Dialectical behavioral therapy (DBT) can be used to treat the symptoms of post-traumatic stress disorder (PTSD). DBT for PTSD usually implements skills training, including mindfulness and distress tolerance, to help people manage and cope with emotional distress. DBT also helps people identify and replace maladaptive behaviors.
Central Concepts of Dialectical Behavior Therapy (DBT)
Dialectical Behavioral Therapy is a type of evidence-based therapy that uses dialectics (or opposites) to target and replace maladaptive behavior and thought patterns with acceptance and tolerance. DBT is widely known as the first-line treatment for borderline personality disorder (BPD), but it can be adapted to address many mental health disorders.
DBT is skills-based, meaning tools are introduced as a means to provide those suffering from mental illness the ability to cope and manage their symptoms. DBT is a structured therapy that traditionally includes individual and group sessions focused on balancing acceptance with validation.1 The therapist takes on a dialectical-thinking approach by modeling and teaching skills related to problem-solving and behavior change.1
What Is PTSD?
PTSD is a trauma and stress-related disorder that occurs in the aftermath of experiencing a traumatic event. It is normal to have an emotional reaction after experiencing trauma, but those with PTSD experience a range of severity of symptoms that deeply impact their ability to function. Symptoms of PTSD can last anywhere from a month to years.
PTSD is common and can affect children, adolescents, and adults. Types of trauma that can cause PTSD include experiencing or witnessing a life-threatening event, catastrophic natural disasters, terrorism, exposure to war or any type of violence, or being the victim of various types of abuse and assault.2
How & Why Does DBT Work For PTSD?
Components of DBT are designed to target and treat mental disorders involving emotional dysregulation, including PTSD.3 When emotionally distressed, our brain responds to survive or cope. Those memories of the response to trauma are stored and re-opened in response to activated distress. Responses to a trigger (automatic biological reactions) could include uncontrollable crying or a complete emotional shut down.
If someone is watching a movie and a certain scene reminds them of their own past trauma (trigger), those uneasy feelings sink in, the brain is activated, memories are unlocked, and some type of behavioral response ensues. This process is commonly understood as the fight, flight, freeze, or fawn response.
8 Common Techniques Used in DBT Therapy For PTSD
In DBT therapy for PTSD, it is stressed that tension and conflict are part of our realities and therefore, there is no “one ultimate truth.” Instead, DBT says there are differing perspectives that can serve a function.4,5,6 Another way to understand this is that DBT acknowledges that we often need to think in the gray areas vs. black and white.
Eight common techniques used in DBT therapy for PTSD:
- Mindfulness: mindfulness can be taught to increase awareness of the present moment including cues, triggers, and feelings without judgment.
- Distress tolerance: it’s important to learn to tolerate stress so we don’t make a stressful situation worse.6
Such threats can be actual or perceived and distress tolerance is essential to management of emotions. - Emotional regulation: we can overcome and effectively manage emotions. It is important to remember that feelings are not wrong, but how we choose to respond to them can be powerful.
- Interpersonal effectiveness: this skill teaches people to cope with conflict, build healthy relationships, and make choices that serve their needs in a healthy, functional manner.
- Exposure and response prevention: typically used to treat obsessive compulsive disorder (OCD), some light exposure is essential to learning how to overcome those triggers in a natural environment. Response prevention refers to the elimination of unhealthy responses or unwanted behaviors, such as avoidance. Practicing exposure in therapy sessions is a safe way to prepare yourself for certain unavoidable triggers.
- Opposite action: this skill means recognizing your personal “action urge” associated with experienced emotion and making an intentional plan to react differently.6
- Validation: people with PTSD may question their own reality and what happened to them because the stress and pain can feel too hard to tolerate. For this reason, validation plays an important role in the healing process.
- Self-acceptance: this form of acceptance is not about being OK with being hurt, abused, or traumatized; self-acceptance is accepting that pain does not always have to mean suffering and that you can overcome what happened to you by taking back control, managing the emotions as they come, and allowing yourself to feel and heal.
Examples of DBT For PTSD
PTSD can manifest in various ways and last for months or years. Fortunately, DBT can help individuals cope in many ways in different areas of their lives. Implementing DBT techniques and concepts, such as different perspectives, mindfulness, acceptance, validation, and exposure, can help in situations at work, in relationships or at home.
Here are examples of how using DBT for PTSD can help in various situations:
Work
The stress of having to perform and produce can be a big trigger for someone with PTSD. There’s so much pressure to keep going and adhere to the demands of their workplace and the world, yet moving forward can feel near impossible.
While these feelings are understandable, a change in perception about work could actually be useful. For instance, if someone was performing well at their job before a trauma, it may be appropriate for a therapist to propose a different perspective. This could help them get back to a healthy mental space and accept that moving forward isn’t necessarily bad just because it’s hard.
