Note: This article is primarily intended to be a resource for mental health professionals who are treating individuals impacted by a history of trauma and who are seeking additional evidence-based tools to support their work. If you are not a mental health professional, you may also find this article helpful in learning more about the topic of trauma.
In the previous article on trauma, we covered what Post-Traumatic Stress Disorder (PTSD) is and what life can be like following a traumatic event or events. Between hypervigilance, intrusive thoughts, sleep disturbances and dysregulation of emotional responses, it can be hard to know how to put one foot in front of the other. Despite this, there is hope. Although starting treatment might seem like the hardest step, it is harder to live with untreated PTSD. So, where does one begin? Marsha Linehan designed Dialectical Behavior Therapy to address multiple and complex problems. DBT lends itself very well to treating traumatic stress-related disorders, including PTSD and complex trauma.
We can conceptualize effective trauma treatment as occurring in three stages:
- STAGE ONE: Stabilization, safety and effective coping. In stage one of trauma treatment, we begin to understand what symptoms are related to trauma and assess the impact of trauma on a person’s functioning. We then begin to connect the sensorimotor aspects of trauma and trauma responses to triggers. Ultimately, and perhaps most importantly, we begin to teach, implement and help clients build mastery in effective coping skills, including mindfulness, grounding and tolerating distress. In stage one, we might see some informal exposure work emerge and begin with exposing the trauma survivor to distressing negative affect connected to their traumatic content; this being said, exposure work is largely completed in stage two.
- STAGE TWO: In stage two, we begin more intensive and formal exposure to trauma content and negative emotions or distress. Stage two trauma treatment is individually based and designed when clients are ready. Evidenced-based therapies such as Written Exposure Therapy, EMDR, DBT-PE, and TF-CBT can all be implemented in this stage.
- STAGE THREE: In stage three, we witness a reconnection to values and a person’s sense of self, their relationships, and their communities.
Beginning in stage one gives us some structure, however it can still be difficult to know what will work and how to begin. Evidence-based treatments (EBTs) for PTSD have limited reach due to high-risk, multi-problem patients often being excluded from research trials. EBTs (like WET, EMDR, DBT-PE and TF-CBT) don’t adequately address the array of problems associated with complex PTSD presentations. Dialectical Behavior Therapy is a thoroughly researched, highly efficacious treatment approach that was originally designed to treat clients presenting with Borderline Personality Disorder and has since been proven to be effective in treating a broad range of emotional, psychological, and behavioral disturbances. For more information on the efficacy of DBT, please visit this website for the latest research updates.
DBT and a Staged Approach
Dialectical Behavior Therapy is also designed as a stage-based approach:
- Stage One: (Stabilization)
- Decrease suicidal/self-injurious behaviors
- Decrease other life-threatening behaviors
- Decrease behavioral dyscontrol
- Decrease therapy and quality of life interfering behaviors (i.e. avoidance of emotions)
- Increase behavioral skills and skills needed to tolerate trauma and PTSD focused
- Stage Two: (Emotional Experiencing)
- Engage in informal and formal exposure
- Decrease post-traumatic stress
- Decrease self-invalidation and self-stigmatization
- Increase emotional experiencing
- Work on secondary targets
- Stage Three: (Problems in Living)
- Increase self-esteem
- Achieve individual goals
- Mastery and willingness
- Improve relationships
- Increase self-reliance
- Stage Four: (Incompleteness)
- Spiritual fulfillment
- Capacity for Joy
DBT teaches skills in four modules: Mindfulness, Distress Tolerance, Emotional Regulation and Interpersonal Effectiveness. By balancing validation and acceptance with behavior change strategies and skills application, clinicians can help individuals target and decrease maladaptive coping strategies. In order to tolerate the decrease in maladaptive skills and eventually to replace them, individuals learn and apply adaptive coping skills taught in each of the four modules. In order to effectively reach and provide relief to the people who need it most, DBT balances the dialectic of acceptance and change. Mindfulness and Distress Tolerance are our acceptance-based skills modules and Emotional Regulation and Interpersonal Effectiveness are our change-based modules. Let’s take a quick look at each of these skillsets.
The Four Modules of DBT
Mindfulness is our core skill set. We know that our brains are masterful storytellers, in fact their job is to generate thoughts. They are constantly manufacturing thoughts from the past or getting ahead of ourselves into the future. Mindfulness helps us turn the mind and redirect our attention to the here and now. We know that for people who have experienced trauma, being in the here and now is exceptionally challenging. Mindfulness in DBT teaches the “What” and the “How” skills of being aware in the present moment:
- What: Observe, Describe , Participate
- How: Non-judgmentally, One Mindfully, Effectively
DT skills teach us how to cope with distress and survive the present without making it worse. We learn to accept that we cannot change, fix, manipulate, avoid, or get rid of our present. Once we accept these things, we turn our attention to how to cope effectively.
ER provides skills to deal with unfamiliar feelings or intense feelings. We learn how to identify, acknowledge, accept, and cope with our emotions.
IE is about improving our relationships, letting go of hopeless relationships and asking for what we want or saying no to requests we cannot or do not want to fulfill.
The stage-based approach of DBT parallels the stage-based approach to trauma treatment, provides the structure to enable us to attune to clients in varying states of distress and possible crises when beginning trauma treatment and follow them through the arc of their recovery. When we teach DBT skills, we create the possibility for people to get in, stay in and ultimately expand their window of tolerance. We can see how skills from the four modules can be applied to the window of tolerance throughout treatment.
While DBT effectively guides the therapist and client through the sometimes rocky terrain of stage one, we do not abandon the framework in stage two and three — we continue to create a validating, non-judgmental environment and practice skills while expanding and tailoring treatment more specifically to individuals’ needs. Once a person has demonstrated the capacity to tolerate discomfort and safely experience distressing thoughts, memories and emotions, they can then begin the challenging endeavor of stage two work. We will not discuss the specifics of various stage two interventions we referenced earlier here in this article, including various exposure therapies. Understanding just how emotionally taxing exposure work can be, it is important to remember that our DBT skills will be crucial in tolerating distress and managing the intense emotions these interventions are likely to produce.
Recovery from PTSD is possible. I tell my clients who are beginning the journey into recovery that sometimes when we feel like we are in a cave, we are actually in a tunnel. If we keep walking, we can make it through to the other side; it’s just much, much harder to do that alone. DBT provides the therapist and the client with tangible, evidence-based approaches to make that journey a worthwhile and successful one.
Dimeff, L., & Linehan, M. (2001). Dialectical Behavior Therapy in a Nutshell. The California Psychologist, 10-13. Retrieved from http://www.dbtselfhelp.com/dbtinanutshell.pdf
Linehan, M. M. (2015). DBT® skills training manual (2nd ed.). Guilford Press.