Dialectical Behavior Therapy (DBT) is a useful therapeutic tool that provides a framework for helping clients achieve mindfulness and acceptance to overcome problematic behaviors and live a more meaningful life. Although it was originally developed to combat self-harm behaviors in borderline personality disorder (BPD), it has shown promising results for use in other disorders. DBT uses skills training and individual psychotherapy as the basis of treating a number of disorders from BPD, substance abuse, anxiety, depression, eating disorders, and post-traumatic stress disorder (PTSD). Many of the techniques borrowed from DBT are useful in clinical practice for Psychiatric and Mental Health Nurse Practitioners.
Adapting Dialectical Behavior Therapy to the Role of the Psychiatric and Mental Health Nurse Practitioner
Dialectical Behavior Therapy (DBT) is a form of cognitive behavioral therapy that aims to teach clients new skills and strategies to help them live a meaningful life and deal with troubling behaviors that may arise. DBT was originally developed by Marsha Linehan for patients with borderline personality disorder (BPD) that displayed self-harm behaviors. There are several steps involved in the process of DBT, but therapy generally involves a combination of skills training and individual therapy with support from clinical staff. Some of the skills learned in DBT include mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Despite its original use with BPD, DBT has been effectively used across a number of disorders for behaviors resulting in self-harm (“What is Dialectical Behavior Therapy (DBT)?,” n.d.).
DBT provides clients with the capability that is needed through skills training and by helping them to become more motivated through individual therapy. The relationship between the client and therapist is paramount in ensuring that ineffective behaviors are replaced with meaningful coping skills. The role of coaching is validation and to ensure that a connection is reached with skills training to identify situations that trigger maladaptive behaviors. This effort is supported by case management in assisting clients to rely on their skills training to identify a more suitable alternative to the maladaptive behavior. In general, the main focus of the therapeutic relationship is for the client to develop mindfulness to identify harmful behaviors and acceptance to fulfill the life that they envision for themselves. By accepting their current situation as it is then clients are able to focus on the present moment and the etiology of their emotion. Mindfulness techniques center around focusing on the present moment while having an awareness to control their emotions through breathing exercises and other skills to focus on the problem at hand.
Skills training is generally performed in groups over four session that meet several times a week. Although the process may take some time, there is an emphasis on stabilizing acute distress and working through the emotional aspects involved. Behavioral skills are usually learned through a combination of group activities to promote skills and homework. Groups will generally meet for a couple of hours each week for six months to complete all of the skills training. The full process of DBT can even take up to a year to complete. The goal is that clients will learn mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness. This allows clients to understand how to be in the moment and deal with emotions to evolve out of difficult situations. In turn, clients learn to communicate their desires and place appropriate boundaries when needed. This ultimately leads the client to alter their emotions in a beneficial manner. Individual therapy generally runs concurrently with the group therapy once a week with no definite termination date. Therapists generally work with clients as a means of motivating clients to apply the skills that they’ve learned in their group work.
Telephone support is used along with DBT as a way of assisting clients with situations as they arise in their daily lives. Support is focused around assisting clients with selecting appropriate skills that they have learned in skills training and therapy to apply to the situation at hand. Likewise, case managers assist the client in a similar way through the dialectical problem-solving strategies they’ve learned in their training. These roles tend to be strictly supportive to help clients select learned strategies instead of falling back on their old ways of self-defeating behaviors and suicidality. One unique aspect of DBT is the use of a caregiver support team that is in place to provide a form of respite and continuous evaluation of the care for therapists and other supportive roles who provide constant support for those with serious mental illness through use of DBT (“What is Dialectical Behavior Therapy (DBT)?,” n.d.).
A main focus of DBT is the emphasis put on systematically treating problems in order of severity. Initially, the focus is stabilization in a time of crisis which usually involves the client experiencing dramatic behaviors intended to cause self-harm. Through crisis intervention, this helps them gain some level of control over problematic behaviors. Ideally, once symptoms have stabilized, the focus turns toward exploring and reflecting on the emotions that resulted in the behavior through therapy. This involves truly experiencing their emotions instead of avoiding what usually results in maladaptive behavior. Once the person finds that things have improved, the focus turns to maintaining this state of well-being and focusing on goals for the future. By the time clients have reached the fourth level they are ready to advance to the next stage while continuing with therapy. Ultimately, this is a time that clients can improve on the past skills to assisting them toward achieving their goals (“DBT Therapy | Dialectical Behavior Therapy,” n.d.).
There are three main theoretical frameworks that form the foundation for DBT: a biosocial model of the development of chronic mental health issues; the mindfulness practice of Zen Buddhism; and dialectics. The biosocial theory contends that some people are predisposed to be emotionally vulnerable and this is exacerbated by environments that lack a stabile structure which ultimately results in self-destructive behavior that is often seen in BPD. The concept of mindfulness relates to being in the present moment to evaluate and interpret a given scenario in an organized manner. Lastly, dialectics aims to reduce stress and promote growth by helping clients to accept less desirable traits while working toward changing these them (“DBT Therapy | Dialectical Behavior Therapy,” n.d.).
