioral measures of distress tolerance, the computerized Mirror-Tracing Persistence task (MTPT; (Quinn et al., 1996; Strong et al., 2003) and the Paced Auditory Serial Addition Task (PASAT; Lejuez et al., 2003).”

“In support of their construct validity, the MTPT and the PASAT have been shown to reliably induce emotional distress among clinical and nonclinical samples (Bornovalova et al., 2008; Gratz et al., 2007; Gratz et al., 2010; Lejuez et al., 2003) and to be significantly intercorrelated (Bornovalova et al.”

“…intolerance negatively affects drug and alcohol outcomes, with individuals low in distress tolerance more likely to drop out of substance use treatment (Daughters et al., 2005a) and subsequently relapse (Brandon et al., 2003; Brown et al., 2002; Daughters et al., 2005b; Quinn and Copeland, 1996).”

“…importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et al., 1990; Lowman and Allen, 1996; Monti et al., 1993; O'Brien…”

“…and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al., 2009; Daughters et al., 2008; Ellis et al., 2010; Howell et al., 2010; Keough et al., 2010; Nock and Mendes, 2008; Zvolensky et al., 2009).”

“…and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al., 2009; Daughters et al., 2008; Ellis et al., 2010; Howell et al., 2010; Keough et al., 2010; Nock and Mendes, 2008; Zvolensky et al., 2009).”

“…of their construct validity, the MTPT and the PASAT have been shown to reliably induce emotional distress among clinical and nonclinical samples (Bornovalova et al., 2008; Gratz et al., 2007; Gratz et al., 2010; Lejuez et al., 2003) and to be significantly intercorrelated (Bornovalova et al.,…”

“These findings extend extant research on the development and utility of targeted distress tolerance treatments for substance use disorders (e.g., Brown et al., 2008) by providing evidence for the positive effects of this treatment on distress tolerance specifically.”

“The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et…”

“The rationale for incorporating emotional exposure omes from research documenting the importance of contextual in particular, emotional) cues in triggering maladaptive behavoral responses such as substance use (Chaney et al., 1982; Childress t al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; itman et al.,…”

“Finally, we included two comparison conditions, including a SC condition that captures non-specific treatment effects and mirrors a common form of treatment often provided in the community (Koekkoek et al., 2010; Andrews, 1993; Spirito et al, 2011).”

“…among SUD patients with borderline personality, antisocial personality, and posttraumatic stress disorders, (Bornovalova et al., 2008; Bornovalova et al., 2011; Daughters et al., 2008) and to predict treatment dropout among substance users in residential treatment (Daughters, et al., 2005a).”

“…self-harm, binge/purge behavior, and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al., 2009; Daughters et al., 2008; Ellis et al., 2010; Howell et al., 2010; Keough et al., 2010; Nock and…”

“The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et…”

“Specifically, the emotional exposure component (see also Otto et al., 2004; Zvolensky et al., 2003) requires participants to practice the skills in session in the context of negative affect (induced through emotional exposure to everyday stressors).”

“This component of the treatment also has the added benefits of promoting immediate behavioral practice and the replacement of maladaptive coping behaviors with more adaptive responses, as well as providing a sense of mastery as patients are assisted in applying new skills to high levels of negative affect (Otto et al.…”

“The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et…”

“This component of the treatment also has the added benefits of promoting immediate behavioral practice and the replacement of maladaptive coping behaviors with more adaptive responses, as well as providing a sense of mastery as patients are assisted in applying new skills to high levels of negative affect (Otto et al.…”

“In particular, there is some evidence to suggest that the venting of emotions is associated with greater emotional avoidance (Riolli and Savicki, 2010).”

“This is particularly concerning given evidence for a positive association between both treatment dropout and relapse and a variety of other negative outcomes, including arrest and imprisonment, suicide, and lethal drug overdose (Britton et al., 2010; Simpson et al., 1997).”

“The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et…”

“…and, most notably, drug and alcohol use (Anestis et al., 2007; Bornovalova et al., 2008; Buckner et al., 2007; Daughters and Lejuez, 2005; Daughters et al., 2009; Daughters et al., 2008; Ellis et al., 2010; Howell et al., 2010; Keough et al., 2010; Nock and Mendes, 2008; Zvolensky et al., 2009).”

