Overview

Dialectical behaviour therapy (DBT) is a type of talking therapy based on the well-known cognitive behavioural therapy, adapted for people who feel emotions very intensely. ‘Dialectical’ refers to considering opposing theories. In the context of therapy, this means understanding how two things that seem contradictory could be true, such as learning to accept yourself and how to change your behaviour. 

DBT is primarily used for treating borderline personality disorder (BPD) but can be applied to treat trauma, often classified as post-traumatic stress disorder (PTSD). Trauma is defined as an emotional response to a distressing event that is difficult to cope with or out of one’s control. Some people describe trauma as the event itself, whereas others use it to describe the person’s response to the event. Either way, trauma can have a huge impact on people’s lives, causing symptoms like confusion, sadness, anxiety, agitation, emotional blunting, and dissociation.¹ 

Many people recover from traumatic events, but some people may need therapy to cope with their symptoms. For these people, DBT can be useful in learning to accept and understand their feelings, and how to manage them. 

Understanding trauma

Trauma is any stressful, frightening, or distressing event. This can be a single event or an ongoing situation. Most people will experience trauma in their lives, but everybody reacts differently. 

It is normal to feel shocked and in denial immediately after the event, however, some people can suffer more long-lasting effects, while others may suddenly develop symptoms years after the event occurred. 

There are many types of trauma a person could experience, including; 

• Childhood trauma 
• Abuse 
• Neglect 
• Domestic violence 
• Sexual assault 
• Bullying 
• Emotional abuse 
• War-related experiences 
• Racial trauma 
• Natural disasters 
• Terrorism 
• Secondary trauma 

Common symptoms and consequences

Trauma causes a range of physical and psychological symptoms, and they can be different for each person. 

In the moment, a traumatic event can trigger the fight or flight response, which is the body’s way of preparing for danger. This involuntary response causes cortisol and adrenaline to be released in the body. The release of these hormones can sometimes delay an emotional response to the trauma. Most people will experience shock and denial after the traumatic event. 

Other common symptoms during or after the event include anger, fear, numbness, irritability, restlessness, confusion, shame, hypervigilance, loss of identity/sense of self, and feeling unsure of what you want or need. Symptoms more specific to PTSD include intrusions (unwanted memories/flashbacks), avoidance behaviour (avoiding objects/environments that represent the trauma), altered cognition and mood, hypervigilance, dissociation, depersonalisation, and derealisation (feeling that things around you are not real).² 

Trauma can have serious consequences on a person’s life. For example, the individual may struggle with taking care of themselves, keeping a job, maintaining relationships or friendships, trusting people, making decisions, remembering things, and coping with change. Some people will also find that trauma makes it difficult for them to simply enjoy their free time.

It is important to address trauma using therapy to prevent symptoms from becoming overwhelming and severely impacting a person’s life. 

Overview of dialectical behaviour therapy (DBT)

DBT was developed in the 1970s by American psychologist Marsha Linehan who recognised the need for a new type of therapy for suicidal women. 

It is based on dialectical philosophy, meaning that therapists attempt to balance their patient’s acceptance of themselves with changes in their behaviour to help manage symptoms. This led to the creation of a comprehensive, evidence-based therapy for patients with borderline personality disorder.³  

Core principles and components

There are four stages of treatment in DBT, where the main principles implemented are: acceptance and change, behavioural, cognitive, collaboration, skills, and support. 

DBT uses a combination of therapy techniques to implement these principles. These techniques include: 

• Group therapy - patients are taught behavioural skills in a group setting 
• Individual therapy - a trained professional guides the patient on how to apply learned behavioural techniques to their own personal challenges
• Phone coaching - patients can call their therapist between sessions when they are experiencing a difficult situation

The core behavioural techniques taught during DBT are mindfulness, distress tolerance, interpersonal effectiveness, and emotion regulation. 

Target populations for DBT

DBT was originally developed for suicidal women, but is now used for anyone who has difficulty managing and regulating their emotions.³ This can be applied to a range of mental health conditions, including borderline personality disorder, suicidal behaviour, self-harm, substance abuse, PTSD, eating disorders, depression, and anxiety. 

