10.5935/1808-5687.20220011 BRIEF COMMUNICATIONS

 

The use of digital technologies for an intervention with a transdiagnostic protocol based on Cognitive Behavioral Therapy and Dialectic Behavior Therapy

 

 

Maria Cecília Ferreira-de-Lima^I; Lia Silvia Kunzler^I,II; Ana Carolina Girão Romero^I; Raquel Machado Marinho^I; Yu Hua Feng^I,III

^IMental Health, Psychiatry and Psychotherapy Clinic, Mental Health, Psychiatry and Psychotherapy Clinic - Brasília - DF - Brazil
^IIUniversity of Brasília, University Hospital of Brasília - Brasília - DF - Brazil
^IIIFederal University of ABC, Center for Mathematics, Computing and Cognition - Santo André - SP - Brazil

Correspondence

 

 

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ABSTRACT

The objective of the current study is to describe the experience of creating and utilizing a transdiagnostic group-intervention protocol with emphasis in Cognitive-Behavioral Therapy and Dialectic-Behavior Therapy using digital technologies. There has been a need to adapt mental health care to a virtual format as a consequence of the COVD-19 pandemic. For this purpose, eight weekly virtual meetings were elaborated for the management of stress and quality of life. The themes approached were: 1) anxiety, 2) insomnia and nightmares, 3) self-esteem and pleasant activities, 4) regulation of intense emotions, 5) anger and assertiveness, 6) depression and bereavement, 7) shame, guilt, and validation, 8) productive and unproductive worries. From June 6, 2020, to November 20, 2021, 6 groups of 8 meetings each were held, totaling 1026 participations. The use of remote conference technologies reduced de barrier of distance, admitting to meetings both the professional team and participants, despite their locations. It has also been observed that this format increased accessibility and coverage, allowing a greater number of people to benefit from interventions to improve their quality of life.

Keywords: cognitive behavioral therapy. Digital Technology. Dialectical Behavior Therapy.

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INTRODUCTION

The COVID-19 pandemic has had a significant impact on the well-being and, in particular, on the mental health of a large part of the world's population. Social distancing, changing routines, reduced engagement in pleasurable activities due to the restrictions imposed, uncertainty and fear of getting ill, in addition to bereavement, have caused an increase in symptoms of anxiety, depression and stress (da Silva et al., 2020; Usher et al., 2020). This evidence is corroborated by a review that points out the neurotrophic action of the virus, which causes the worsening of psychiatric conditions and the appearance of new symptoms in people without a history of mental illness (Vindegaard & Benros, 2020).

The conditions described above led to an increase in demand in the mental health area, which was not only observed in terms of treatment, but also in terms of actions for education, cognitive restructuring, and assistance in coping with the new reality and prevention of psychiatric illness (da Silva et al., 2020). Consequently, from the earliest stages of the pandemic, the commitment to adapt services and adjust the offer to current needs emerged (Moreno et al., 2020). And, despite the interest and development of digital resources in mental health having existed for a long time, with the onset of the COVID-19 pandemic, there was a real explosion in the use of resources that allowed innovation, development, and expansion of mental health services (Torous et al., 2020).

The use of digital technologies has enabled continued access to trained professionals and exponentially expanded their coverage. Thus, digital resources have grown enormously worldwide, in order to accommodate current needs and increase the offer of such services to a greater number of people. This would not always be possible with the in-person modality (Ben-Zeev, 2020). The increased use of online consultations, digital platforms, software, and applications has enabled greater access to evidence-based treatments, and improvement of the resources being used, in addition to the integration of traditional therapies (Graham et al., 2020), such as Cognitive-Behavioral Therapy (CBT) and Dialectical-Behavior Therapy (DBT).

A systematic review published in 2019 (Gentry et al. 2019) indicated the viability of therapeutic group approaches by videoconference with similar results to in-person treatment, in addition to high participant satisfaction. Another review concluded that online group interventions conducted by healthcare professionals, can have a moderate impact on participants' anxiety (Currie et al., 2022).

Cognitive therapies, as a group of related approaches, involve cognitive, behavioral, emotional, and interpersonal changes necessary for the understanding and treatment of mental disorders and have been adapted to the reality of the pandemic (Kazantzi et al., 2021). The flexibility of these approaches makes them suitable for the current historical and sanitary moment.

Cognitive-behavioral therapy was developed in the 1960s by Aaron Beck, initially for the treatment of depression. It is currently considered an evidence-based line of psychotherapy for the treatment of various clinical conditions, in addition to being effective in preventing mental illness and improving quality of life (David et al., 2018; Hofmann et al., 2012). The main techniques used in this modality, which is collaborative and pragmatic, are cognitive restructuring, Socratic dialogue, therapeutic alliance, and behavioral experiments. The tools are important for emotion regulation, making CBT effective as a transdiagnostic treatment (Schaeuffele et al., 2021). The adaptation of group CBT for videoconference is an efficient and promising alternative for the treatment of anxiety and related disorders (Milosevic et al., 2021).

