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What is Dialectical Behavior Therapy?

Dialectical behavior therapy, or DBT, is one type of cognitive behavioral psychotherapy. This theory was first developed by Marsha M. Linehan in the late 1980s as an effort to better treat individuals presenting with borderline personality disorder. Since that time, this type of therapy has also been widely used as a way to treat various other types of mental health disorder, including those defined by substance abuse.

Simply put, dialectical behavioral therapy is offered by many clinicians in Denver and is an approach to treatment that emphasizes the various psychosocial aspects of treatment that are present today. The theory that is related to this approach is that many people tend to react in an overly emotional manner towards certain situations, such as those typically found in family and friend oriented relationships. Dialectical behavioral therapy is also a way of relating why the arousal levels in some people increase far more rapidly than other people. When this happens, they will attain a higher degree of emotional stimulation as well, and it will take noticeably longer to return to normal levels of arousal once again.

When an individual is diagnosed with borderline personality disorder, he or she experiences severe emotional swings. The world is often seen in black and white, and one crisis after another seems to occur on a continual basis. Not many people can understand these reactions, so there is no available positive coping mechanism for them to latch on to. Individuals who felt invalidated as a child, for example, may not have anybody that identifies with them. This will result in a sudden surge of emotion that needs to be dealt with in one way or another. The concept of dialectical behavior therapy is a way of teaching positive coping skills that will help with this.

Traits of Dialectical Behavior Therapy

There are three main characteristics of dialectical behavior therapy in Denver that need to be understood in order to understand the role that it plays in addiction recovery.

  • Dialectical behavior therapy is support-oriented – This involves helping the individual identify his or her unique strengths and to build on them so he or she can feel better about their life.
  • Dialectical behavior therapy is cognitive based – This involves helping the client to identify the thoughts, beliefs, and assumptions that he or she has that makes life harder.
  • Dialectical behavior therapy is collaborative – This involves the constant attention that is given to the relationships between staff and clients.

Specifically, the “monitoring of patient progress” was discussed as attending to the efficacy of treatment and clinical utility. That is, clinicians should employ a systematic and scientific evaluation of whether their treatments are working with their patients, while simultaneously considering the applicability, feasibility, and usefulness of their interventions within the context of the treatment setting. It should be noted, that while the APA Task Force (2006) provided a general description of “monitoring patient progress” they did not include a specific method and/or technique for how the monitoring of patient progress might be accomplished. For example, clinician judgment (which is discussed later) could be one possible method of “monitoring patient progress.” However, regardless of how patient progress is monitored, the fact that the APA Task Force (2006) included it as a component of “clinical expertise” seems to indicate that it is a critical aspect of evidenced-based practices.

Evidence-based Practices in Psychology: Soliciting Patient Feedback & Monitoring Patient Progress

When considering “clinical expertise” within the context of evidenced-based practices, soliciting feedback from patients regarding their treatment might be at least one avenue for developing “clinical expertise.” The process of asking patients about their experience while engaged in therapy would be one example of what is known as outcome monitoring. Outcome monitoring/measurement attempts to assess treatment outcome through the use of standardized measures of clinical severity. In other words, outcome monitoring hopes to capture a patient’s actual response to treatment in an effort to enhance treatment. Outcome monitoring tools require at least two data points, such as the start of treatment and another occurring at a later date (e.g., termination session, follow-up session). Ideally, outcome monitoring follows a repeated measures process that tracks both the amount and rate of change (e.g., session to session administration). Additionally, this real time, or session to session, feedback being provided to therapists regarding patient progress appears to coincide with the APA Task Force’s definition of “clinical expertise” and engages patients’ perspectives on their treatment. Furthermore, it appears that outcome monitoring plays a crucial role in outcome management. However, the term “outcome management” is distinctly different than “outcome monitoring.”

Outcome management is designed to improve the overall effectiveness of health care services within a health care system. Instead of individual treatment outcome monitoring, outcome management seeks to discover whether or not services are improving over time throughout the entire system. This practice allows for policy makers, administrators, supervisors, etc. to examine the effectiveness of psychotherapy across a wide range of treatments and patients.

Clearly, outcome monitoring and outcome management work together to improve psychotherapy and overall health care services. However, when considering the APA Force’s (2006) definition and emphasis on the development of “clinical expertise,” soliciting feedback from patients about their experience in psychotherapy is at least one method therapists could utilize to monitor patient progress. Understanding evidence-based practice through this conceptual lens decreases the emphasis on RCTs or empirically supported treatments, and moves psychotherapy outcome research towards what is now known throughout the field as “practice-based evidence.”

Practice-Based Evidence Approach

Recall that the patient-focused research movement in Denver was started in hopes of better understanding an individual course of psychotherapy through asking the patients themselves what made their treatment the most effective. This research framework helped pave the way towards what is now known as practice-based evidence. Practice-based evidence, like patient-focused research, is based on the assumption that improving psychotherapy is derived from demonstrating that interventions are effective for individual patients in “real-life practice settings.” Castonguay and colleagues believe that “practice-based evidence is premised on the adoption and ownership of a bona fide measurement system and its implementation as standard procedure within routine practice.” In other words, practice-based evidence may be viewed as patient-focused methodologies implemented within a routine care setting.

