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In the mental health field, the treatment of post-traumatic stress disorder (PTSD) has seen significant advancements in recent years. One such breakthrough is the integration of dialectical behavior therapy (DBT) with prolonged exposure (PE) techniques. This powerful combination, DBT Prolonged Exposure (DBT PE), offers a comprehensive and effective approach to healing trauma.

Trauma Treatment For Those With Co-Occurring Problems

The DBT PE protocol was designed by psychologist Melanie Harned to treat PTSD in high-risk clients who may struggle with multiple diagnoses. In other words, many people with PTSD have other complex issues in addition to their trauma: Concerns like self-harm behavior, suicidal ideation/urges, and emotion regulation difficulties to name a few.

The stage-based strategy used in the integrated DBT and DBT PE protocol treatment addresses the whole spectrum of issues faced by severe and complicated PTSD clients. DBT PE is based on the established technique of prolonged exposure therapy, but modified and enhanced to meet more complex client needs.

Understanding PTSD and Its Challenges

Post-traumatic stress disorder is a debilitating mental health condition that can occur after experiencing or witnessing a traumatic event. PTSD is characterized by intrusive thoughts, flashbacks, hypervigilance, and emotional numbness. People with PTSD often avoid reminders of the trauma, leading to a restricted and diminished life.

Trauma can be compounded if an individual’s environment sends feedback that their behavioral or emotional reactions to their trauma are unacceptable; this invalidation can be traumatic in and of itself. This type of invalidation can be especially impactful when it comes from a valued or central figure, or figures, in the individual’s life, especially if the trauma survivor relies on that person or people to meet important needs.

Traumatic invalidation undermines an individual’s understanding and acceptance of their personal experience and can lead to feelings of insecurity and despair. Traumatic invalidation can be seen in many forms (criticizing, ignoring, blaming, controlling, or judging) and can exacerbate PTSD symptoms.

Traditional Prolonged Exposure Therapy for PTSD: Limitations in Certain Populations

Prolonged exposure therapy, which is one part of the integrated DBT PE model (the other part being standard dialectical behavior therapy), has long been recognized as a leading evidence-based treatment for PTSD. PE involves gradually exposing individuals to the traumatic memories and situations they have been avoiding. This exposure helps individuals process traumatic experiences and reduce avoidance behaviors.

Traditional PE can be challenging for some individuals, especially those who have difficulty regulating or coping with intense emotions. Additionally, the official prolonged exposure manual (Foa et al., 2007) specifies several contraindications for treatment, including imminent threat of either suicidal or homicidal behavior and serious self-injurious behavior occurring within the last three months.

Dialectical Behavior Therapy: Limitations for Clients With PTSD

Standard DBT (the other component of DBT PE) is a widely acclaimed therapy originally developed to treat borderline personality disorder; over the years, the applications for DBT have expanded widely to address a range of conditions, including eating disorders, mood disorders, and substance use disorders. DBT focuses on developing skills for emotional regulation, distress tolerance, mindfulness, and interpersonal effectiveness.

While DBT has demonstrated benefits for a variety of issues, its impact on PTSD has traditionally been modest. The estimated prevalence of PTSD among patients undergoing DBT in regular practice settings ranges from 57 percent to 73 percent. Although it is common, PTSD has historically not been a focus of DBT, leading to a relatively low rate of diagnostic remission of PTSD after a year of DBT.

Additionally, among DBT patients with PTSD, higher severity of PTSD at the treatment start, and lack of improvement in PTSD symptoms during DBT, are associated with poorer outcomes in domains like self-injurious behavior and acute suicide risk.

An Integrated Model: Prolonged Exposure and DBT

Integrating standard DBT and prolonged exposure has been shown to improve outcomes, notably for the subset of patients with PTSD and co-occurring problems. In one clinical trial, at treatment end, 71 to 80 percent of DBT PE patients no longer met the criteria for PTSD; only 40 percent of patients who completed DBT alone achieved remission (from PTSD).

Further, the trial found that those patients who completed DBT PE were 2.4 times less likely to attempt suicide than those patients who completed DBT alone (17 percent for DBT PE completers vs. 40 percent of completers of DBT alone). More significant post-treatment improvements in depression, anxiety, dissociation, general distress, and psychosocial functioning were seen in patients who completed DBT PE versus patients completing DBT alone.

How DBT PE Works

DBT PE begins with standard DBT and the objective of increasing coping capacity and stabilizing emotions and behaviors before moving on to the second stage of treatment. As the client moves to the second stage, the focus turns to actively treating PTSD symptoms (the PE stage). After DBT PE is complete, standard DBT is used in the third stage of treatment to target any residual problems and improve functioning.

Targeting Avoidance

Among the features that make DBT PE effective is its focus on addressing the main feature believed to keep people locked in their PTSD: avoidance. In DBT PE, clients are guided in gradually approaching trauma-related thoughts, memories, and situations that are actively being avoided. PE participants begin to see that avoidance provides short-term relief from their PTSD, but actually ends up fueling the PTSD long-term. Similarly, facing fears head-on is anxiety-producing in the short term but is generally found to be freeing and leads to a sense of empowerment and enhanced control in the long term.

The Three Stages of DBT Prolonged Exposure:

Stage 1: Learn and integrate DBT-based coping skills so individuals can better tolerate and regulate their emotions. Clients join a weekly DBT skills group and meet with the therapist for individual DBT treatment once each week.

Stage 2: Individual sessions with the therapist may be longer and more frequent during this stage. Clients will begin to actively treat their PTSD symptoms using the following procedures:

• In vivo exposure: facing feared situation(s), object(s), or activity/activities directly in real life.
• Imaginal exposure: with the therapist present, the client is guided in imagining the feared situation(s), object(s), or activity/activities.
• Processing: reflecting on emotions that arise during the exposures to gain new, adaptive perspectives about the trauma.

Stage 3: Clients will return to DBT treatment alone to consolidate their learning and create a plan for symptom relapse prevention. As treatment comes to a close, there is a focus on building meaning and purpose (referred to in DBT as “a life worth living”) in a life that will no longer be governed by PTSD symptoms.

DBT PE: A Comprehensive Treatment and Hopeful Option for Many

Among the many benefits of DBT PE, the intervention is considered a safe modality for extremely vulnerable individuals. The structure creates a scaffold of security and support during the challenging journey of trauma processing.

DBT provides a framework for therapists to safely monitor and treat suicidal ideation and self-harm behaviors when present; after all, DBT is the gold standard treatment for suicidality and self-harm. Further, as the client moves into the trauma processing stage of the treatment, they’ve already established a foundation of skills and tools for coping, which increases the client's tolerance of potentially destabilizing trauma work.

Given the nature of PTSD, it is very common for clients in DBT PE to have difficulty remembering their traumatic events. DBT PE does not require a client’s memory to be fully intact for the treatment to be successful.

Hope for Healing From PTSD

DBT PE offers a powerful and transformative approach to healing for individuals struggling with post-traumatic stress disorder, addressing both trauma-related symptoms and underlying emotional challenges. As research continues to support the efficacy of this approach, it holds great promise for individuals seeking relief from the debilitating effects of PTSD and reclaiming their lives.