Dialectic Behavioral Therapy was developed by Marsha Linehan and was first published in 1991. It is considered one of the third-generation cognitive therapies and was initially developed to treat women with severe emotional dysregulation and chronic suicidal behavior. In recent decades, however, DBT, as a multimodal and flexible therapy, has been adapted for various clinical conditions involving emotional dysregulation (Ritschel et al., 2015). This line consists of three fundamental foundations: behavioral therapy, dialectical thinking, and Zen philosophy, which allow the integration of acceptance and strategies for change and the acquisition of skills necessary for emotional regulation. The developed skills are divided into four large groups: 1) mindfulness; 2) interpersonal effectiveness; 3) emotional regulation; and 4) tolerance of discomfort (Linehan, 2018; Mehlum, 2021).

More recently, online DBT via videoconferencing has been studied and implemented, and, despite the challenges inherent in the change, there seems to be good acceptance by both patients and professionals, in addition to greater adherence (Lakeman et al., 2022; van Leeuwen et al., 2021).

Hence, by adopting the two theories, CBT and DBT combined, a protocol with interventions in the cognitive, emotional, and behavioral aspects is proposed to provide an improvement in mental health. The objective of this article, therefore, is to present the elaboration and implementation experience of a transdiagnostic protocol based on CBT and DBT for group care.

 

METHODS

The present work is a methodological study, descriptive in character, that presents an approach composed of interventions which combine CBT and DBT techniques and skills training.

Team

The team is composed of five health professionals: two medical doctors and three psychologists. Both doctors are certified therapists by the Brazilian Federation of Cognitive Therapies, hold the title of specialist in Psychiatry, and have undergone Dialectical Behavior Therapy Training. Two of the psychologists have also taken the Dialectical Behavior Therapy Training and completed the Dialectical Behavior Therapy Training. Two of the psychologists are specialists in Neuropsychology, one of them is also a specialist in Cognitive-Behavioral Therapy and another psychologist is a specialist in Behavior Analysis.

Instruments

Zoom Meeting: video conferencing software that is compatible with macOS, Windows, Ubuntu, Mint, Linux, CentOS, Fedora, and OpensSUSE operating systems. It has stable performance and is user-friendly, in addition to not requiring the participant to download the software onto their device. The free plan allows video conferencing between the host and one participant for an unlimited time, or up to 100 simultaneous participants with a 40-minute time limit. Paid plans are available in order to increase the restrictions on time and number of participants, and the Zoom Pro one was used in this work. The main features used by the team were: scheduling sessions in advance and sending out the access link to participants; enabling a waiting room for participants to remain in until the host gave them permission to enter the session; muting participants when they first enter the meeting; managing microphones and cameras by the meeting host; enabling group chats; and sharing supporting material presentations during the meeting.

WhatsApp: free multiplatform instant messaging, voice, and video calling app that allows users to share images, audio, videos, documents, payments, and links. It is compatible with smartphones running the Android, iOS, and KaiOS operating systems. Among the app's available features, three of them were largely used: 1) communication group in which all participants can send messages - widely used by the team at all stages of the protocol: idealization, elaboration, execution, and evaluation; 2) communication group in which only administrators can send messages - the Think Healthy Group was created, where mental health and dissemination materials are sent; 3) Broadcast list - allows the same messages to be sent simultaneously to all participants.

YouTube: free video sharing platform that hosts a broad range of materials that are largely diverse in: content, quality, quantity, duration, language, among others. By using the platform, the team was able to share the videos created with the topics addressed in the meetings so that participants could complement what they had seen during the live meetings. As it is an open channel, the general public also has access to the content.

Procedure

Conception - a professional from the public health system of the Federal District who is not part of the team that adapted and applied the protocols contacted one of the two medical doctors who participated in the present study, and is introduced in the Team section. The professional suggested web-based group interventions to support COVID-19 front-line health professionals, helping them to cope with the stress resulting from the situation. The aforementioned team deemed the suggestion relevant and developed an adapted protocol based on DBT, with the purpose of favoring stress management. The intervention group was then offered through the Zoom platform, and named Group 1. At the time, the idea was to offer only a single edition of such a group. However, when Group 1 was concluded, the team identified patients who would benefit from having extended access to the adapted protocol. During their weekly team meeting, it was decided that the Zoom groups should be maintained, but for the general public, aiming to provide strategies for managing stress and improving quality of life. It was also decided that the protocol would be based on the two approaches, TCC and DBT.

Elaboration - the materialization of the intervention protocol was also carried out by the team using digital technologies: weekly online meetings which lasted 90 minutes; decisions and conduct alignments at any given time, through text or voice messaging apps; material preparation with software for creating and editing graphic presentations.

