DBT Trauma Therapy
DBT Trauma Therapy
This blog post discusses DBT Trauma Therapy (aka Trauma Focused DBT) and is piggybacking off my most recent blog, Skills for Trauma Survivors: Dialectical Behavior Therapy. Today we will expand on what we discussed previously, so if you haven’t already read it, you can catch up HERE.
Let’s pick back up where I left off in discussing DBT - specifically the ways in which we can apply DBT to trauma and trauma recovery!
There are two main topics that I want to touch on in this conversation:
What is a skillful approach to trauma recovery using the DBT theory framework and skills?
What is prolonged exposure in the context of DBT? How is it applied? How is it functional?
What is DBT for trauma therapy: a skillful approach?
A skillful approach for trauma focused DBT is effectively applying skills to the situations, behaviors, and experiences happening in our life that we want to change, cope with, tolerate, or move through in a different way.
Ultimately, we are learning and applying various coping skills to daily life, help reduce symptoms and activation, and continue to work towards our goals.
Mindfulness for trauma:
Mindfulness for trauma brings in the first core principle of DBT that I believe to be highly effective in trauma recovery is the skill of mindfulness.
Mindfulness for trauma does not necessarily mean meditation. The two are frequently confused, but many people believe meditation is actually harmful to people with trauma. Through the lens and framework of DBT, mindfulness is a very different approach.
Mindfulness for trauma isn’t just about sitting with your thoughts and getting over-exposed to trauma. The trauma focused mindfulness approach in the context of DBT is about slowing down and noticing what’s happening in an informed way so we can select the skills we need in that moment.
Mindfulness is paying attention to the present moment on purpose with no judgment.
There is internal-based mindfulness, like focusing on your breath, or external-based mindfulness, like paying attention to the sounds outside of your body.
Mindfulness is also how we check in with ourselves - What am I feeling today? What are my symptoms?
In DBT language, we use the word “vulnerabilities” to describe what we sense and feel in the environment that makes us more sensitive to our symptoms, emotional reactivity, or feeling overwhelmed.
Pausing to do a self-assessment is a mindfulness practice that helps us check in with our vulnerabilities and proceed accordingly with the appropriate skills.
Things to look at when self-assessing:
Rank your distress level on a scale of 1-10.
What body sensations are you feeling? Try to name them without analyzing them.
What emotion(s) are you feeling? Can you put a name to what you are feeling? Can you sense what emotional tone exists at this moment?
What are your thoughts doing? Can you focus on what you want to focus on without engaging in certain thought patterns? Do you feel distracted or foggy?
Based on this information, we can determine what we need and what skills to utilize. This is also a great way to check in with ourselves on whether or not we need help or support, indicating it's time to reach out.
Ultimately, self-assessment and monitoring help us hone our ability to recognize early indicators of distress and dissociation or accumulation of an emotional or stress burden.
Accumulation of an emotional or stress burden is when we collect stressful and emotional weight that, if we are not processing these emotions or relieving our stress, we are going to carry it with us and pile on more as time goes on.
When we practice mindfulness, we exercise a muscle and strengthen it to be helpful when we need it. This muscle is the ability to notice.
By having the ability to notice when stress is accumulating, we can do something about it before it gets out of hand. This is a vital skill for someone with trauma.
You can get maxed out quickly when you have no skills or knowledge on regulating your emotions and stress levels. When we max ourselves out, doing the things that make “life worth living” is difficult.
Personally, I love to write and play instruments, but when I feel the creative side of my brain shut off or become inaccessible, it is very bothersome for me. It feels like an entire part of myself is shut down. If I accumulate a lot of stress and emotional burden throughout my week without employing my regulating/processing skills, I’m setting myself up for that experience.
Strengthening that mindfulness muscle helps us stay grounded in the present moment. For survivors of trauma, this is incredibly important because it establishes safety.
Suppose I am present in my present moment, which is safe physically and emotionally. In that case, that helps me be more calm and grounded, even if my brain is having a moment where it feels unsafe.