Therapeutic process in DBT 

DBT sessions can vary depending on the therapist or provider, but the process usually consists of a pre-treatment assessment to determine if DBT is suitable for the person and to what extent. They may offer a few sessions where they provide information about DBT, and then the client decides if it is suitable for them. The therapy then consists of three types of intervention: 

Individual therapy sessions

These usually take place once a week. They consist of working on the patient’s goals and how to improve their quality of life by addressing the issues faced, such as mental health problems, employment, and relationships. 

Patients will be asked to fill in diaries and complete homework in between sessions, to track their feelings and emotions and identify any patterns or triggers. These are then used to guide the next session. 

Group skills training

These group sessions are where patients learn skills to apply to their daily lives to help cope with symptoms. This aspect of DBT is less like therapy and more like teaching. 

The four skills taught in these sessions are mindfulness, distress tolerance, interpersonal effectiveness,  and emotional regulation. Sometimes the therapist will incorporate activities like roleplay, and patients may be asked to complete homework to practise implementing these skills in their day-to-day lives. 

Phone coaching for crisis situations

Phone coaching is meant for support in between sessions when patients need it. This can be for advice on how to use the DBT skills they have learnt, or to help in a crisis (like feeling suicidal or wanting to self-harm). The therapist will lay out rules for phone coaching, such as a limit on the length of the call, a time window during the day in which calls are allowed, and the length of time that must be left between calls. This is to ensure the patient does not rely too heavily on the therapist, and the therapist is not put under too much pressure. 

Stages of DBT

Stage 1

The first stage aims to get the patient in control of their self-destructive behaviours. This is sometimes called stabilisation. During this stage, patients are taught the foundational skills needed for managing their emotions and reducing impulsive behaviour. 

These skills are taught in group skills training. The patient cannot move on to the next stage until they have been stable (not using self-destructive behaviours) for a set amount of time. 

Stage 2

This stage addresses the patient’s trauma and any other issues causing emotion dysregulation. The skills learned in stage 1 are applied to more challenging scenarios, and new skills may be taught to more specifically address trauma. 

Stage 3

The next step aims to build greater self-respect and self-esteem, and, consequently, improve relationships and quality of life. The skills previously learned are applied to practise self-awareness, self-acceptance, and self-validation. 

Stage 4

The final stage is about achieving meaning and purpose in life, and therefore, greater happiness. DBT skills are used to help people get the most out of their lives, for example, by strengthening relationships and tackling life goals.

Skills taught in DBT 

The skills taught in group skills training are designed to help people manage their emotions to improve their daily lives. 

This is where the dialectical aspect comes into play, as two of the skills are based on building acceptance (mindfulness and distress tolerance), and the other two help to implement behavioural changes (emotion regulation and interpersonal effectiveness). 

Mindfulness 

Mindfulness helps patients focus on the present moment to gain awareness of their thoughts, feelings, and surroundings. Practising mindfulness helps to reduce negative emotions that come with trauma, such as anxiety and depression. 

It also helps to control impulses, such as the desire to commit self-destructive behaviours.² 

Distress tolerance 

These skills help the individual to cope with and accept their emotions in difficult situations. This can help the person to remain calm and focused and prevent self-destructive behaviour. Some of the distress tolerance skills taught in DBT are distraction, improving the moment, self-soothing, and listing pros and cons of not tolerating the distressing situation. 

Emotion regulation 

This involves reducing vulnerability to negative emotions by learning to identify, label, and change them. This helps to improve emotional stability by reducing the intensity of negative emotions and increasing positive ones. It also allows the person to have more control over their emotions. 

One way that therapists teach this is by telling patients to identify how they are feeling and then do the opposite. For example, if the patient recognises that they are feeling like they want to withdraw from friends and family, they should make plans to spend time with them. 