Planning - 1) The dissemination material was distributed via WhatsApp, along with the contact information of one of the team professionals in charge of registration. 2) After the contact, to complete registration, those who were interested were instructed to pay and send their personal information along with the payment receipt. 3) Once registered, the participant's contact was added to the transmission list for session participants. 4) One day before the session, the access link to the virtual room was created and sent through the broadcast list. 5) The room was configured so that all participants were muted upon entering the meeting; at the start of the session, the participants were admitted into the meeting and an attendance list was created to determine who was absent so that these participants could be contacted immediately to be reminded of the meeting. 6) Those present and absent were counted at the end.7) Individual observations of participants were also recorded on occasion. 8) Throughout the week, the participants received supplementary material on the topic addressed.

Execution - the meetings' openings were always conducted by the same professional, who gave a brief description of the two lines of therapy, as well as the guidelines to ensure respect for group members and mandatory confidentiality. As in therapy sessions, from session 2 onwards, after the opening, there was a summary of the previous session, and 10 to 15 minutes were made available for participants to describe difficulties and results achieved with the application of the strategies offered in the previous session. After the opening and the review of the homework practice, the session's content was presented with the help of PowerPoint slides. The presentation lasted approximately 50 minutes and was followed by the contributions of the participants, who could use their audio or send a written message via discussion chat. At the end of the meeting, the same professional responsible for the opening emphasized that the team members would be available through telephone contact. Altogether, the session lasted approximately 90 minutes.

Some other complementary details about the procedures adopted are: Throughout the process, the team offered support to participants who faced any problems with the app, in addition to being available to clarify doubts about how the group worked, the content covered in the sessions, and supplementary material. During the creation of the access link or the meeting, the desired configuration was defined, such as whether the participants' microphones would be muted or unmuted when they joined the meeting. The team established that all participants' microphones would be muted upon entering the session in order to facilitate the organization, but participants could unmute their microphones whenever someone wanted to make a contribution. In the chat, it was possible to send private messages to team members and participants, as well as general messages to the whole group. It was also possible for the meetings to be recorded. However, this feature was not used to protect the confidentiality of the participants.

 

RESULTS

On June 6, 2020, the first session of the first therapeutic group for the general public took place using the Stress Management and Quality of Life Protocol, developed and applied by the Mental Health Team. Another seven meetings took place in the following weeks: June 13, 20, and 27, 2020; and July 4, 11, 18, and 25, 2020. The topics addressed were, respectively, 1) anxiety; 2) insomnia and nightmares; 3) self-esteem and pleasurable activities; 4) regulation of intense emotions; 5) anger and assertiveness; 6) depression and bereavement; 7) shame, guilt and validation; and 8) unproductive and productive worries. The contents which were worked on are listed in Table 1.

Between June 6, 2020 and November 20, 2021, six intervention groups were carried out. The six cycles of eight meetings had a total of 48 sessions with 1026 participants altogether. The smallest number of attendees in all sessions was 14 participants, and it happened within the third group, during the Regulation of Intense Emotions session. Meanwhile, the session that addressed the topic of Productive and Unproductive Worries had the largest number of participants, with a total of 37, in its first edition.

The use of online conferencing technology has broken down the distance barrier, allowing staff and participants to access services regardless of their location. The professionals could carry on working together even when they were in different cities, such as Brasília, Campo Grande, Florianópolis, Fortaleza, Porto Alegre, Rio de Janeiro and São Paulo.

The same fact was observed among the participants, who were in different cities and states of Brazil, as well as the Federal District: Amazonas, Brasília, Ceará, Goiás, Maranhão, Mato Grosso do Sul, Minas Gerais, Paraná, Rio de Janeiro, Rio Grande do Sul, Santa Catarina and São Paulo. Participants were also located in different countries: South Africa, Germany, Argentina, Canada, United States, France and Portugal.

Some of the tasks which were considered as differential features of the protocol and which were attributed a positive added value were: sending material in advance for familiarity with the topics and practices addressed; welcoming participants at the beginning, during, and end of each session; attendance control of those registered for the meeting; individual contact to remind participants of the meeting, in case of absence; visual monitoring of participants' reactions throughout the sessions; responses to oral and written submissions and contributions; telephone contact in adverse situations, in which an individual intervention would be appropriate; complementary material to reinforce the practices and training proposed during the sessions; availability of the technical staff for contact, even outside the meeting hours.

The Mentalflix channel, registered on YouTube, was launched on March 29, 2020, and the access address is: https://www.youtube.com/c/Mentalflix. Regarding its scope, until February 5, 2022, it had a total of 387 subscribers. 7332 views were obtained, with 404 hours of viewing. The video "CALM DOWN Strategies" (Estratégia ACALME-SE, in Portuguese) was the one that gathered the most subscribers, and was also the one with the highest viewing, being watched 610 times. The video "Interpersonal Effectiveness: DEAR MAN" garnered the most weighted number of impressions, with 40 positive reactions out of 480 views. The video "Strategies for Addressing Mental Imagery" had the highest raw number of reactions,with 41 positive reactions out of 531 views.