Research findings from numerous studies support the effectiveness of DBT in a number of disorders. This was especially true as it pertains to the treatment of BPD, self-harm, PTSD, and suicidal behaviors.
A study comparing different forms of DBT in patients with BPD and a history of suicide attempts and/or non-suicidal self-injury (NSSI) episodes “found that a variety of DBT interventions with therapists trained in the DBT suicide risk assessment and management protocol were effective for reducing suicide attempts and NSSI episodes. Interventions that included DBT skills training were more effective than DBT without skills training, and standard DBT may have been more superior in some areas” (Linehan et al., 2015).
Another recent study evaluating the clinical effectiveness of brief DBT skills training as an adjunct intervention for high suicide risk in patients with BPD found that DBT participants “showed greater reductions in suicidal and NSSI behaviors between baseline and 32 weeks. DBT participants also showed greater improvements than controls on measures of anger, distress tolerance, and emotion regulation at 32 weeks. They concluded that this is a viable option that may be a useful adjunctive intervention for the treatment of high-risk behavior associated with the acute phase of BPD” (McMain et al., 2016).
Goldstein et al. (2015) compared DBT with psychosocial treatment as usual (TAU) for adolescents with bipolar disorder. Adolescents receiving DBT “attended significantly more therapy sessions over 1 year than did adolescents receiving TAU, possibly reflecting greater engagement and retention. Adolescents receiving DBT demonstrated significantly less severe depressive symptoms over follow-up and were nearly three times more likely to demonstrate improvement in suicidal ideation. The authors concluded that DBT may offer promise as an adjunct to pharmacotherapy in the treatment of depressive symptoms and suicidal ideation for adolescents with bipolar disorder”.
Bohus et al. (2013) looked at the use of DBT for PTSD after childhood sexual abuse in patients with and without BPD. “The aim of the study was to determine the efficacy of a newly developed modular treatment program (DBT-PTSD) that combines the principles of DBT and trauma-focused interventions. They concluded that DBT-PTSD was an efficacious treatment for PTSD related to child sexual abuse, even in the presence of severe co-occurring psychopathology such as BPD”.
A randomized controlled trial (RCT) looking at DBT group skills training for attention deficit hyperactivity disorder (ADHD) among college students “found that participants receiving DBT group skills training showed greater treatment response rates and clinical recovery rates on ADHD symptoms and executive functioning, and greater improvements in quality of life. The authors concluded that DBT group skills training may be efficacious, acceptable, and feasible for treating ADHD among college students” (Fleming, McMahon, Moran, Peterson, & Dreessen, 2015).
Perepletchikova et al. (2017) examined the feasibility and preliminary efficacy of DBT adapted for preadolescent children (DBT-C) with disruptive mood dysregulation disorder (DMDD). “Children 7 to 12 years old with DMDD were randomly assigned to DBT or treatment as usual (TAU). Remission rates were 52.4% for DBT-C and 27.3% for TAU. Improvements were maintained at 3-month follow-up. The authors concluded that DBT-C demonstrated feasibility in all prespecified domains. Outcomes also indicated preliminary efficacy of DBT-C”.
The underlying assumption in DBT is that problematic behaviors are the result of a person lacking beneficial skills when the needs arise. Likewise, there can also be a lack of knowledge surrounding how to use these skills appropriately. This results in many of the maladaptive behaviors seen with BPD and other disorders. The purpose of DBT is to teach effective skills to clients to replace maladaptive that usually arise (“How DBT Helps – Behavioral Tech,” n.d.). As a result, DBT has shown effectiveness in reducing suicidality, self-harm, depression, anger management, emotional problems, and anxiety disorders (Neacsiu et al., 2014) (Neacsiu et al., 2010). Additionally, improvements in emotion regulation (Axelrod et al., 2011), experiential avoidance (Berking et al., 2009), and assertive anger (Kramer et al., 2016) have been associated with changes in substance abuse, depressive symptoms, and social skills during DBT. This supports the idea that DBT is effective because it teaches positive coping skills and techniques to manage different aspects of emotion.
DBT has shown itself to be effective among clients from different backgrounds in relation to age, sex, sexual preference, race and ethnicity. Although DBT was implemented in the United States, several randomized controlled trials (RCTs) performed in other countries produced similar results (“How DBT Helps – Behavioral Tech,” n.d.).
Overall, DBT has emerged as a useful therapy for a number of disorders since it was first developed for use with BPD. Its success can largely be attributed to the importance that it places on individual therapy and skills training to promote the development of new and effective skills to replace old patterns of maladaptive behavior. It is easy to see why this is a useful tool for the Psychiatric and Mental Health Nurse Practitioner, especially for conditions that are less amendable to medication for symptom control.