“Providing evidence for their convergent validity, distress intolerance on these tasks has been found to be heightened among SUD patients with borderline personality, antisocial personality, and posttraumatic stress disorders, (Bornovalova et al., 2008; Bornovalova et al., 2011; Daughters et al., 2008) and to predict t…”

“Indeed, distress intolerance is robustly associated with substance use coping motives, as well as substance use frequency and substance use disorders (SUDs) (Buckner et al., 2007; Howell et al., 2010; Marshall-Berenz et al., 2011; Vujanovic et al., 2011).”

“The rationale for incorporating emotional exposure comes from research documenting the importance of contextual (in particular, emotional) cues in triggering maladaptive behavioral responses such as substance use (Chaney et al., 1982; Childress et al., 1994; Drummond and Glautier, 1994; Franken et al., 1999; Litman et…”

“Finally, we included two comparison conditions, including a SC condition that captures non-specific treatment effects and mirrors a common form of treatment often provided in the community (Koekkoek et al., 2010; Andrews, 1993; Spirito et al, 2011).”

“Finally, we included two comparison conditions, including a SC condition that captures non-specific treatment effects and mirrors a common form of treatment often provided in the community (Koekkoek et al., 2010; Andrews, 1993; Spirito et al, 2011).”

“(91) provide preliminary evidence that a six session Skills for Improving Distress Intolerance Program added to residential substance use disorder treatment showed both improvement in distress tolerance skills and clinical outcomes compared with supportive counseling.”

“For example, in a recent randomized control trial, distress tolerance was improved by implementing a treatment consisting of a number of strategies including acceptance, distraction, and interpersonal skills (see Bornovalova et al. 2012).”

“One recent study of individuals with substance use disorders found that a brief DT skills training intervention increased behavioral DT relative to control conditions (Bornovalova et al., 2012).”

“…been developed for substance users to specifi cally increase skills to tolerate distress and control behaviors in the context of emotional distress (Bornovalova et al., 2012), which is largely informed by Dialectical Behavioral Therapy (DBT; Linehan, 1993; Linehan et al., 1999) and Acceptance and…”

“Patients were eligible for the study if they met the following criteria: (1) age 18-70 years; (2) presence of chronic back pain (defined as more than 3 months of pain, at an average severity of 4 or higher on a 0-10 scale); and (3) current prescription for an opioid analgesic medication for pain.”

“suggesting that active treatment components are responsible for improving distress tolerance.(44) Overall, improvements in psychological symptoms were associated with improvements in distress tolerance in the mind–body group but not in the control group.”

“In addition, a pilot study of aDI treatment for substance use disorders found significant reductions in behavioral measures of DI over time (Bornovalova et al., 2012).”

“Distress tolerance (DT), or the ability to tolerate aversive emotional states, is another risk factor that appears to be environmentally-mediated given that it changes with treatment (Bornovalova et al. 2012; McHugh et al. 2013) and is associated with genetic vulnerabilities (Amstadter et al.”

“There is evidence that the experience of PTSD symptoms may confer risk for suicidal behavior in general (Fordwood, Asarnow, Huizar et al, 2007 ) and within SUD populations specifically (Bornovalova, Gatz, Daughters et al, 2012 ).”

“Bornovalova et al. (2012) developed a distress tolerance treatment, called skill for improving distress intolerance (SIDI), aimed at enhancing distress tolerance among individuals receiving inpatient treatment for substance use disorders.”

“Moreover, the brief DT treatment, in comparison to supportive counseling and treatment-as-usual, evidenced higher rates of clinically significant improvement in DT (Bornovalova et al. 2012).”

“Various intervention formats, such as Dialectical Behavior Therapy (DBT; Becker & Zayfert, 2001; Linehan, 2015) and Skills for Improving Distress Intolerance (SIDI; Bornovalova et al., 2012), have each been shown to improve distress tolerance.”

“Emerging empirical and theoretical literature suggests that DT may be context sensitive (Bernstein, Trafton, Ilgen, & Zvolensky, 2008; Leyro et al., 2010; Vujanovic; Bernstein et al., 2011) as well as amenable to change via intervention (e.g. Bornovalova et al., 2012; M. M. Linehan, 1993).”

“An additional avenue of exploration might be targeting low DT within structured interventions, including exposures to uncomfortable internal states (Bornovalova et al. 2012).”

“Specifically, depressed females with low distress tolerance could benefit from treatment that aims to improve distress tolerance (e.g., Bornovalova et al., 2012), and increase access to alternative positive reinforcers when experiencing negative affect (e.g., Daughters et al., 2008).”

“Studies have found that the unwillingness to experience distress may be a dimension of emotion dysregulation that is particularly relevant to SUD patients regardless of their co-occurring psychopathology [119,120].”

