B.F Skinner greatly contributed to the development of behavior therapy from which dialectical behavioral therapy developed. Behavioral therapy sought to change human behavior by use of positive or negative reinforcements such as rewarding or praising good behavior and ignoring bad behavior. Cognitive behavioral therapy was developed out of the behavioral model described by B.F Skinner and added the influence of thoughts and emotions in the changing of behavior by helping the patients to develop coping mechanisms. Improvements to the cognitive behavior therapy have led to newer approaches to changing patients behavior including Dialectical Behavioral Therapy and Acceptance and Commitment Treatment.
Dialectical Behavioral Therapy(DBT) was developed by Marsha Linehan in the late 1980s mainly to treat patients with borderline personality disorder although it has been shown to be effective against other mental disorders.
Theoretical assumptions & concepts
DBT emphasizes psychotherapy and group skills classes in which patients learn new skills and are taught strategies to enable them to develop a life that they wish to lead. DBT focuses on helping the patient to work on methods that they can use to decrease harmful behaviors and replace them with effective and fulfilling behavior.
DBT is made up of the following components:
Enhancing capabilities with DBT skills training: involves group classes where the patients are taught skills and assigned homework which is meant to help them apply the skills they learn in their everyday life. The group meetings are usually weekly for two and a half hours. Completion of the program takes about 24 weeks. The skills that are taught are; mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance.
Enhancing motivation with individual therapy: runs concurrently with the skills training and is focused on ensuring that the client stays motivated and helping them apply the skills they are being taught.
Ensuring generalization with coaching: this involves the use of in the moment coaching whereby patients can call their therapists to help them navigate a challenge that they face in their everyday life.
Structuring the environment with case management: this approach enables the client to manage their lives and ensures that the therapist only intervenes when absolutely necessary.
Supporting the therapists with the DBT consultation team: therapists work in conjunction with other professionals such as case managers and skills training group leaders in order to ensure that the therapists do not suffer burnouts and stay motivated.
Definitions of health & illness
Health is described as the complete wellbeing of the physical, social, and mental spheres, and not just the lack of infection or disease. Illness is defined as a period of sickness that affects the body or mind.
Goals of therapy
It aims to ensure that the patients build a life that they consider as worth living.
Implicit social and cultural assumptions
The assumptions made by DBT are:
Clients
Individuals want to improve.
Individuals are doing the best they can.
Individuals have to solve their problems although sometimes they may not be the cause of the problems.
Individuals with suicidal ideations have unbearable lives as they currently are.
Individuals cannot fail in acquiring the skills taught by DBT.
About the treatment
The most important thing about therapy is clarity and compassion.
The relationship between the therapist and the patient is a relationship of equals.
The therapists also need support to provide quality treatment to the patients.
The principles of behavior also affect the therapists and not just the patients.
The cultural assumption is that behavior is universal and therefore DBT can be applied to people of all races, ethnicities, cultural backgrounds and religious creeds.
Relevancy and/or application to clinical problems, issues, populations
This method of therapy was originally developed to treat suicidal individuals who had a diagnosis of borderline personality disorder and is currently the gold standard for this population. Research has shown that it also effective in the treatment of post-traumatic stress disorder, substance use disorders, depression, and eating disorders.
Workload of the therapist
DBT recognizes that a therapist needs support help in order for them to stay motivated and be efficient in helping their patients. The workload of the therapist is reduced as compared to other therapeutic modalities. DBT therapists are usually supported by skills training group leaders and case managers and the therapists also work as a team.
Research support
Research published in the Elsevier journal is amongst many that support the effectiveness of DBT in managing borderline personality disorder. DBT has also been proven to be therapeutic in the treatment of drug dependence and research supporting this fact was published in the American Journal on Addictions.
Strengths and weaknesses
The strengths of DBT include:
The patient is taught skills that enable them to cope with their challenges.
The patient is involved in creating the goals of the type of life they want to lead.
It increases the self-esteem and hope in the patients.
DBT is a very effective therapy modality, and so far weaknesses that have been cited include that DBT misunderstands our concept of being human and how we behave under conditions of despair. A research done in New Zealand suggests that DBT is not as effective as thought in the prevention of suicide.
Relevancy to the work of advanced practice nursing
DBT is particularly important to Clinical Nurse Specialists who will choose to specialize in psychiatric and mental health since it presents them with the best method that has been empirically proven in managing borderline personality disorder. Knowledge of the existence of DBT is also important for APRNs in general since it will enable them to refer their patients to therapists who use the method to ensure their patients receive the best care.
