Dialectical Behaviour Therapy (DBT)
Dialectical Behavior Therapy (DBT)
Dialectical Behavior Therapy (DBT)
Dialectical behavior therapy is a cognitive therapeutic technique used in the treatment of chronically suicidal individuals that have also been diagnosed with borderline personality disorders. Though DBT was originally developed to treat this group of patients, the technique has been effective in the treatment of other disorders that include, but are not limited to, depression, substance dependence, post-traumatic stress disorder, as well as eating disorders. Presently, the treatment technique is widely recognized as the gold standard for the treatment of the chronically suicidal population (Linehan et al., 2015). This treatment technique is a complex combination of various methods and procedures that are used simultaneously to handle the borderline personality disorder (BPD) patients. However, it can be broken down into its four components; Phone coaching, therapist consultation team, individual therapy and skills training group. The skills training group component is the most widely recognized component of the dialectical behavior therapy. In this component, clients’ (patients) capabilities are the focus of the component and the therapy providers seek to teach the clients behavioral skills (Steil et al., 2012). The group component is often run like a classroom with a team leader who is charged with the responsibility of giving homework after each session for the group members to practice at home. Ideally, the group meets weekly for 24 weeks to learn various skills and to practice them throughout the week. After the 24 weeks, the skills lessons are repeated for the rest of the year. However, recent developments have seen additional scheduled classes being used to teach subsets of these skills to particular clients and populations in order to increase the effectiveness of this criterion (Priebe et al., 2012).
Phone coaching is an additional component that is used to assist the efficiency of the group method. However, unlike the group method, the phone coaching sessions are personal as the client gets a one-on-one treatment session with the therapist. The calls can be made in-between the session to the therapists when the client feels they need the therapist the most. Phone coaching has proved to be very effective in helping the clients deal with difficult situations that they may encounter during their everyday lives. Individual therapy, the third component, focuses on helping to enhance the client’s motivation and helping the clients in applying the skills that they keep learning in the weekly group sessions. Ideally, the individual sessions also occur weekly to run concurrently with the group sessions and continue for as long as the patient is still in therapy. Lastly, the last component, therapist consultation team component is more of a therapy session for the providers than it is for the clients. Usually, for the severe cases, therapy providers often find it difficult to deal with the cases using the normal procedures. The aim of this component is to keep the therapy providers motivated, and competent enough to deal with the difficult-to-treat cases. The therapists, together with the team leaders, meet once a week to deliberate on the various cases and discuss the unique cases.
Various researchers have researched on the dialectical behavior therapy, its uses and how effective the therapeutic technique has proven to be in the past. DBT has proven to be effective in dealing with the severe cases of mentally unstable clients with suicidal tendencies and with people with tendencies to inflict self-injuries. However, for most of the patients that often require the use the use of this technique, they often have a combination of problems that act as the underlying cause of the problem. The various components in the technique address various behavioral patterns and it is important to identify the various behavioral patterns that have been influenced by a particular method or therapeutic. Recognizing the effect of the various components on particular behavioral patterns helps in making the treatment procedure more effective. If certain behavioral patterns reduce after the application of a particular method, then an increased focus on the method will accelerate the reduction of the negative behavioral patterns. Recognizing the various behavior patterns and their influence on the patient’s overall behavior also helps in highlighting the areas that need more emphasis and those thane need less emphasis. Focusing on the main areas that require emphasis helps accelerate the treatment process. According to Stepp et al. (2008), highlighting the important areas helps in achieving effective outcomes. In a recent research conducted by Stepp and his colleagues on 27 patients in a university-affiliated mental hospital for people enrolled in the DBT program, the research highlighted several issues on the skills utilization for the various patients.