Sometimes trauma survivors’ brains and bodies might be replaying a traumatic memory telling them it's unsafe. So, grounding into the present moment helps reestablish safety as we go.
Oftentimes, when we feel we’ve lost purpose, meaning, or connection to our life, we’re not as present as we want to be.
Survivor or not, a valuable piece of mindfulness and grounding is that being more present means experiencing the richness and beauty of all the different parts of that moment.
DBT Wise Mind for trauma therapy:
When we practice mindfulness and grounding in the present moment, we connect to our Wise Mind.
Our Wise Mind will notice if the things in our present moment are really working for us.
Is it working for mental and physical health?
Is it working for my personal values and my long-term goals?
If something isn’t working, is there anything that I can alter to change my experience?
Wise Mind helps us select what skills we need to use and what boundaries we need to set with people.
When I’m in tune with my Wise Mind, I can interpret and act on my experiences appropriately. Wise Mind tells us the next indicated step, although it can’t always help us project far in the future.
In any given moment, especially when we are in the thick of our symptoms, sometimes the only thing we can do is figure out the next step. You may not be able to figure out what the next right thing after this right thing is. You have to get to that next destination first and then decide on your next steps. Wise Mind can help us get there.
The way to get to Wise Mind is through mindfulness and by being grounded and fully in the present moment. By observing ourselves without judgment, we can achieve this.
Dialectic of Trauma: Vulnerability Management vs Change and Growth
The following key principle of DBT and its application to trauma (and just life in general) is the dialectic between challenging yourself/working toward your goals while also taking care of yourself.
Many of my clients ask me, “What am I supposed to do to reach my goals while also taking care of myself?”
It is a very valuable question because we will always have multiple demands at any given time.
For example, when we want to grow and reach our goals, this involves taking steps that activate emotions. It’s natural during those times that we may feel increased anxiety, agitation, or emotionality.
Challenging ourselves means knowing an emotional toll will be taken. There will be times in our lives when we don’t have the emotional resources to challenge ourselves, and that’s okay.
We live in a capitalistic society, so our vulnerabilities are frequently ignored. We internalize the message that any and all needs that we have must come second to our productivity.
This message devalues our need to care for ourselves and overvalues what we can contribute or show for our time.
Before undergoing a challenging experience, looking at what emotional resources you have on hand is essential. Ask yourself:
Do you have room for this stress burden to challenge yourself?
Have you accumulated a lot of stress, and have you managed it enough to make room for something that will challenge you and help you grow?
If you don’t have room, you can move into what I call vulnerability management without judgment.
Vulnerability management means doing things to restore our emotional resources, rebuild them, strengthen them, and collect more of them so we can challenge ourselves in the near future.
This can look like basic self-care:
Eating regularly
Getting good sleep
Taking care of hygiene needs
Moving your body
Structuring your time and your schedule
Emotional rest
Emotional rest is just as important as physical rest! This can look like sitting on your couch watching a light-hearted show or film, cuddling with your dog under a blanket, or spending time with loved ones that will allow you to release emotionally.
Emotional recovery can also mean getting active, going out and doing things, connecting with friends, going to events, or experiencing new things. Being social can be very nourishing and life-giving for some people!
Knowing your own personal restorative activities is very powerful. This is where your Wise Mind and noticing muscle come into play.
It is also up to our Wise Mind to indicate what is time to take care of our vulnerabilities and what is trauma avoidance.
Trauma Avoidance
Trauma avoidance is when we move away from engaging in something - sometimes unconsciously, but often consciously - because it will activate us in some way, shape, or form.
Trauma avoidance is not always problematic. Sometimes we do need to prioritize vulnerability management practices. Sometimes the things we’re avoiding will be highly overwhelming to us, and we do need to break them into smaller steps or expose ourselves to them step by step rather than all at once.
