Why fold treatment for PTSD into DBT? (Part 1)

Apr 22, 2022 | DBT for Specific Populations

This feature by Emily Cooney, PhD is Part 1 of 2 in a series about the DBT Prolonged Exposure protocol. In this first part, Emily begins with explaining DBT PE as an evidence-based approach to treating suicidal and self-injuring individuals with BPD who have PTSD. She addresses what DBT PE involves and the roles of changing behavioural avoidance, changing cognitive avoidance, and changing beliefs.

Treating post-traumatic stress disorder (PTSD) in the context of borderline personality disorder (BPD) is frequently deemed a high-risk activity, owing to concerns that the distress associated with treatment could be potentially lethal for individuals with a history of self-injury and suicide attempts.  At the same time, so many struggles experienced by clients in DBT seem to be cued or maintained by traumatic stress.  

This challenge was the impetus for treatment developers to begin trying to treat PTSD: the unmet needs of individuals with BPD who were living with untreated PTSD. There are two main evidence-based approaches to treating suicidal and self-injuring individuals with BPD who have PTSD; the DBT Prolonged Exposure protocol (DBT PE) developed by Melanie Harned and DBT for PTSD (DBT-PTSD), developed by Martin Bohus.  DBT PE by Melanie Harned is the focus of this blog.

What does DBT PE involve?

The DBT PE protocol integrates two effective treatments (DBT for BPD and prolonged exposure for PTSD) and offers them as a treatment option for individuals living with PTSD and severe comorbid conditions characterized by complex and high-risk behaviours, such as substance dependence, dissociation, self-injury, and suicide attempts.  It has most often been provided within the context of standard DBT.

In brief, prolonged exposure therapy conceptualizes PTSD as a problem of avoidance of reminders of traumatic experiences. It frames avoidance and problematic beliefs acquired during and after trauma exposure as transacting to create and maintain PTSD.

Changing behavioural avoidance

The treatment focuses on systematically and intentionally engaging in avoided activities and experiences in one’s life to block the behavioral avoidance that characterizes PTSD.  This is ‘in-vivo’ (IRL) exposure.   Examples of this might involve a survivor intentionally going to the public park where they were raped or someone deliberately swimming in a two-piece when they have previously swum in a swimming costume with shorts and a tee-shirt, owing to trauma-related beliefs that they will be sexually assaulted if they wear clothing that reveals any of their body.  Importantly, such exposure tasks are functionally related to reclaiming their life from PTSD.  Specifically, they involve avoided activities that the person wants to be able to do in their life or that allow behavioural tests of trauma-related beliefs that are keeping the person stuck in PTSD.

Changing cognitive avoidance

The treatment also focuses on cognitive avoidance (avoidance of the memories and thoughts related to the trauma) by deliberately recalling the event, so the person can learn new information about themselves, the event, and their ability to tolerate the experience of thoughts, emotions, and memories related to the trauma. This is ‘imaginal’ exposure and involves having the person describe specific traumatic events out loud and in detail repeatedly during therapy sessions.

Changing beliefs

The treatment also includes time for processing after imaginal exposure i.e. reflecting on the impact of the event on their beliefs about themselves, the world, emotions, and other people, and reflecting on the implications of new learning they’re gaining from exposure on those beliefs.  Change or lack of change in specific emotions guide the focus of those discussions, and illuminate the beliefs and unjustified emotions that drive and maintain PTSD-related suffering.  This information helps the client and therapist develop specific in-vivo tasks that will test the beliefs, and also ensures the client refrains from behaviours that could maintain the emotions and beliefs.  A common example of this is cleaning oneself after imaginal exposure.  It’s not uncommon for clients to want to shower after completing their imaginal homework, however this action can maintain unjustified disgust and the concomitant belief that they are a disgusting person.  Another common urge is to scratch oneself, curl up, and make oneself small while recalling the trauma.  These urges often occur in the context of shame, and essentially communicate to the individual that shame matches the facts.  Relaxing hands, sitting upright, and undertaking a ‘regal posture’ can provide a behavioural antidote that will ultimately help the individual become free from unjustified shame.

Read here for part 2, in which Emily goes into further explanation on changing beliefs, how to motivate clients, and what the data tell us about DBT PE.

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.


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