Q&A

Using DBT Skills to Support Trauma Treatment

Working with trauma can be a complex clinical challenge, particularly when persistent symptoms such as intrusive memories, dissociation, or high-risk coping behaviours make it difficult for clients to feel safe enough to engage in therapy. DBT skills offer a practical toolkit for therapists navigating this complexity. They can support clients at every stage of trauma recovery: preparing for targeted trauma work, staying engaged during it, and consolidating gains afterward. Even for clinicians not working within a formal trauma protocol, DBT skills provide strategies for reducing the impact of trauma-related symptoms on both client wellbeing and the therapy process itself. Dr Melanie Harned, developer of DBT Prolonged Exposure (DBT PE), has devoted her career to improving treatment for people affected by trauma. In this Q&A, she shares how DBT skills can be tailored to help clients achieve meaningful, lasting change.

Therapists may hesitate to begin trauma-focused work because they worry clients need to be more resourced or regulated first. From your perspective, how do DBT skills help bridge the gap between active dysregulation and effective trauma processing?

While not all clients require stabilization prior to trauma-focused treatment, DBT skills can be a game changer for those who do. These clients often present to treatment with significant behavioral and emotional dysregulation that make it unsafe or ineffective to engage in trauma-focused work. Many of these clients have spent years trapped in a vicious cycle where PTSD fuels problems that contraindicate trauma-focused treatment.

DBT skills can help clients break out of this cycle by teaching them how to tolerate intense distress without engaging in destructive behaviors and to regulate trauma-related emotions without avoiding. When tailored to fit the specific needs of each client, DBT skills can provide the foundation needed to benefit from trauma-focused treatment and, ultimately, to get relief from trauma-related suffering.

Dissociation often shows up right in the therapy room. When a client begins to disengage or lose contact with the present moment, how do DBT skills help you respond in a way that supports re-engagement without escalating distress?

In DBT we often say: “we have a skill for that!” This is certainly true for dissociation, which is a very common problem among people with a history of trauma. I often start with mindfulness skills to help clients become aware of their specific warning signs for dissociation. These are typically physiological changes such as tunnel vision, feeling dizzy, having difficulty hearing, getting cold, or yawning. The goal is for clients to notice these changes and then quickly use other skills to stop the dissociation from getting more intense.

These often include skills that provide intense Sensations (the “S” in the Wise Mind ACCEPTS skill) such as holding ice in their hand, taking a hot or cold shower, eating a sour candy, listening to loud music, or smelling vinegar. When dissociation occurs in the therapy room, these skills can be used to help clients stay present and get the most out of their session.

Many therapists are familiar with DBT skills at a conceptual level. What shifts when those skills are used moment-to-moment with trauma-related dysregulation, rather than introduced more generally?

DBT skills are not a one-size-fits-all approach. To be most effective, it is critical to help clients learn how to tailor the DBT skills to specific situations to meet their unique goals. This requires trying a variety of skills and figuring out which ones work best for them. For example, early in treatment we often focus on teaching clients crisis survival skills to get through intense trauma-related dysregulation without doing anything to make it worse. I often ask clients to try a variety of these skills (e.g., TIP, distracting, self-soothe) and to put together a crisis survival kit of the skills that work best for them.

Similarly, it is important to help clients learn when to use one skill versus another. Many clients tend to over-rely on the crisis survival skills – distracting their way through life – and underuse emotion regulation skills that will help to change emotions in the long run. For example, if a client is constantly afraid at work because one of their co-workers looks like their abuser, relying only on crisis survival skills to get through the workday is unlikely to be effective. Instead, we need to help clients learn to pick skills to fit the moment, perhaps using distraction when there is an important deadline (e.g., focusing on a work task and staying away from the co-worker) and using opposite action during breaks (e.g., engaging the co-worker in conversation).

How does having a concrete, skills-based framework for stabilisation change the therapist’s own experience of doing this heavy work?

It is very common for therapists to feel anxious about doing trauma-focused work, particularly with clients who struggle with intense dysregulation. The DBT skills give us a massive toolkit of evidence-based strategies to help clients prepare for trauma-focused treatment. By learning the DBT skills inside and out, therapists often gain confidence in their ability to guide clients through this challenging work.

I also think therapists can benefit tremendously from using the DBT skills ourselves – both in and out of therapy sessions – to stay as effective as possible with our clients. I frequently use strategies like opposite action (e.g., to push clients to do hard things even when it makes me anxious), radical acceptance (e.g., of my emotional reactions to hearing trauma details), and accumulate positives (e.g., to increase pleasurable activities outside of work).

From the client’s perspective, what differences do you see when DBT skills are used effectively alongside trauma-focused treatment?

For many clients, the idea of engaging in trauma-focused treatment is scary and overwhelming. Often at the core of their fear is a belief that they won’t be able to tolerate the intense emotions elicited by these treatments, and that these emotions may cause them to lose control, become unable to function, and possibly even die. Having a strong foundation in DBT skills can help clients feel more prepared to take on the rigors of trauma-focused treatment and less afraid that it will undo them.

Many clients also find it helpful to know that the DBT skills they have learned can boost the effectiveness of trauma-focused treatments by, for example, helping them to approach rather than avoid trauma cues, stay mindful and present in session, experience intense emotions without escaping, and refrain from destructive behaviors.