Relationships
When trauma goes unaddressed, your romantic relationships will likely address the trauma at some point. For someone with PTSD due to a history of psychological, physical, sexual, spiritual, or emotional abuse, it is going to take a lot of work and commitment to rewire the brain’s automatic responses to perceived or actual threats of violence, manipulation, infidelity, etc.
Say you’re in a new relationship with a seemingly stable partner. Although this can feel exciting, those with relationship PTSD may be hypervigilant, hyper-focused on the “what-ifs,” and unintentionally living life waiting for something bad to happen.
A common trauma response might look like the survivor overreacting by drawing conclusions based on the suspicion that the new partner is manipulating them. Using DBT, a therapist could incorporate mindfulness (awareness this is a big reaction and pausing) and acceptance. Yes, something bad did happen before, but with DBT you will work on rejecting the painful and negative associations of the past.
Leisure
Hypervigilance and startle responses are common following exposure to violence. It is importantto validate these feelings, but also to activate your wise mind in order to prevent constant catastrophic living or the overwhelming fear that something bad is going to happen again. Someone who was assaulted while jogging on their favorite trail may work with a therapist to do imaginary exposures to the scene, talk about distress and emotional response, and work on overcoming the desire to flee.
A good DBT and trauma therapist will acknowledge that survivors can be aware of their surroundings, make safe choices, but also work through the fear associated with moving forward.
Future Goals
Many people with PTSD fear the unknown. Trauma tends to have an ability to put everything else in life on hold. For someone who is the survivor of a random act of violence, such as an assault, life may feel fragile and unstable. High emotions and worry might tell them to ruminate about the potential for future stressors or future acts of violence.
A DBT therapist may propose looking at what behaviors are not working or serving you well in the moment and introduce skills like opposite action, which allows trauma survivors to take some control over distressing feelings and change habits of shutting down.
What to Expect at Your First Session of DBT For Trauma
Standard DBT for trauma includes weekly individual sessions, skills group sessions, and phone coaching for emergencies. A provider taking this approach may only use certain components. At the first appointment, they’ll address why you wanted to come to therapy and identify your personal goals. It’s important for them to get an accurate diagnosis in your first few sessions, but a diagnosis can change throughout the course of treatment.
Whether you’re seeing a DBT therapist online or in-person, they will likely want to discuss your mental health history, trauma history, and whether there are any concerns about your current safety. They will ask if you are a current risk to yourself or anyone else and determine the appropriate level of care for your needs.
People who have experienced trauma may feel nervous about starting therapy. It is a therapist’s role to acknowledge the difficulty of your experiences and the important step you are taking in starting therapy.
The details typically addressed during your first therapy session include:
- Therapist and client roles
- Confidentiality and its limitations
- Structure of sessions
- Frequency and length of sessions
- Duration of treatment
- Fees for session and if there are fees for missed or canceled appointments
- What crisis supports or resources are available
- Determining an emergency contact and trusted support system
Is DBT Effective For Treating PTSD?
DBT skills are commonly incorporated in most treatment plans (both outpatient and inpatient residential) because they’re useful to anyone struggling with mild to severe mental health issues. First developed in 1993, many clinicians and researchers have found that DBT principles are an effective standalone treatment that can also be adapted and fused with other types of therapies.
A 2008 study demonstrated the effectiveness of applying DBT acceptance and validation skills to incarcerated youth with a history of trauma and exposure to violence, indicating DBT as a promising method of rehabilitation.7,8
Most recently in 2022, Dr. Melanie Harned published her DBT PE manual after years of researching the effectiveness of combining DBT and prolonged exposure (PE) for the treatment of PTSD.
How to Find a DBT Therapist
Most importantly, it is necessary to find a DBT therapist you feel safe with and comfortable opening up to. This can be determined by being clear about what your needs are and creating an alliance with your therapist to reach your goals. It is perfectly appropriate to ask them if they are skilled in treating your condition and what approaches they typically take.
Therapists who are skilled in trauma-informed care understand the impact and complexity of traumatic experiences.
Ways to find a trauma therapist include:
- Search for providers in network through your insurance provider’s website
- Search an online therapist directory to narrow your search down by cost, availability, and expertise
Final Thoughts On DBT For PTSD
PTSD affects millions of children and adults each year. Trauma takes time to process but many people deny themselves peace by refusing to acknowledge what happened. Confronting the trauma may sound counterproductive if you want to avoid it and “just move on,” but there’s likely some kind of internal conflict lingering with unrecognized impact on you or your loved ones.
For Further Reading
DBT for PTSD Infographics
