Treating PTSD During Dialectical Behavior Therapy: The DBT Prolonged Exposure Protocol

Helping High-Risk and Multi-Problem Clients with PTSD Build Lives Worth Living

Individuals with PTSD often present to have not typically targeted PTSD. When to help these tremendously suffering treatment with multiple, severe comor- not treated, PTSD increases the risk of individuals recover from trauma and bid problems such as suicidal and self- suicidal and self-injurious behavior and build lives worth living. injurious behavior, severe dissociation, is likely to interfere with achieving substance use, and personality disor- recovery. ders. In fact, 66% of individuals with The DBT Prolonged Exposure (DBT PE) PTSD have two or more comorbid dis- protocol was developed by Dr. Melanie orders and up to 30% attempt suicide. Harned specifically to treat PTSD Unfortunately, these types of high-risk among high-risk and multi-problem and multi-problem clients are often clients who are receiving DBT. The DBT unable to access effective PTSD PE protocol is based on Prolonged treatment. These individuals are often Exposure therapy2 and was adapted to excluded from PTSD treatments due to fit the needs of this complex client pop- their severity, and treatments ulation. DBT with the DBT PE protocol is designed for this population such as a comprehensive treatment designed Dialectical Behavior Therapy (DBT)1

Special points of interest: “The DBT PE protocol is now an  DBT with the DBT PE protocol is a comprehensive treatment for high-risk, important part of standard DBT multi-problem, and difficult-to-treat clients with PTSD. for clients with PTSD. All DBT  The treatment has been delivered and researched in outpatient, intensive clinicians need to learn how to outpatient, and residential settings with adults and adolescents. deliver this new and highly effective protocol.”  Research indicates the treatment is feasible to deliver, acceptable to clients, safe, and effective in reducing PTSD, suicidal and self-injurious behavior, dis- Dr. Marsha Linehan sociation, shame, guilt, depression, and social impairment. DBT Treatment Developer

Treatment Stages and Targets The treatment is delivered in 3 stages. achieved sufficient stability, Stage 2 Stage 1 consists of standard DBT includ- focuses directly on treating PTSD. The ing weekly individual therapy, group DBT PE protocol is delivered in weekly skills training, therapist consultation 90-120 minute therapy sessions while team, and between-session phone clients continue to receive all modes coaching. The focus in Stage 1 is on of DBT. Once the DBT PE protocol is helping clients achieve control over life- complete, Stage 3 uses standard DBT threatening and other severe behaviors, to address any remaining problems in and increasing behavioral skills in the living. Often the focus of Stage 3 areas of emotion regulation, distress treatment is on improving relation- tolerance, mindfulness, and interperson- ships and increasing valued activities al effectiveness. Once clients have such as work or school. Page 2 The DBT PE Protocol

The DBT Prolonged Exposure Protocol: How it Works Avoidance is a major factor The DBT PE protocol aims to helping to gain new perspec- that maintains PTSD and help clients stop avoidance tive about what happened prevents recovery. There are and instead confront trauma- before, during, and after the two ways that people with related thoughts and situa- traumatic events. PTSD typically avoid. The tions so that trauma can be In vivo exposure means first is trying to push away effectively processed. To do confronting avoided situa- memories, thoughts, and this, the DBT PE protocol tions “in real life.” Clients Imaginal Exposure feelings about the trauma. uses two types of exposure. are asked to gradually The second is avoiding situa- Imaginal exposure involves approach situations that tions, people, and objects revisiting the traumatic expe- they have been avoiding that are reminders of the rience in one’s imagination because they remind them trauma. Although avoiding and describing it out loud of the trauma. In vivo trauma-related thoughts and during therapy sessions. exposure has been found to situations works to reduce Imaginal exposure to the be very effective in reducing distress in the short run, it traumatic memory is very excessive fears and actually prolongs and inten- effective in reducing trauma- avoidance after trauma. sifies post-trauma reactions In Vivo Exposure related symptoms and in the long run. Research Support DBT+DBT PE has been evaluated as a 1-year outpatient treatment in Acceptable Feasible Safe Effective an open trial (n=13)3 and a

randomized controlled trial (n=26)4 74% of clients Among clients Adding DBT PE to conducted in a research clinic. prefer to receive a There was no completing 1 year DBT doubles the Clients were recently suicidal and combined DBT and of DBT, 80-100% evidence of rate of diagnostic self-injuring adult women with PE treatment over began DBT PE after worsening in any either treatment an average of 20 outcome domain. remission of PTSD PTSD and an average of 6 alone.5 weeks of DBT. (80% vs. 40%). additional diagnoses including borderline personality disorder. Clients in DBT+DBT 80% of clients in Clients in DBT+DBT Of these, 73% PE were 2.4 times DBT+DBT PE Pilot studies in community PE were highly completed the full less likely to achieved recovery satisfied with the DBT PE protocol in attempt suicide and outpatient, intensive outpatient, in terms of global treatment they an average of 13 1.5 times less likely and residential settings with men functioning vs. 0% received. sessions. to self-injure than and adolescents have also shown those in DBT alone. in DBT alone. promising results. References

Contact Information 1. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press. 2. Foa, E. B., Hembree, E., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional Melanie Harned, Ph.D., ABPP processing of traumatic experiences. New York: Oxford Press. Research Director, Behavioral 3. Harned, M. S., Korslund, K. E., Foa, E. B., & Linehan, M. M. (2012). Treating PTSD in suicidal and self-injuring women with borderline personality disorder: Development and preliminary evaluation of a Research and Therapy Clinics Dialectical Behavior Therapy Prolonged Exposure protocol. Behaviour Research and Therapy, 50, 381- Box 355915 386. University of Washington 4. Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialec- Seattle, WA 98195 tical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol Email: [email protected] for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research Tel: 206.616.1542 and Therapy, 55, 7-17. 5. Harned, M. S., Tkachuck, M. A., & Youngberg, K. A. (2013). Treatment preference among suicidal and self-injuring women with borderline personality disorder and PTSD. Journal of Clinical Psychology, 69,749-761.