The Think Healthy WhatsApp Group was created on April 26, 2021, and its link is: https://chat.whatsapp.com/B5gKpzqsqKb5x2mMXTT21y. On February 5, 2022, there were a total of 218 participants, and 73 files were sent among media, documents, and links.

 

DISCUSSION

Holding the meetings online enabled the combination of a number of participants that would not have been possible in-person, both in terms of physical space and location. The increased accessibility of the digital technologies that were used allowed approaches that would have encountered hurdles in the real world.

Since the CBT and DBT manuals were prepared for in-person meetings and there is still a lack of literature on web-based group interventions, the team had to adapt the strategies for the online environment. Some of these adaptation characteristics are described in the article that reports the experience of DBT therapists (Zalewski et al., 2021) and that points to the need for knowledge, experience, and creativity to maintain patients' attention and commitment. The use of visual resources represented a distinguishing feature. The engagement and participation of individuals were observed, as well as their understanding of the proposed interventions, which were supported by the use of images, audio and videos. The sessions were frequently called "classes," and it was reported that the content was innovative, and presented in a light and practical way.

The protocol presented in this article used different platforms, apps, and resources, corroborating the need to use different tools to overcome the challenges of skill training in online group (Landes et al., 2021). Another review highlighted the importance of combining available resources in technology since the data survey showed that research predominantly used only one modality. This scope review also reveals the scarcity of clinical trials that investigate possible differences between web-based, in-person, and hybrid approaches in order to consolidate the benefits of approaches using technologies. However, it also pointed to the inevitability of ongoing web-based mental health care, which reinforces the importance of research in this area (van Leeuwen et al., 2021).

The authors of the 2021 editorial concluded that cognitive and behavioral therapies are being adapted in innovative ways to address the challenges posed by current times (Kazantzis et al., 2021). When elaborating the content of the protocol sessions, the combination of CBT and DBT strategies and techniques seemed logical, as they worked on distorted thoughts and emotion regulation, respectively (Linehan, 2018; Schaeuffele et al., 2021). Thus, the main proposition of the approach that was described seems promising: change of unwanted behaviors and adequate coping in stressful situations. A clinical trial study is needed to assess the effect of skills training to deal with emotional dysregulation and the restructuring of dysfunctional cognitions to intervene in the diversity of symptoms and diagnoses.

The presence of at least four team professionals in all the 40 sessions that were conducted allowed the division of tasks, which contributed to a broader and more comprehensive approach and was perceived as a differential. Moreover, it was a facilitating factor for the observation of the participants´ behavior during the meetings, as well as during individual contact outside the sessions, whenever necessary. According to a systematic review (Currie et al., 2022), the group approach, with the constant presence and guidance of professionals, made the intervention less expensive for the participants while still being effective in dealing with various mental health issues. It was observed that the combination and cohesion of the clinical staff favored feelings of acceptance and commitment by the participants, enhancing their adherence and engagement with the work proposal.

Along the way, demands for new topics to be addressed were identified, as were requests to continue having meetings at the end of the cycle. With this, the team devised other protocols, such as a monthly meeting group to address different topics, a specific group for the management of emotional eating, and a group for adolescents.

A voluntary social modality named "How to Cope Group" was also offered. This group consists of an open and free-of-charge meeting to present punctual techniques for dealing with specific issues. There was no fee for participants; however, a voluntary donation to a social support entity was suggested for those who could afford it and felt comfortable with it.

Limitations of the Study

This work sought to present the design and application of a protocol of interventions based on CBT and DBT only in a descriptive manner. It is suggested that the effects of this approach on various aspects of mental health and quality of life be studied in the future. A comparison of combined CBT and DBT interventions to CBT and DBT interventions alone can also be made. Furthermore, the assessment of whether the proposed protocol presents different results when applied to groups with different characteristics is suggested.

 

CONCLUSION

The available digital technology resources helped in the integration of practices, techniques, and tools recommended by CBT and DBT. In this way, it was possible to offer confrontation options that aim at cognitive restructuring and emotional regulation in a new format. The expansion of the service offer proved to be relevant, viable, and comprehensive. The benefits that were observed seem to compensate for eventual losses inherent in the impossibility of physical presence.

 

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Correspondence:
Maria Cecília Ferreira-de-Lima
E-mail: macecilialima@gmail.com

Este artigo foi submetido no SGP (Sistema de Gestão de Publicações) da RBTC em 20 de Agosto de 2021. cod. 247
Artigo aceito em 22 de Março de 2022.