DBT focuses on equipping skill to clients and expects the patients to use the skills on a daily basis to help with improvement of their condition. The research conducted by Stepp in the mental clinic sought to determine the effectiveness of the DBT program and the level of skill utilization achieved by the patients enrolled in the DBT program in the mental clinic. In the research, Stepp and his colleagues used the Personality Assessment Inventory Borderline Features Scale to measure the level of skill utilization at the beginning of each new skills training module. The skills under measurement were the basic skills that the DBT method seeks to instill in the patients enrolled in the program. The skills include mindfulness, emotional regulation, distress tolerance, as well as interpersonal effectiveness. The research, conducted for a year, revealed the following findings; the patients in the clinic showed an overall reduction in the DBT features. The improvement was also consistent in the affective instability and with the negative relationship aspects as well.
Secondly, the study also revealed a reported increase in patients using the new skills increasingly as the treatment period progressed. The increased usage of the skills was reported for the following skills; emotional regulation, distress tolerance, interpersonal effectiveness, and mindfulness. The period under study was one year. Thirdly, as the skills-usage increased with progress in the treatment, there was also a reported decrease in the DBT features over the same period. Some of the features that reported a decrease include negative relationships, affective instabilities, as well as identity disturbances. The aim of the study was to examine the effect of the DBT skills on the DBT features over the period of treatment. In this case, the period of treatment was one year. The research was successful in identifying the reduction of DBT features over the course of treatment and serves to highlight the impact the skills had on the treatment of the outpatients. The study also revealed that one skill set could also be used to predict the changes in other skill sets. Overall, there was a positive conclusion on the impact the DBT technique had on the patients and the research findings serves to highlight the effectiveness the dialectical behavior therapy has in chronic suicidal cases with post-traumatic disorders.
DBT has also been adapted over time to fit various populations (O’Connell & Dowling, 2014). As an instance to prove its real world adaptation, a recent study, conducted in a pubic mental clinic reveals the effectiveness of the criteria in dealing with the mental problem issue as well as the cost-effectiveness of the procedure for the treatment of the parasuicidal cases. In the research study, there were one-hour weekly individual sessions, 2-hour weekly group sessions, phone coaching sessions, as well as 90-minute therapist team sessions. The clinical staff in the mental clinic consisted of social workers, nurses, psychologists with a minimum masters qualification, as well as occupational therapists. The evaluation procedure to determine the effectiveness of the procedures and the cost effectiveness of the entire process revealed that the DBT procedures were not only effective, but they were also cost-friendly. Patients that were enrolled in the DBT program for over six months showed reduced suicidal behaviors and suicide attempts, and non-suicidal attempts as well. The emergency room visits also recorded a decline over the same period. The cost of treatment was also significantly lower for the DBT patients compared to other patients in the clinic. The average cost difference between the two groups was in the excess of over $ 5,000 Australian dollars (Pasieczny & Connor, 2011).
Development of the DBT technique
The history of the dialectical behavior technique traces its roots in the 1970s, when the cognitive behavior technique was the main treatment procedure for patients with mental problems or with various disorders. Dr. Lineham, credited with discovering the DBT was actively trying to find the best treatment procedures for women with suicidal tendencies (MacPherson, Cheavens, & Fristad, 2013). During those times, she evaluated the effectiveness of the cognitive behavior technique and found out that the procedure was ineffective in many aspects of its application. First, the clients receiving the CBT (Cognitive Behavior Therapy) treatment resented the focus the treatment process laid on change. In retaliation, the clients withdrew from the sessions and became angry in the process. Withdrawing from the treatment rendered the process useless as far as those patients were concerned. Secondly, Dr. Linehan realized that the clients were unintentionally determining the level of treatment that they were receiving. They would act in ways that would encourage ineffective treatment procedures such as changing the topic to discuss issues that they were comfortable with, but that were not helpful as far as the treatment process was concerned (Swenson, Torrey & Koerner, 2014). Thirdly, Lineham discovered that the standard model that was being used in the CBT process was proving to be ineffective owing to the number of cases that were being handled by the clients. The therapists were being overwhelmed by the cases and were unable to handle all the complexities that each individual case presented.