“Accordingly, as substance use treatment development efforts have targeted the mechanisms known to contribute to poor treatment response, novel DT-specific interventions (Bornovalova et al., 2012), and existing treatments with DT-specific components (Dimeff & Linehan, 2008), have been incorporated into substance use tr…”

“Together, these findings underscore the utility and importance of laboratory-based assessments of treatment outcomes (Bornovalova et al., 2012).”

“One intervention that may be particularly useful in targeting DT within this population is skills for improving distress intolerance, a six-session individual treatment for low DT that has been found to significantly improve both DT and depression among patients in residential SUD treatment (Bornovalova et al. 2012).”

“Empirical work likewise shows that acceptance-based manipulations and interventions tend to improve distress tolerance (Bornovalova et al., 2012; Juarascio, Parker, et al., 2020; Kraemer et al., 2016; Wang et al., 2019).”

“12 Evidence from these studies suggests that distress tolerance as a component in treatment may prove useful for smoking cessation treatment.”

“distress tolerance is a dimension significantly associated to treatment outcomes of SUDs (17,18).”

“Given evidence that DI can be reduced with targeted interventions (Bornovalova et al., 2012; Macatee and Cougle, 2015), psychosocial treatments for individuals with depressive and anxiety disorders, particularly those who present with high levels of worry, may benefit from inclusion of DI-targeted intervention modules.”

“In recent years, a DT-based intervention for SUD has shown promise in improving DT in adults in residential SUD treatment (Bornovalova et al., 2012), although this trial did not document changes in SUD-related outcomes (e.g., craving).”

“…specific to samples of adults who have moved into recovery from SUDs demonstrate similar patterns: those who struggle tolerating distress often display poor substance use treatment outcomes, including both relapse and withdrawal from treatment (Bornovalova, Gratz, Daughters, Hunt, & Lejuez, 2012).”

“This may be because many SUD interventions focus explicitly on negative emotion (e.g., Bornovalova et al., 2012; Brewer et al., 2009; Witkiewitz & Bowen, 2010), or because the number of studies on SUD and positive emotion (k=7) was smaller than the number assessing negative emotion (k=30).”

“In addition to providing more flexibility, expanded treatment models should also account for the impact of trauma on drug use behaviors and use a trauma-informed approach to treatment [44] that leverages and seeks to build internal and external patient resources [83] such as distress tolerance [84, 85] and social supp…”

“Interventions targeting DT have shown potential in reducing depressive symptoms (Bornovalova et al., 2012), and an increase in DT after cognitive-behavioral therapies was associated with decreased anxiety and depression symptoms (McHugh et al., 2014).”

“…for drug use disorders has received encouragement from additional pilot studies, including those examining cue exposure for opioid dependence (Tull et al. 2007) and distress tolerance treatments for substance use disorders (Bornovalova et al. 2012) and nicotine dependence (Brown et al. 2008).”

“Preliminary research supports their effectiveness in treating addictive disorders (Bornovalova et al., 2011; Bowen et al., 2009).”

“In addition, a recent study found that patients with substance use disorder who received a brief treatment aimed at improving emotional intolerance reached a clinically significant improvement compared to patients who received supportive counselling (Bornovalova et al. 2012).”

“Similarly, DT, indexed behaviorally, has demonstrated significant associations with SUD severity, initiation, and treatment outcomes (Ali et al., 2015; Buckheit et al., 2020; Richards et al., 2011).”

“Although treatments have been developed for low DT individuals (Bornovalova et al., 2012; Linehan, 1993), distress overtolerant behaviors are normally not a focal component of treatment.”

“Some interventions targeting DT [35–38] have shown promising results, which had led to a growing interest in understanding the role of DT in the association between distal variables (such as personality traits) and psychopathology [39].”

“In the current study, largely in response to participant feedback from the pilot RCT, we modified the DTI from the version used in Macatee and Cougle (2015) in the following ways: (1) We used idiographic distress scripts in both session one and two; (2) Participants used an index card to construct a customized impleme…”

“As has been initially shown to be effective among substance-using populations and early-lapse smokers (Bornovalova, Gratz, Daughters, Hunt, & Lejuez, 2012; Brown et al., 2008), future interventions for individuals with HIV may benefit from specifically targeting ability/ willingness to tolerate…”

“ings, such an approach might need to be modified to focus specifically on sadness.(46) While longitudinal studies are needed to further docu-”