Treating Trauma in DBT

I was first introduced to Dialectical Behavior Therapy (DBT) in 2002 while working as a predoctoral psychology intern at McLean Hospital. This was also the first time I worked with clients who were suicidal, self-harming and had multiple, severe disorders that often included Borderline Personality Disorder. In that context, I began to learn about DBT as a treatment that could help high-risk clients learn important skills to cope more effectively with current life problems.

Given my research background in gender-based violence, I was also particularly attuned to the prevalence and impact of trauma in the lives of many clients I worked with in DBT. Over time, I also became increasingly aware that very few of these clients received effective treatment for PTSD due to fear that trauma-focused treatments would be unsafe or ineffective for this population.

In 2004, I began a postdoctoral fellowship with Dr Marsha Linehan, the developer of DBT, with the goal of helping to develop DBT’s second stage of treatment which targets PTSD. With Marsha’s support, I began trying to treat PTSD among clients in our DBT program at the University of Washington. Based on this initial pilot work, in 2009 I obtained my first grant to formally develop and test what is now known as the DBT Prolonged Exposure protocol (DBT PE) for PTSD.

The Dialectical Behavior Therapy Prolonged Exposure protocol (DBT PE) is an adapted version of Prolonged Exposure Therapy for PTSD (PE) that is intended to be integrated into standard Dialectical Behavior Therapy (DBT) for clients with PTSD.

The integrated DBT and DBT PE treatment is delivered in stages. Stage one is standard DBT focused on helping clients gain control over life-threatening and impulsive behaviors by increasing their use of behavioral skills. Once a sufficient level of stability is achieved, DBT PE is delivered in stage two to formally treat PTSD.

The DBT PE protocol includes three primary treatment procedures. In vivo exposure involves approaching avoided but safe trauma-related situations. Imaginal exposure is done by having clients describe specific traumatic events out loud and in detail. Processing occurs after imaginal exposure and involves helping clients to develop new perspectives about their traumatic experiences.

Altogether, the goal of these procedures is to reduce the intensity of unjustified trauma-related emotions by facilitating corrective learning about the meaning of past traumas. After DBT PE is complete, the final stage of treatment involves using standard DBT to address clients’ remaining treatment goals, which are typically related to building a life without PTSD.

Dialectical Behavior Therapy (DBT) organizes treatment targets according to a hierarchy in which life-threatening behaviors are the highest priority, followed by therapy-interfering behaviors and quality-of-life-interfering behaviors. In this target hierarchy, PTSD is considered a quality-of-life-interfering behavior that should only be addressed after life-threatening and therapy-interfering behaviors are sufficiently controlled.

Although PTSD is not formally treated until stage two of DBT, it is recognized as an important factor that often contributes to many of the higher-priority problems targeted in stage one. For example, PTSD symptoms such as flashbacks, dissociation and intense reactivity to trauma cues are often in the chain of events leading up to suicidal and non-suicidal self-injury. Therefore, PTSD is not ignored in stage one of DBT, but rather it is addressed using a present-focused approach in which clients are taught skills to cope effectively with PTSD and trauma cues.

DBT also conceptualizes Borderline Personality Disorder as stemming from a transaction between an invalidating environment, which can include abuse and trauma, and biologically-based emotional vulnerability. This biosocial model underpins case formulation in DBT and often helps clients to develop a more compassionate and trauma-informed perspective on their problems.

In the Dialectical Behavior Therapy Prolonged Exposure protocol (DBT PE), six readiness criteria are used to decide when clients are ready to start trauma-focused treatment. These criteria are: 

1. Not at imminent risk of suicide

2. No recent suicidal or non-suicidal self-injury (that is, for at least two months in outpatient settings and one month in intensive treatment settings)

3. Able to control urges to engage in suicidal or non-suicidal self-injury when in the presence of cues for those behaviors

4. No serious therapy-interfering behaviors

5. PTSD is the highest priority quality of life target and the client wants to treat it now

6. Able and willing to experience intense emotions without escaping.

We orient clients to these readiness criteria early in Dialectical Behavior Therapy (DBT) and often use them to develop a treatment plan that aims to help clients receive trauma treatment as soon as possible. In my research studies, it has taken an average of 20 weeks of DBT for actively suicidal and self-injuring clients with Borderline Personality Disorder to meet these criteria and be able to start DBT PE.

When developing the Dialectical Behavior Therapy Prolonged Exposure protocol (DBT PE), my goal was to stick as closely as possible to standard Prolonged Exposure (PE) and only make changes to better fit the needs of high-risk and complex clients and/or to increase compatibility with Dialectical Behavior Therapy (DBT). For example, I modified the Trauma Interview conducted in session one of PE to assess and plan to treat multiple traumas (rather than one).

I also expanded the types of trauma we treat to include traumatic invalidation, which involves extreme and severe invalidation of clients’ personal characteristics, reactions and values (for example, via criticism, ignoring, excluding or emotional neglect). These types of experiences are extremely common and the source of tremendous suffering for many clients in DBT but have typically not been addressed in PE and other PTSD treatments because they do not meet the definition of trauma used to diagnose PTSD in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.

Other adaptations include:

• Developing a dialectical framework to provide psychoeducation to clients about reactions to trauma

• Using in vivo exposure to target situations that elicit unjustified shame

• Coaching clients to use DBT skills during exposure when needed to achieve effective levels of emotional engagement

• Conducting processing through an emotion regulation lens in which DBT strategies are used to help clients up- or down-regulate specific trauma-related emotions.

The question of whether clients need stabilizing treatments such as Dialectical Behavior Therapy (DBT) or DBT skills training prior to PTSD treatment is a rather controversial issue in our field. Some experts argue that many clients, such as those with Complex PTSD or severe comorbid conditions, require stabilization prior to engaging in trauma-focused treatment. Other experts argue that stabilization treatments are overused and often unnecessarily delay PTSD treatment. I think there is truth on both sides of this dilemma.

In my opinion, the default should be to offer trauma-focused treatments first whenever possible and to reserve stabilization treatments only for clients with severe problems that are likely to make trauma-focused treatments unsafe or ineffective. For example, clients who pose a safety risk to themselves or others, such as those with recent suicide attempts, ongoing self-harm and/or acute suicide risk typically need stabilization. In addition, problems that significantly interfere with a client’s ability to engage effectively in treatment (such as severe dissociation during sessions or frequent non-attendance), are a higher priority than PTSD (for example, acute housing insecurity), and/or are likely to interfere with the mechanisms of trauma-focused treatment (for example, an inability to experience emotions without pervasive avoidance), are likely to require stabilization first.

Ultimately, the goal is to enable clients who need PTSD treatment to receive it as rapidly and effectively as possible. Therefore, if stabilizing treatments are provided first, they should be delivered as efficiently as possible.