Treating PTSD During

Dialectical Behavior Therapy:

The DBT Prolonged Exposure Protocol
Helping High-Risk and Multi-Problem Clients with PTSD Build Lives Worth Living
Individuals with PTSD often present to have not typically targeted PTSD. When to help these tremendously suffering
treatment with multiple, severe comor- not treated, PTSD increases the risk of individuals recover from trauma and
bid problems such as suicidal and self- suicidal and self-injurious behavior and build lives worth living.
injurious behavior, severe dissociation, is likely to interfere with achieving
substance use, and personality disor- recovery.
ders. In fact, 66% of individuals with
The DBT Prolonged Exposure (DBT PE)
PTSD have two or more comorbid dis-
protocol was developed by Dr. Melanie
orders and up to 30% attempt suicide.
Harned specifically to treat PTSD
Unfortunately, these types of high-risk
among high-risk and multi-problem
and multi-problem clients are often
clients who are receiving DBT. The DBT
unable to access effective PTSD
PE protocol is based on Prolonged
treatment. These individuals are often
Exposure therapy2 and was adapted to
excluded from PTSD treatments due to
fit the needs of this complex client pop-
their severity, and treatments
ulation. DBT with the DBT PE protocol is
designed for this population such as
a comprehensive treatment designed
Dialectical Behavior Therapy (DBT)1

Special points of interest:

“The DBT PE protocol is now an
 DBT with the DBT PE protocol is a comprehensive treatment for high-risk, important part of standard DBT
multi-problem, and difficult-to-treat clients with PTSD. for clients with PTSD. All DBT
 The treatment has been delivered and researched in outpatient, intensive clinicians need to learn how to
outpatient, and residential settings with adults and adolescents. deliver this new and highly
effective protocol.”
 Research indicates the treatment is feasible to deliver, acceptable to clients,
safe, and effective in reducing PTSD, suicidal and self-injurious behavior, dis- Dr. Marsha Linehan
sociation, shame, guilt, depression, and social impairment. DBT Treatment Developer

Treatment Stages and Targets

The treatment is delivered in 3 stages. achieved sufficient stability, Stage 2
Stage 1 consists of standard DBT includ- focuses directly on treating PTSD. The
ing weekly individual therapy, group DBT PE protocol is delivered in weekly
skills training, therapist consultation 90-120 minute therapy sessions while
team, and between-session phone clients continue to receive all modes
coaching. The focus in Stage 1 is on of DBT. Once the DBT PE protocol is
helping clients achieve control over life- complete, Stage 3 uses standard DBT
threatening and other severe behaviors, to address any remaining problems in
and increasing behavioral skills in the living. Often the focus of Stage 3
areas of emotion regulation, distress treatment is on improving relation-
tolerance, mindfulness, and interperson- ships and increasing valued activities
al effectiveness. Once clients have such as work or school.
Page 2 The DBT PE Protocol

The DBT Prolonged Exposure Protocol: How it Works

Avoidance is a major factor The DBT PE protocol aims to helping to gain new perspec-
that maintains PTSD and help clients stop avoidance tive about what happened
prevents recovery. There are and instead confront trauma- before, during, and after the
two ways that people with related thoughts and situa- traumatic events.
PTSD typically avoid. The tions so that trauma can be In vivo exposure means
first is trying to push away effectively processed. To do confronting avoided situa-
memories, thoughts, and this, the DBT PE protocol tions “in real life.” Clients
Imaginal Exposure feelings about the trauma. uses two types of exposure. are asked to gradually
The second is avoiding situa- Imaginal exposure involves approach situations that
tions, people, and objects revisiting the traumatic expe- they have been avoiding
that are reminders of the rience in one’s imagination because they remind them
trauma. Although avoiding and describing it out loud of the trauma. In vivo
trauma-related thoughts and during therapy sessions. exposure has been found to
situations works to reduce Imaginal exposure to the be very effective in reducing
distress in the short run, it traumatic memory is very excessive fears and
actually prolongs and inten- effective in reducing trauma- avoidance after trauma.
sifies post-trauma reactions related symptoms and
In Vivo Exposure
in the long run.

Research Support
DBT+DBT PE has been evaluated
as a 1-year outpatient treatment in
an open trial (n=13)3 and a
Acceptable Feasible Safe Effective
randomized controlled trial (n=26)4
74% of clients Among clients
conducted in a research clinic. prefer to receive a completing 1 year There was no Adding DBT PE to
Clients were recently suicidal and evidence of DBT doubles the
combined DBT and of DBT, 80-100%
PE treatment over began DBT PE after worsening in any rate of diagnostic
self-injuring adult women with either treatment remission of PTSD
an average of 20 outcome domain.
PTSD and an average of 6 alone.5 weeks of DBT. (80% vs. 40%).
additional diagnoses including
borderline personality disorder.
Clients in DBT+DBT 80% of clients in
Clients in DBT+DBT Of these, 73% PE were 2.4 times
Pilot studies in community DBT+DBT PE
PE were highly completed the full less likely to
attempt suicide and achieved recovery
outpatient, intensive outpatient, satisfied with the DBT PE protocol in
in terms of global
treatment they an average of 13 1.5 times less likely
and residential settings with men to self-injure than functioning vs. 0%
received. sessions.
and adolescents have also shown those in DBT alone. in DBT alone.
promising results.

References
Contact Information 1. Linehan, M. M. (1993). Cognitive-behavioral treatment of borderline personality disorder. New York:
Guilford Press.
2. Foa, E. B., Hembree, E., & Rothbaum, B. O. (2007). Prolonged exposure therapy for PTSD: Emotional
processing of traumatic experiences. New York: Oxford Press.
Melanie Harned, Ph.D., ABPP
Research Director, Behavioral 3. 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
Research and Therapy Clinics Dialectical Behavior Therapy Prolonged Exposure protocol. Behaviour Research and Therapy, 50, 381-
Box 355915 386.
University of Washington 4. Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialec-
Seattle, WA 98195 tical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol
Email: [email protected] for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research
Tel: 206.616.1542 and Therapy, 55, 7-17.
5. Harned, M. S., Tkachuck, M. A., & Youngberg, K. A. (2013). Treatment preference among suicidal
and self-injuring women with borderline personality disorder and PTSD. Journal of Clinical Psychology,
69,749-761.