This feature by Emily Cooney, PhD is Part 2 of 2 in a series about the DBT Prolonged Exposure protocol. In the first part, Emily began with explaining DBT PE as an evidence-based approach to treating suicidal and self-injuring individuals with BPD who have PTSD. She addressed what DBT PE involves and the roles of changing behavioural avoidance, changing cognitive avoidance, and changing beliefs. In part 2, she continues with more on changing beliefs, understanding what the data tell us, and how she motivates clients to do this treatment.
When we left off in part 1, we were looking at changing beliefs as a part of the treatment. There is more to be said about changing beliefs as we continue here.
Exposure tasks help the person gather more information about the world, other people, and what is normative in terms of behaviour and responses to trauma. Often the focus is on the client’s judgments related to responsibility for the event that occurred, and related to their reactions during and after the event. As therapists, we are well-placed to facilitate early corrective experiences for these beliefs, as we’re often the first person to hear about the trauma, which can be particularly important for traumas involving interpersonal betrayal. One survivor of a near-lethal assault by an ex-partner said that they couldn’t look at me following their first imaginal exposure, because they felt so ashamed about staying with the perpetrator for so long, and they were certain that I was judging them. Talking about this and tracking the events that led up to the assault was a major aspect of their recovery.
The process of gathering this corrective information is a balancing act. In the moment with that client, I had a strong urge to leap to reassurance about my absence of judgment, and to provide nuanced validation about how it might be that someone would stay in an abusive relationship. However paradoxically, telling the client their shame was misplaced may have served to amplify that emotion. I held off disclosing my own response to their story until the client and I had explored the multiple reasons why they had stayed with their partner and the aspects of their history and the context that made it incredibly difficult to leave. Deciding when to question clients to support the search for what’s being left out of their own perception of their traumatic experiences and when to directly confront the invalid assumptions and beliefs that fuel unjustified guilt, shame, fear and self-disgust is a dialectical balancing act. The same goes for supporting clients to refine their wise discernment on what aspects of a situation constitute useful and adaptive signals of danger and what reminders of trauma cue fear which doesn’t match the facts.
What do the data tell us?
Research on DBT PE has indicated that the treatment is feasible and safe for clients. The two treatments providing the basis for DBT PE each have a wealth of evidence to support their benefit. The primary data sources for the combined efficacy of DBT PE come from a small randomised controlled trial by the treatment developer, two effectiveness trials conducted in the VA and in several public mental health agencies, and a study of outcomes reported by clinicians after attending DBT PE workshops. Data from the randomized controlled trial indicated that about 80% of individuals who complete DBT PE experience full remission from PTSD.
How do I motivate my clients to do such a demanding treatment?
The opportunity to treat their PTSD is often a very powerful incentive for our clients. As such, it is typically a conversation that DBT PE practitioners will have in DBT pre-treatment, as part of the commitment process. The treatment developer’s early trials indicated that access to DBT PE was associated with a much faster cessation of life-threatening behavior than the outcomes found in Linehan’s early DBT trials. This is noteworthy. Essentially it indicates that requiring sustained abstinence from life-threatening behavior as one criterion for starting treatment for PTSD serves as a massive incentive for refraining from those behaviors. For some clients, being informed in pre-treatment that this was a requirement to get access to DBT PE led them to decide to stop engaging in those behaviors immediately, and they began DBT PE a couple of months later. Essentially, potent contingencies created capabilities within a time frame that neither they nor we may have thought possible. The take-home message from this is that we should be having these conversations with our clients as early as possible in pre-treatment to take advantage of that leverage. This may be a powerful source of hope, inspiring our clients to progress sooner and faster towards a life experienced as worth living.
Where can I find out more?
There is a wealth of resources for providing treatments for PTSD, many of them freely available through the National Center for PTSD website hosted by the US Department of Veterans Affairs. For DBT PE, the DBT PE website is a clearinghouse of information, including the research data for this approach, podcasts by the treatment developer providing an overview of the treatment in a way that’s accessible to practitioners and laypeople, an inspirational recording of a service user’s experience of DBT PE, and refillable electronic forms that allow therapists to document and track outcomes associated with both in vivo and imaginal exposures.
Providing this treatment has revolutionized my practice, and has been the most clinically meaningful work of my professional life. I truly believe that for DBT practitioners, offering some form of evidence-based treatment for PTSD for individuals living with BPD is usually a necessary component of treatment and a recovery milestone. I think it reduces the risk of relapse from BPD, because undergoing treatment for PTSD requires us to get in contact with and learn how to tolerate intensely distressing emotions. Essentially, it offers an intensive masterclass in how to practice mindfulness to emotion with our most feared and painful cues. There’s some evidence to suggest that changes in shame are early predictors of outcome in the treatment of BPD. Frequently, treatment for PTSD, particularly for interpersonal traumas, requires targeting both shame and the beliefs acquired or strengthened by exposure to those traumas that drive ongoing avoidance and self-hatred. Once someone has been through those restorative experiences and obtained and attended to corrective information, you can’t un-ring that bell. Whatever other events they encounter, they have this additional awareness that they have been through a demanding and transformative process and experienced freedom and empowerment as a result. I think this is enormously protective in the face of further trauma and adversity.
I am intensely grateful to the courageous individuals who work with this client group and prioritized the development and application of evidence-based treatments for PTSD and to their early clients who were willing to participate in that research. This is anxiety-provoking work and would have required courage and commitment by everyone involved. I am only trained in one of these approaches, and one that offers a set of criteria that I think can be easily applied to determining readiness for beginning other evidence-based PTSD treatments for high-risk individuals with PTSD as well.
Harned’s DBT PE treatment manual, Treating Trauma in Dialectical Behavior Therapy, is now available. Packed with clinical vignettes, a review of current data, and electronic access to treatment forms and handouts, I would recommend the text to anyone who works with individuals who are living with BPD and PTSD. I think it is a profoundly impactful contribution to the field.
Emily Cooney, PhD is a clinical psychologist who has worked in the US, the UK, and New Zealand with children and adults in a range of inpatient and outpatient settings, with a particular focus on Dialectical Behavior Therapy (DBT). She is co-director of the DBT and DBT for Substance Use Disorder teams for Yale-New Haven Psychiatric Hospital’s Adult Intensive Outpatient Program. Read her full bio here.