Integrating Dialectical Behavior Therapy Into Exposure Therapy for Complex Posttraumatic Stress Disorder

Posttraumatic stress disorder (PTSD) is a common comorbidity in eating disorders patients. Patients who present with both PTSD and an eating disorder are often considered challenging to treat, and are frequently considered poor candidates for exposure therapy. Yet we have found it is sometimes easier to treat PTSD symptoms first via exposure than to treat the eating disorder in the presence of full-blown PTSD. Thus, identifying strategies to improve patient tolerance and to broaden the range of patients deemed appropriate for exposure therapy is a crucial next step for those of us who advocate the use of exposure for PTSD.1

Although considerable evidence supports the effectiveness of exposure therapy for PTSD, recent discussions with colleagues indicate that many therapists are “giving up” on this treatment. In particular, clinicians argue that exposure does not meet the needs of highly comorbid PTSD patients, some of whom also have eating disorders.

Exposure therapy involves exposing patients to anxiety-provoking stimuli for prolonged periods to reduce associated fears. Repeated trials are typically used to enhance between-session habituation. In the case of exposure for PTSD, patients are exposed to memories of traumatic events (i.e., imaginal exposure) and to stimuli that remind the patient of the trauma (i.e., in vivo exposure).

Dialectical Behavior Therapy

In an attempt to identify strategies to facilitate exposure, we turned to the literature on borderline personality disorder (BPD). Individuals with complex PTSD are similar to those with BPD in that they are often considered to be very difficult to treat. One reason for this is the global nature of their emotional distress. In addition to chronic anxiety, persons with PTSD experience significant sadness/depression, shame, guilt, and anger. Many have chaotic lives and are involved with legal battles, abusive relationships, or may be unemployed.

Dialectical behavior therapy was designed by Linehan to address the impulsive behaviors, life chaos, and emotional deregulation associated with BPD and thus is useful for treating these same problems in individuals with PTSD. The increasing use of DBT in the treatment of eating disorders by many clinicians suggests possible utility in this area as well.

‘Modified DBT’

Patients with complex PTSD have a spectrum of problems dealing with emotions, ranging from full-blown BPD to difficulties specifically related to individual trauma histories. When patients exhibit chronic and severe suicidal behavior and a lack of basic skills for self-regulation, we refer them to comprehensive DBT programs. Most of the patients who enter our program, however, exhibit more circumscribed difficulties in these areas. While these patients are frequently considered “exposure-intolerant” by other clinicians, we have found that they are often able to complete exposure treatment with more limited “doses” of DBT. We refer to this more limited dosing as “Modified DBT.”

DBT Biosocial Theory

The biosocial theory states that difficulties associated with BPD are produced when a person with temperamental vulnerability is raised in an invalidating environment.2 Linehan designed the biosocial theory to improve therapists’ ability to maintain a positive attitude towards their patients. Linehan’s research suggests that maintaining a noncritical stance towards BPD patients is highly important,3 and we believe the same is true for patients with PTSD. Although working with trauma survivors is emotionally draining for therapists, we have found that using the biosocial theory improves our ability to like our patients.

Individuals with complex PTSD frequently experience significant invalidation during their lives and, as a result, often find the invalidating environment concept helpful. Discussion of invalidation may focus around others’ reactions at the time of the trauma (e.g., telling the patient to put the experience behind him or her); others’ reactions to PTSD symptoms; or events not directly related to the trauma that adversely influenced him or her during childhood. In addition, explaining that self-invalidation can perpetuate distress improves understanding and in some cases helps to correct dysfunctional beliefs. Patients often say, ‘I shouldn’t feel this way’ or ‘I should be over this.’ Yet, we have been surprised at how often these patients spontaneously begin to alter their beliefs once such beliefs are identified as examples of self-invalidation.