In response to theses problems, Dr. Lineham assembled a research team with which they sought to make significant modifications. The new modifications introduced a major change in the form of acceptance. While the CBT focused on the change, the new modifications highlighted and introduced the concept of acceptance to the equation. The acceptance issue helped patients feel more comfortable with the treatment process. The accepted notion communicated to the clients that their thought processes were accepted that they were valid (Pasieczny & Connor, 2011). The feeling of trusting their minds helped the patients accept the treatment and to avoid withdrawing from treatment programs. However, the new procedures and modifications did not do away with the change processes. Instead, the acceptance criteria would work together with the change processes. The change was inevitable. In order to benefit from the treatment process, patients had to change. The dialectical concept was also introduced. The concept of dialects was an important aspect because the treatment sessions were often characterized with high emotions and polarized feelings. The extreme feelings from either or both the clients and the therapists made the original CBT model challenging could be solved to a great extent by the introduction of the dialectics strategy (Miller, Carnesale & Courtney, 2014).
The research team also ensured that there was a balance between the change and the acceptance strategies even within the same session. Dr. Lineham also introduced new changes to the treatment structure and defined some core principles that had to be met for a therapeutic session to meet the new standards. These functions included; maintaining the client’s motivation to change, restructure the treatment environment to enable the treatment process, enhance the client’s capabilities, enhance the therapists’ motivation, as well as making sure that the new client capabilities can be applied to other areas (Koerner, 2013). Dr. Lineham proposed that it was the therapist’s responsibility to ensure that they created a conducive environment for the client to feel comfortable enough to participate in the treatment process. The skills need to be acquired through the skills group sessions and strengthened through the assignments. The generalization of the client’s capabilities is possible through phone coaching and through the group session homework assignments. Dr. Lineham’s research team proposed that the therapists needed to prevent burnout and lost efficiency through the weekly therapists team meetings to refresh and to keep themselves competitive. Restructuring the environment to fit the definition of an ample environment that would be conducive to the treatment process would be undertaken with the involvement of the client’s family members. Meeting with the family members is a crucial step, especially for outpatient clients whose treatment progress is directly affected by the home environment and their relationships with other family members (Frazier & Vela, 2014).
Other Behavior Therapy Models
Behavioral therapy is a popular therapeutic technique whose efficacy and effectiveness has since been determined and proven by a number of clinical trials. The paper’s discussion focuses on DBT. However, the DBT technique is just one of other therapeutic models that are available for treatment of various mental illnesses. Other behavioral therapy techniques include, but are not limited to; Cognitive behavior therapy, the applied behavior analysis, habit reversal training, as well as the social learning theory.
Cognitive behavior therapy (CBT)
The cognitive behavior medal is widely considered as the predecessor of the dialectical behavior therapy. Whatever the case may be, the CBT model was the most popular behavior therapy used for mental illnesses before the emergence of the DBT. Dr. Lineham, and her team of researchers based their DBT model on the CBT technique. The cognitive behavioral therapy is a therapy treatment method whose basic principles is based on cognitive as well as behavioral principles. The cognitive therapists had a belief that the conscious thoughts had the ability to influence a person’s behavior. With the behaviorists, they believed that the disorders were as a result of the relationship between their phobia and their reactive response towards their phobia. A combination of the two principles formed the basis of the cognitive behavior therapy.
The CBT technique’s core principles lie in change. However, the dialectic behavior therapy has additional features. Apart from the change factor that is instrumental in the treatment process of the patients, the DBT technique introduced the acceptance principle. Clients found it difficult in the CBT sessions where the therapists focused, entirely, on changing. The DBT technique proved to be more effective as the patients were encouraged to accept their thoughts and to trust their emotions before they were encouraged to change.