Interpersonal effectiveness 

This skill teaches people how to be more assertive in a relationship without it having a negative impact. This is done by learning how to listen and communicate effectively, set boundaries, and resolve conflicts in healthy ways. 

These skills can increase the patient’s self-esteem, strengthen their relationships, and reduce feelings of loneliness and isolation.⁴ 

Application of DBT to trauma

As DBT was created for people with emotion dysregulation, which has been theorised to be caused by past traumas, it makes sense that this type of therapy can be applied to trauma. DBT particularly focuses on validation and acceptance. 

Several of the skills taught during DBT are aimed at helping the person accept themself, others, and the world. Some of the skills that especially target this are mindfulness, radical acceptance (taught during distress tolerance skills training), and validation. 

Standard DBT does not specifically target trauma, so some adaptations have been made. There are two main types of adapted DBT for trauma: DBT-Prolonged Exposure (DBT-PE) and DBT-PTSD.

DBT-PE

This adaptation uses a shorter stabilisation period of about two months. Clients then move on to trauma work, where they repeatedly revisit memories and experiences relating to their trauma, such as certain places or acts. These are repeated until the trigger no longer causes high levels of distress. 

DBT-PE has proved highly successful for many patients, with a two-fold reduction in the amount of self-harm and suicidal behaviours compared to those in standard DBT. 60% of clients who  finish DBT-PE are no longer classified as having PTSD. Alongside this, clients learn all of the typical DBT skills during this therapy, which they can continue to practise once therapy is over.⁴ 

DBT-PTSD

This adaptation was designed for people with complex PTSD (C-PTSD), which is classified as having all the same symptoms of PTSD as well as emotion dysregulation, disturbed relationships, and a negative view of themselves. C-PTSD is usually experienced by people who have suffered childhood abuse, such as sexual or physical abuse. 

DBT-PTSD aims to tackle the trauma immediately, in order to quickly reduce the dysfunctional behaviours that patients use to reduce their distress, such as self-harm, dissociation, and substance-abuse. This means that the usual first stage in DBT, stabilisation, is omitted. Instead, features of DBT are added to the exposure-based trauma work, and patients must practise daily skills and complete homework. 

Research by Dr. Martin Bohus, who developed DBT-PTSD, found that this style of therapy can be used for patients who are currently exhibiting suicidal and self-harming behaviours, substance abuse, and disordered eating without increasing their risk. One downside to this is that some patients may gain less skills than those who use standard DBT or DBT-PE.⁴ 

Integration of mindfulness in trauma therapy

Mindfulness is defined as paying attention to the present moment intentionally and non-judgmentally. Mindfulness-based therapies have been recommended as a good alternative or supplementary treatment for trauma. They help the patient focus on the present, allowing them to accept and feel their thoughts and emotions as they occur, without judgement. 

Mindfulness is thought to be particularly useful for PTSD patients due to its ability to manage emotional extremes (suppressed and overwhelming feelings), which is a common symptom of PTSD. More specifically, mindfulness can help to target the key symptoms of PTSD including avoidance and negative thoughts, such as self-blame, shame, and guilt.² These approaches can be less distressing than trauma-focused therapies, and consequently have lower drop-out rates.⁵

DBT often incorporates mindfulness in order to help patients accept their thoughts, emotions, sensations, and impulses as they experience them. This strategy helps the patient to regulate and use mindfulness as a coping mechanism during a trigger, which can help them to avoid negative thought patterns and prevent self-destructive behaviours. 

Evidence-based support for DBT in trauma

One study on female patients who completed one year of DBT for trauma found that there was a 45% decrease in the number of visits to A&E centres after treatment. Additionally, an increase in employment/school attendance was found, from 1 patient in employment before treatment, to 8 patients in employment or education after therapy.⁶  

Other research carried out by the founder of DBT, Marsha Linehan, has found that when compared to the standard treatment offered for BPD, DBT was more effective at reducing the number of suicide attempts, admission to psychiatric units, A&E visits, and risk of suicidal behaviour.⁷ 

Comparison with other trauma therapies 

Many people think that DBT is more suited to treating trauma than its predecessor CBT, because CBT focuses on changing thought patterns and behaviours. For many people suffering from trauma, this can make them feel misunderstood, criticised, and invalidated. DBT’s use of acceptance skills can help people to feel that the way they are feeling is valid, and therefore, can help to reduce dropout rates. 