Dialectic of Acceptance/Change

Recently much has been written about the need to balance acceptance and change-based strategies.5 Linehan, however, was among the first to recognize the wisdom of balancing behavior therapy’s historic focus on change with explicit attention to acceptance. The dialectic of acceptance and change is critical for both PTSD and eating disorders and exists on two levels, that of the patient and that of the therapist.

For the complex PTSD patient, balancing the dialectic entails admitting that there are things about oneself and one’s life that cannot be changed. No matter how much patients may wish things were different, they cannot undo past traumas, mistakes, or failures by themselves or others. Patients must also address this dialectic in relation to their emotions. Patients enter therapy wanting to escape their painful emotions, a goal that presents a paradox for therapy since the amelioration of emotional suffering requires acknowledging their negative emotions so one may respond effectively.

The therapist must also maintain a balance between acceptance and change. Behavior therapy is a change-oriented treatment. With it, we help patients to change their maladaptive behaviors, dysfunctional thoughts and, by the first two methods, their negative emotions. Even acceptance is reached via change. For example, acceptance of weight in bulimia nervosa is often achieved via cognitive restructuring (CR), a change procedure.

As Linehan notes, approaches that focus on change are clearly necessary, and a therapist who unconditionally accepts the patient without focusing on change is likely to do little good because new behavior and skills are neither taught nor learned. Acceptance techniques such as repeated and explicit validation, however, are also critical since PTSD patients often feel misunderstood when they are asked to make changes that seem impossible. When therapy overemphasizes the need for change relative to acceptance, patients may re-experience the invalidation that occurred at the time of the trauma. This is particularly true for survivors of abuse, who often experienced invalidation from legal and social systems as well as from family and friends. Making therapy “invalidation-free” is crucial to achieving a safe setting in which to address traumatic experiences.

Reducing invalidation in exposure therapy can be quite difficult. For example, a very articulate group of patients once informed us that simply by teaching exposure we were invalidating their primary coping strategy. In essence, the whole notion of exposure implied to these patients that their use of avoidance to cope was somehow wrong. We now explicitly encourage patients to discuss the benefits of avoidance, which validates its use as a coping strategy, before beginning to examine the negative consequences associated with avoidance. Feedback from patients about this change in focus has been uniformly positive and we find that patients are more committed to engaging in exposure therapy as a result.

Exposure and Mindfulness

After conducting exposure with many “unsuitable” patients, we have become aware of the extent to which exposure is not merely a technique but also a skill that a patient must acquire. In complex PTSD patients, trauma-related stimuli often trigger a range of emotions, such as anger, guilt, or shame. For exposure to be successful in facilitating habituation of anxiety responses, however, the patient must learn to selectively focus attention on the anxiety associated with the stimuli. Selective focusing of attention requires patients to scan the range of their affective responses and then selectively attend to sensations of anxiety to the exclusion of other emotions. As several patients have noted, this is not a skill that they necessarily bring to treatment.

Mindfulness enables patients to observe and label their emotional reactions to traumatic memories. Thus, they learn to identify the sensations associated with anxiety (versus shame, guilt, anger) and selectively attend to them. A number of our patients have reported that once they learn to focus on their anxiety, they can “shelve” other emotional reactions in order to complete the exposure task at hand.

Dangers/Pitfalls

Although modified DBT is a useful tool for helping patients complete exposure therapy, it is important to point out potential problems that may arise from its use. First, it is clear that many PTSD patients can complete exposure therapy without the addition of DBT. Second, while current treatment manuals don’t fully address the needs of clinicians, there is an ever-present danger that merging interventions may “water-down” efficacious treatments. Similarly, use of modified DBT may decrease the therapist’s attention to the core components of exposure-based treatment, thus resulting in inadequately administered or incomplete exposure.

The Future

While DBT has been scrutinized as an intervention for parasuicidal and impulsive behaviors, its routine use to enhance exposure therapy has not been empirically studied. We believe that integrating DBT-based therapy leads to improved tolerance of exposure therapy for PTSD. Systematic clinical investigations, however, are needed to demonstrate this effect and to examining the underlying mechanisms of this approach.