Understanding DBT and its Trauma Adaptations

Dec 11, 2023

Ethan Sapienza

Dialectical Behavioral Therapy (DBT) was originally created by Dr. Marsha Linehan to treat Borderline Personality Disorder. In recent years, DBT has increasingly been found to be effective for any person struggling with up and down, difficult to manage emotions (what’s formally been called emotion dysregulation). Those experiencing such emotional tumult can often struggle with lashing out at loved ones, making impulsive decisions, substance abuse, suicide and/or self-harm behaviors.

Research has shown that many of these kinds of clients who seek DBT likely also have trauma histories and may meet criteria for a PTSD diagnosis (66% of those with PTSD have two or more additional mental health disorders, and 30% attempt suicide (1, 2)). There are growing theories that emotion dysregulation is often fueled by previous traumas. What’s more likely to inspire painful feelings and high distress than traumatic triggers? DBT is greatly beneficial for those learning new ways to manage their emotions and engage with the world; however, the standard protocol does not target trauma, and in fact discussing trauma is explicitly avoided in Stage One of the treatment (when clients are struggling with severe, life-threatening behaviors).

Two major treatments have been developed to address PTSD within the DBT framework: DBT-PE and DBT-PTSD. To help understand the differences between the two treatments (with such similar acronyms), here is a brief guide:

DBT-Prolonged Exposure (PE)

Stabilization has been a necessary precursor to beginning trauma work in the field of mental health treatment. Essentially, this means that clients must be able to experience emotional difficulty without engaging in destructive behaviors before diving into past traumas. DBT-PE, instead, attempts to rework that timeline by requiring a shorter period of stabilization (two-months of no self-harm or suicidal behaviors), and then allows clients to begin trauma work. This puts clients on the fast track towards reducing the impact of trauma, while still spending time honing their DBT skills.

Developed by Dr. Melanie Harned, the DBT-PE protocol follows much of the same aspects of comprehensive DBT (individual sessions with diary cards and behavioral chain analyses, skills group, skills-based phone coaching, and consultation team). The addition of Prolonged Exposure (PE), originally created by Dr. Edna Foa, aims to reduce symptoms of PTSD by repeatedly revisiting traumatic memories and experiences related to past traumas (such as visiting certain places or performing certain acts) over and over again until they no longer cause high distress. Think of watching a scary movie once as compared to watching it a thousand times.

DBT-PE has drawbacks for those who cannot achieve the stabilization requirements or for those who cannot afford potentially three therapy sessions a week. Additionally, this treatment has exclusions for clients who have severe dissociation (the experience of life seeming off, distant or unreal as distress rises), current psychosis, or active substance dependence. Additionally, a decent amount of outside homework is required for clients enrolling in DBT-PE treatment.

That being said, for those who can receive the treatment, research has found that DBT-PE is highly effective. It doesn’t increase safety risks, clients in DBT-PE are found to have more than double the reduction in self-harm and suicide as compared to those in standard DBT, and 60% of clients no longer meet criteria for PTSD upon completion of the treatment. Additionally, clients also benefit from getting the entire gamut of DBT skills by attending skills group and focusing on skills application for at least part of their individual sessions.


DBT-PTSD, created by Dr. Martin Bohus, was specifically designed for adult clients with Complex PTSD (C-PTSD) who are victims of childhood sexual and/or physical abuse. (C-PTSD is a diagnosis currently only recognized in the ICD 10 and is for people who struggle with all the features of PTSD, while also endorsing symptoms of emotion dysregulation, disturbed relationships and a negative self-concept.) There is current debate in the field about the difference between C-PTSD and BPD, or whether they’re one in the same. The rationale for the treatment is that a client’s dysfunctional behaviors in DBT are functionally related to post traumatic stress, as clients may self-harm, become suicidal, dissociate, or abuse substances in order to temporarily reduce the distress tied to traumatic triggers (like someone cutting to calm down after remembering a previous assault). Essentially, the theory behind DBT-PTSD is that in order to truly reduce such severe behaviors, one must target the trauma as quickly as possible.

The old school rule of stabilization gets thrown out the window in DBT-PTSD. Dr. Bohus’s research found that exposure-based treatment to trauma can be administered to clients currently struggling with suicidal and self-injurious behaviors, substance use, disordered eating, and highly dissociative features, without increasing their risk (3, 4). This research is core to the treatment, as it does not follow the typical protocol of comprehensive DBT and instead adds features of DBT (as well as elements of ACT and cognitive therapy) into exposure-based trauma work. Skills group is not required in the treatment and instead, clients are asked to engage in daily skills practice and homework completion. Additionally, phone coaching only is used for severe behaviors, while the DBT consultation team remains the same as in standard DBT.

Because this approach focuses on targeting trauma, one potential drawback is that clients’ skills acquisition and generalization possibly lag behind those who commit to standard DBT or DBT-PE.

A major trial found that DBT-PTSD, as compared to Cognitive Processing Therapy (another evidence-based treatment for trauma), resulted in a remission from PTSD in 80% of clients who completed the treatment. This was found to be a success rate 15% higher than clients who received CPT in the same study. With such high effectiveness, such minimal exclusion criteria, and the requirement of only one weekly session, DBT-PTSD is a potentially highly accessible treatment for clients struggling with pervasive emotion dysregulation (3).

Research is currently being conducted on DBT-PSTD’s efficacy for teens (reports from a recent training I attended are that initial findings show the treatment to be even more effective for adolescents than adults) as well as for those who have trauma histories outside of physical or sexual abuse.

Works Cited

  1. 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 Dialectical Behavior Therapy Prolonged Exposure protocol.
    Behaviour Research and Therapy, 50, 381-386.
  2. Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research and Therapy, 55, 7-17.
  3. Bohus M, Kleindienst N, Hahn C, Müller-Engelmann M, Ludäscher P, Steil R, Fydrich T, Kuehner C, Resick PA, Stiglmayr C, Schmahl C, Priebe K. Dialectical Behavior Therapy for Posttraumatic Stress Disorder (DBT-PTSD) Compared With Cognitive Processing Therapy (CPT) in Complex Presentations of PTSD in Women Survivors of Childhood Abuse: A Randomized Clinical Trial. JAMA Psychiatry. 2020 Dec 1;77(12):1235-1245. doi: 10.1001/jamapsychiatry.2020.2148. PMID: 32697288; PMCID: PMC7376475.
  4. Bohus M, Dyer AS, Priebe K, Krüger A, Kleindienst N, Schmahl C, Niedtfeld I, Steil R. Dialectical behaviour therapy for post-traumatic stress disorder after childhood sexual abuse in patients with and without borderline personality disorder: a randomised controlled trial. Psychother Psychosom. 2013;82(4):221-33. doi: 10.1159/000348451. Epub 2013 May 22. PMID: 23712109.