This is where it’s really important to connect to our Wise Mind, so we can gauge all of that, mainly because vulnerabilities change from moment to moment. You may have many emotional resources at midday, but those emotional resources might be spent later in the evening.
What is really valuable about this is it also gives us a barometer on where things are going with our recovery. Suppose you’re constantly in vulnerability management mode and notice that you want to challenge yourself but struggle to get there. In that case, it might mean assessing and examining what’s really happening.
Do you need more vulnerability management?
Do you need more support?
Do you need to build your discomfort tolerance so you can challenge yourself to do something hard?
For example, if you know you avoid conflict and are in a situation where you need to have a difficult conversation. but you’re already emotionally flooded and overwhelmed going into it; that would be the time to rest.
Being emotionally burdened may make it impossible to have that conversation, reinforcing your avoidance of conflict.
Perhaps you employ the DBT skill of gentle avoidance, which politely creates space between you and the person you’re conflicting with to sure up your resources. Then once refueled with emotional resources, you can have that difficult conversation.
Vulnerability management is to restore and recover energy and emotional resources. For some individuals, this might look like keeping things very light in their lives, keeping the content they expose themselves to (TV shows, books, conversations, activities, etc.) light and cheerful. Keeping everything light and polite means they don’t engage in anything that will activate them personally.
You can also engage your distress tolerance skills of distraction, self-soothing, improving the moment, and radical acceptance in the sense that this isn’t the period of time where we’re challenging ourselves to change anything. We’re working on how to tolerate what is going on and how to keep ourselves regulated.
When we push for change or growth, our long-term goals may not seem that complicated, but they may be really tough for you right now.
For example, I call my year of personal recovery my “year of ease” because I did everything possible to make my life easy while I processed my trauma. This did take a financial toll as I ordered a lot of takeout and signed up for delivery services to ease that burden. Cooking and cleaning were hard to do during this time, and running errands was incredibly difficult. Leaving the house for anything other than work was nearly impossible.
Part of my radical acceptance was accepting that emotional resources were scarce for me then. No amount of skills would change the trauma burden that was elevating my vulnerabilities at the time.
As I reduced my trauma burdens with my recovery, I noticed I had more room to engage in challenges like running errands. The willingness to do them was not always there, but that's where pushing myself to grow came into play.
The skills we use to challenge ourselves for change and growth include our interpersonal effectiveness skills around communication and emotion regulation skills rather than distress tolerance skills because we’re not in distress.
Emotion regulation skills are used when we’re practicing our emotion IQ. We know what we’re feeling, we’re identifying those feelings, and we can move fluidly through them. We can move through them by experiencing the emotion, being mindful of it, allowing it to come and pass, problem-solving the different issues that arise in our lives around the emotion, and acting opposite to emotions that may interfere with our long-term goals.
Ideally, when we’re in this zone of optimal growth and development, we balance our vulnerability management with our push for change and acceptance. We’re doing things that take care of our vulnerabilities while taking steps toward our long-term goals daily.
Those daily steps may differ in size and intensity but are consistent nonetheless.
Two other key principles include:
Do what works! Rather than doing what you think should work or what people tell you is the “right way” of doing things; do what works for you! What is your wise mind saying will work best for YOU and the situation?
Take a non-judgmental stance.
When we approach something with judgment, we have an idea of how it “should be.” This puts us in a place of active denial of how it actually is. It’s much more effective to say, “This is how it is right now, and it is not working.” When we are in that non-judgemental place, it may not be pleasant, joyful, or peaceful, it’s just a fact. It allows us to be more effective in addressing the problem.
A non-judgemental stance helps us creatively address our own needs. When we’re in a space of judgment, we tend not to do things that take care of our needs effectively. For example:
“I should be able to get through this just fine.”
“I should be able to work through this day just fine.”
“I should be able to function.”
“I shouldn't be struggling this much with these feelings.”
Instead of managing, soothing, or problem-solving our needs, we moved toward doing nothing and continued to suffer. Not only is this wildly ineffective because nothing changes, but it’s also extremely painful and self-invalidating to hold ourselves in this way.