The implementation of a bona fide measurement system may include outcome monitoring tools/management systems, which are typically administered pre-/post therapy, repeated intervals, and/or session to session within routine care settings. Benefits of practiced-based evidence include: the reconciliation of competing interests between researchers (who often lack clinical experience) and practitioners, researchers working collaboratively with practitioners to explore research questions regarding service delivery that result in appropriate and applicable treatment recommendations, and practitioners having a tendency to rely more on practiced-based evidence research findings than other types of research, such as RCTs. Therefore, practiced-based evidence has the potential to impact the practice of psychotherapy at both the individual and community levels. Whether a therapist is working in private practice, a community-based agency, or a large-scale health care organization, practice-based evidence can assist in the process of improving their treatment delivery. However, practice-based evidence also allows for practitioners to create provider networks that encourage the sharing of research expertise, resources, and data that can then be utilized to grow the existing base of evidence regarding psychotherapy practice, process, and outcome. Thus, practice-based evidence seeks to empower clinicians who are hoping to increase their effectiveness through exploring issues that are important, relevant, and salient to their unique treatment contexts.

In closing this section, it should be noted that practice-based evidence is not a move to eliminate evidence-based practices. Nor should it be interpreted as a competitive research paradigm. Rather the practice-based evidence framework endeavors to take advantage of practitioners’ clinical expertise in an effort to enhance psychotherapy for a particular therapist in a particular setting. Therefore, it draws upon the principles of patient-focused research and begins to close the gap that exists between evidence-based practices and research findings that apply to “real-life” settings. Indeed, each of these complementary research paradigms points toward the use of routine outcome monitoring tools/management systems in order to identify patient deterioration and hopefully to adjust treatment accordingly to improve psychotherapy outcome.

Routine Outcome Monitoring

Collectively, patient-focused research, evidence-based practices, and practice-based evidence has produced research, which has overwhelmingly suggested that soliciting patient feedback is critical when hoping to ensure a positive treatment outcome. It should be made clear that alternative methodologies (efficacy and effectiveness studies) may have solicited information from patients, but those studies did not always utilize outcome measures that were reliable, valid, sensitive to change (i.e., components of a bona fide measurement system), nor was the feedback being provided during a course of treatment, or on a session-to-session basis. All of which are suggested basic components of routine outcome monitoring tools. Additionally, efficacy and effectiveness studies were not always conducted in routine care settings. A more comprehensive discussion regarding routine outcome monitoring will be presented later sections. Nonetheless, it is possible that practicing therapists have not been and/or are still not using the most effective methods for soliciting patient feedback.

This unwillingness is especially worrisome because research has consistently demonstrated two facts: patients do deteriorate, and therapists are not able to detect treatment deterioration in patients. Regarding the first fact, patient deterioration during a course of treatment appeared to be linked to patient characteristics, but this deterioration has also been correlated with therapist behaviors. That is, not only were patients deteriorating, therapists might actually be contributing to the deterioration process. Thus, patient deterioration, one type of an iatrogenic effect, revealed that psychotherapy produced its own version and type of treatment side effects. Iatrogenic effects are commonly understood as any treatment that unintentionally causes harm. Although these (damning) findings were reported in the 1970’s, at the time they were largely ignored by the field of practicing therapists. In turn, these research findings suggest that therapists needed to develop methods of soliciting patient feedback that would specifically identify patients at risk for deterioration if they hoped to prevent premature termination and the reduction of iatrogenic effects associated with psychotherapy.

While therapists might have been willing to ignore the problem of patient deterioration, third party payers and health administrators were not so quick to overlook ineffective treatments. The fact that at least some patients were failing to respond to psychotherapy became an area of concern for healthcare facilities interested in cost related issues. Consequently, health maintenance organizations, political policies, and economic constraints forced therapists to examine treatment failure. As such, therapists were then faced with the challenge of justifying therapy services (their jobs) while simultaneously acknowledging patient deterioration. As a result, patient-focused research began exploring the development and use of feedback systems or outcome measurement. In turn, these feedback tools and systems began to address the fact that therapists were unable to identify patient deterioration. Thus, these measurement tools and systems were implemented in an effort to identify and reduce patient deterioration, which would hopefully reduce overall health care costs.

Conclusion

All of this information demonstrates the importance of dialectical behavior therapy in addiction recovery programs offered in Denver, Colorado. If you feel that you have a problem with alcohol or drugs, it is important to seek assistance in controlling the issue as soon as possible. You have had the strength to admit you have a problem, so now it’s time to fix it. Spend some time talking to loved ones and gathering their thoughts on your actions while drinking. If they don't believe you have a problem, be persistent and convince them that you do need help.

Quitting alcohol can be done alone, but it is incredibly difficult. You should look for rehabilitation centers near you, or even some that are a little farther away, but have a program that interests you. Finding the right fit is important because this will ensure you completion and success within the program.

Sources:

https://psychcentral.com/lib/an-overview-of-dialectical-behavior-therapy/

http://behavioraltech.org/resources/whatisdbt.cfm