Dialectical Behavior Therapy and PTSD: How DBT Can Help You Heal
For clients with PTSD, one of the most troubling aspects of seeking treatment is confronting the trauma itself. While treatments like exposure therapy and eye movement desensitization and reprocessing (EMDR) are proven to treat trauma, they are only effective if the client has already received skills training to help them cope with the aftermath in their everyday life.
Though initially developed for borderline personality disorder, dialectical behavior therapy (DBT) has been empirically tested and proven effective for PTSD as well (1, 2, 3). DBT treatment focuses on building trust between client and therapist as they work through four core modules: mindfulness, interpersonal effectiveness, emotional regulation, and distress tolerance.
Many trauma survivors have difficulty recognizing and regulating emotions like emptiness, guilt, shame, and anger. This leads to negative thought patterns such as believing they will never recover, they are permanently damaged, or that they will never be able to trust others again. Those thoughts in turn lead to problems with interpersonal relationships and destructive behaviors–all of which are addressed by DBT.
DBT helps clients to identify, recognize, and regulate their own emotions through distress tolerance and emotional regulation. These processes work in tandem with mindfulness skills that emphasize observing thoughts and feelings before acting on them. Mindfulness training is often the first step in DBT as it teaches clients how to stay present while they observe their thoughts and emotions. Skills such as nonjudgmental thinking, radical acceptance, and an emphasis on choosing to do things one-mindfully help the client to see beyond black and white thinking and accept other possibilities. This is especially helpful with anger, guilt, and shame–which in turn help the client in attending to relationships.
For many clients with PTSD, communicating wants and needs to the people around them is highly difficult. In many cases, clients have had their feelings invalidated as the people around them fail to understand the trauma. This increases feelings of worthlessness, lowers self esteem, and increases destructive behaviors as a means of communicating through action when the client goes unheard.
Interpersonal effectiveness focuses on building self respect, learning how to say no, learning how to ask for help, and how to handle conflicts in a healthy way. These skills help the client to identify toxic relationships and gives them the skills to let go of people who are unhealthy for them. It also reinforces positive interactions that help build and maintain healthy relationships. By feeling capable with the people around them, a client with PTSD will recover a sense of self respect and realize that isolation and destructive behaviors are no longer to necessary to get what they need.
One of the most difficult aspects of PTSD are intense, seemingly uncontrollable emotions. The bewildering reactions of trauma are often frightening and make the process of regulating emotions far more difficult, especially when the client doesn’t understand why they feel the way they do. It’s even harder when the people around them have no explanation, either. Because emotions are so intense and illogical, it isn’t uncommon for someone with PTSD to avoid those emotions and make attempts to numb them with destructive behaviors–especially substance abuse. As one would expect, this often makes things worse.
DBT skills training effectively shows the client how to examine their own reactions and emotions. The first step is to help identify and broaden the client’s knowledge of both positive and negative emotions. Knowing how those emotions are commonly experienced can shed light on a particular reaction and provide validation for it. One the reaction is understood, the client can work backwards to identify the emotion–and the circumstances that provoke it–so they can prepare themselves accordingly. This is the core of emotional regulation. The client learns to become capable with their emotions and regains a sense of control over them.
Distress tolerance is aimed at alleviating situations that cannot be immediately resolved. These are behavioral strategies that utilize distraction, self-soothing, and find ways to improve the moment when a client is in crisis. Several are commonly used coping skills such as opposite action, grounding, and breathing exercises–but many are unique in that they utilize mindfulness to help the client stay in the present.
For a client with PTSD, staying present while in crisis is vital, and it requires both willingness and acceptance to face the critical situation. By using distress tolerance strategies in combination with radical acceptance, DBT teaches clients a solid approach to handle themselves in crisis–thus preparing them for facing their trauma if they desire to do so.
Once they have these skills in place, the client will have a sense of safety and sureness they did not possess before. Knowing that they can self-soothe on their own, ask for help, know how to get out of unhealthy situations, and recognize their symptoms before they turn into crises empowers clients with PTSD. This realization counters the belief that one is permanently damaged, or will never recover, because the client now knows that belief is no longer true.
When the client regains their ability to empathize with and validate themselves, trust their own reactions, and counter false beliefs, they may feel as though they have finally opened their eyes. While PTSD is a terrible experience, it cannot permanently erase a person’s integrity. Much of what DBT aims to accomplish is to help the client to see themselves as who they truly are–someone worthy of acceptance, happiness, and love. It requires hard work and willingness, but with the right skills and the right support, it is certainly possible for clients to overcome their trauma and integrate their experiences in a meaningful way.
1: Steil, R., Dyer, A., Priebe, K., Kleindienst, N. and Bohus, M. (2011), Dialectical behavior therapy for posttraumatic stress disorder related to childhood sexual abuse: A pilot study of an intensive residential treatment program. J. Traum. Stress, 24: 102–106. doi: 10.1002/jts.20617
- Cukor, J., Spitalnick, J., Difede, J., Rizzo, A., & Rothbaum, B. O. (2009). Emerging treatments for PTSD. Clinical Psychology Review, 29(8), 715-726.
- Harned, M. S., & Linehan, M. M. (2008). Integrating dialectical behavior therapy and prolonged exposure to treat co-occurring borderline personality disorder and PTSD: Two case studies. Cognitive and Behavioral Practice, 15(3), 263-276.
- Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York: Guilford Press.