Another evidence-based therapy for trauma is cognitive processing therapy (CPT). CPT is a more specific and organised form of CBT, consisting of 12 sessions divided into phases of psychoeducation, understanding your thoughts and feelings, learning new skills, and changing your beliefs.⁸ 

Research comparing CPT with DBT-PTSD to treat people with C-PTSD found that both CPT and DBT-PTSD were successful in treating the participants, but DBT-PTSD was more effective, with 58% achieving remission of symptoms when undergoing DBT-PTSD, compared to 41% remission for CPT. This is strong evidence to support both types of therapy as an effective treatment for severe PTSD.⁹

Challenges and considerations

Barriers to DBT implementation

Barriers can stem from both the system and from the individuals in need of DBT. Some of the most difficult systemic barriers to overcome include a lack of trained therapists, a shortage of training resources, and insufficient investment from healthcare organisations. 

In terms of the individuals requiring DBT, one of the main barriers is resistance to therapy. This is where the patient is in opposition to the therapy process and rejects the therapist’s suggestions. This can also mean that there are not enough patients to adequately fill the group skills training sessions.¹⁰

Addressing comorbid conditions

People with BPD often suffer from comorbid PTSD. This is because BPD is usually caused by childhood trauma. There is a wealth of evidence on the efficacy of DBT for both BPD and PTSD, and results have shown that DBT is often a successful treatment for both conditions, especially when an adapted DBT (e.g., DBT-PTSD) is used.¹¹ 

Other conditions that often occur alongside PTSD include depression, anxiety, and substance-use disorders.¹² DBT helps to tackle these indirectly by teaching the individual acceptance and validation, which helps to improve their outlook on life and reduce feelings of depression. DBT also provides individuals with techniques to manage negative emotions, which often cause depression, anxiety, and impulsive behaviour (e.g., substance abuse). The mindfulness aspect of DBT seems to be useful for many mental health conditions, and therefore is a useful tool to help address not only trauma, but any other comorbidities the patient may have. 

Future directions and innovations

Ongoing research in DBT for trauma

New research is investigating the usefulness of DBT-PTSD for teenagers. Results show that DBT-PTSD is more effective in this age group than adults. Perhaps, this is due to targeting the trauma sooner after it occured, or because the patient’s brain is still developing. 

There is also new research on using DBT-PTSD for patients who have suffered trauma that is not related to physical or sexual abuse.⁴ This research is important as most of the evidence for DBT-PTSD so far comes from patients with a history of physical or sexual abuse, making it uncertain whether the outcomes would be the same for people who have suffered different types of trauma, such as secondary trauma. 

Most of the research on DBT has previously focused on women with BPD. However, some studies have looked into the effectiveness of DBT for other symptoms or clinical populations. For example, there have been promising results for DBT as a treatment for parasuicidal behaviour, substance-use disorders, eating disorders, and depression in the elderly.³ 

Integration with technology 

With the world turning evermore digital, it is important that therapy can be adapted to the use of technology via teletherapy. This has the potential to make DBT much more accessible. 

However, removing the personal element may have negative consequences, such as making group skills sessions more challenging and less effective, engagement and motivation from patients may be reduced, and drop out rates might increase. 

Summary

Dialectical behaviour therapy (DBT) is a type of talking therapy specially adapted for people with intense emotion dysregulation. DBT helps them to accept and validate their feelings, rather than telling them what they should be doing differently. Using a combination of mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness skills across four key stages of treatment, DBT provides a comprehensive, supportive and non-judgemental approach to treating trauma. The success of DBT in treating trauma and BPD shows its potential promise for treating other mental health conditions, such as depression and anxiety. Further adaptations may need to be introduced to make the therapy more accessible and personalised.