Applied Behavior Analysis
The behavior therapy is hugely based on the learning theory principles whereby interventions are systematically applied to the patients to significantly improve their behaviors to socially acceptable levels. The interactions between the environment and the behaviors are analyzed and the effect they have on the individual is used to determine the best treatment for the patient. A control behavior is used in the modification process. Arguments have arisen to question the ethical basis of using the technique in the treatment process. However, the end result and the possibility of the patient getting treatment in the end is the motivating factor.
Applied behavior is different from dialectic behavior therapy as DBT therapists do not use other behaviors to influence the client’s behavior. Instead, the patient is encouraged to accept their thought processes and then encourage them to change via the use of skills learnt in group meetings. In DBT, skills are used to modify the behavior and the client has a feeling of free will and retains the decision-making ability throughout the treatment process.
Habit reversal training
The habit reversal training technique is a multi-component package and is used to successfully treat a wide range of repetitive disorders. The treatment package is made up of five components, including awareness training, relaxation training, competing response training, contingency management, as well as generalization training.
The habit reversal training is similar to DBT in the sense that the training routine with habit reversal training and the skills acquisition takes a similar routine and patients are taught new habits that are meant to replace the negative thoughts and behaviors. However, the habit reversal training is effective in addressing mild repetitive disorders and is not effective in treating serious mental cases such as suicidal tendencies.
Advantages of using the DBT technique
The DBT technique has an advantage over the other technique for a variety of reasons; One, the technique teaches patients techniques that are helpful in coping with the symptoms of DBT patients. The skills are also multi-purpose because they can be used in coping with other mental conditions as well. Two, the technique offers an opportunity, during the group sessions for some group interactions. The method always works for patients who make an effort to follow on the skills learnt.
Disadvantages of using the DBT technique
Some of the skills taught in the DBT programs are unbearable to some people and are often ignored by the patients. They are also responsible for some patients disliking the treatment sessions. Two, an overwhelming number of skills are taught in these group sessions and some of the clients find it difficult to learn some of these skills.
The Dialectical Behavioral therapy technique is a gold standard for the treatment of patients with borderline post-traumatic disorders and with suicidal tendencies (Cameron, 2015). However, the therapy technique was an improved version of the initial cognitive behavior technique that was popular prior to the 1970s. However, Dr. Lineham, together with her research team, made significant modifications to the CBT technique that tremendously improved the effectiveness of the process of DBT. The DBT process is anchored on equipping the clients with a skill set that would help in reducing the DBT features. The DBT model is broken down into four components that work in unison to ensure that the process is successful (Pistorello et al., 2012). These components include; the group session, the individual; session, the phone coaching as well as the therapists’ team sessions. Ideally, the model describes that the group sessions should be conducted once a week, the individual sessions also have a similar schedule. The phone coaching is done in-between the group sessions. All theses components adhere to basic principles that underline the core values of the DBT technique. These core values include; creating an acceptable environment that is conducive for clients so stimulate acceptance from them. The clients’ capabilities need to be enhanced to enable progress in treatment and the generalization of the skills to new environments. The therapists also need to rejuvenation meetings once a week to deliberate on difficult cases and to keep themselves competitive (Andión et al., 2012). The initial CBT technique had challenges that the new DBT technique solved. The cognitive behavior therapy technique focused on clients’ change. The focus on change often led to retaliation from clients and withdrawing from the treatment sessions, often making the whole process counterproductive. The DBT technique introduced new concepts such as acceptance that helped more clients to accept the treatment process while still maintaining the change factor. Additionally, the dialectics concept, where both the change and the acceptance concepts oscillated and often used together even within the same session was popularized. Even though the initial introductions of the DBT concepts were meant to address women with suicidal tendencies, the technique has been adapted to treat various populations and for use in different settings (Bloom et al. 2012). Its efficiency is not in doubt as the therapeutic technique’s uses have been expanded to other disorders such as eating disorders (Bankoff et al., 2012), substance abuse and addiction, as well as non-suicidal self-inflicting injuries.
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