Holding a non-judgemental stance for ourselves is crucial as survivors. It enhances self-validation, helps us combat internalized gaslighting, and helps us build self-compassion to heal.
DBT Prolonged Exposure:
DBT Prolonged Exposure is a behavioral intervention for PTSD that engages some cognitive behavioral therapy. However, DBT prolonged exposure protocol differs from that of general prolonged exposure.
When discussing behavioral focus, we primarily focus on understanding the behavioral cycle we engage in, AKA the cognitive triad (thoughts → feelings → behaviors). This cycle is how behaviors get reinforced, how the environment responds to behaviors in a way that either reinforces or punishes them.
We use this principle to make changes and help people meet their recovery goals.
Essentially we’re using the mechanism of exposure, which means reexperiencing triggering events in a safe, moderated way to build habituation.
Habituation is when the brain gets used to the triggering stimuli and no longer sends out alerts that activate the individual. The theory is that when our brain becomes accustomed to experiencing these memories, it helps move them into long-term memory rather than keeping them in the present moment.
2 primary forms of exposure:
Imaginal Exposure = person is visualizing the traumatic experience.
Imaginal exposure is the primary mode that is used for processing trauma memories. It can happen in session as well as out. This is usually done verbally, where the client is asked to close their eyes, visualize the scene, and then recite what is happening aloud using descriptive present-tense language. This process gets repeated over and over.
The client records themselves in session and listens to that recording outside of session.
This process is set up with a therapist, so safety parameters are around it.
In Vivo Exposure = person exposes themself to something triggering in real life.
This is specific to things and experiences the individual has avoided due to their trauma, which they want to work on not avoiding.
We’re rewiring the brain so that it is no longer associating that triggering thing with the trauma but with normal everyday experiences because they’re doing it repeatedly.
For example, if someone is terrified to take their trash out because something dangerous happened to them while doing this, they may feel exposed, vulnerable, and at-risk in a way, so they never take the trash out but want to make sure they can do this again. In vivo exposure is what they can do out of session where they practice taking the trash out repeatedly, allowing the stress to rise and fall.
This method gets discussed in an exposure hierarchy. The individual will talk with a therapist and rank exposure items that are low distress all the way up to what is high distress. You’ll start exposing yourself to each item, beginning at the lower levels and working your way up to the higher levels until habituation occurs at every level.
A solid sign that habituation has occurred is when there’s no emotional or physiological activation; sometimes, people even become bored with the activity.
Ultimately, the goal is to reduce avoidance and generalization of fear that happens in the world with trauma. When a trauma memory gets triggered, we want it just to be a regular occurrence in the brain.
Whenever we notice something in the world or our senses pick up on something, relevant memories are commonly activated. Sometimes those memories are trauma memories. When we’re habituated to those trauma memories, our brain will no longer recognize them as distressing, and we can release and let go without intense trauma symptoms.
In the practice of prolonged exposure, we’re activating trauma emotions, allowing them to come, rise, spike, and resolve naturally.
With Dialectical Behavior Therapy Prolonged Exposure (DBT-PE), we must first get stable and grounded with DBT practices. We will do an entire year of adherent and comprehensive DBT untile there are no longer any risks of life-threatening or therapy-interfering behaviors. Once that initial therapy is complete, we shift into prolonged exposure sessions.
The idea is that clients are not using their learned skills during the exposure to regulate their emotions. This is what feels unusual.
This is because when we use skills during a trauma exposure, it's potentially activating avoidance rather than habituation. The idea is that during the exposure activity, whether that's the imaginal activity in session, listening to the audio outside of session, or engaging in the in vivo exercises, that period of time the individual is not using any skills to regulate their emotions. Outside of those exposures, they are able to use those skills and allow emotions to come, rise, peak, and fall naturally.
Typically, as symptoms rise, peak, and fall naturally, especially with trauma exposure, it is commonly followed by grief. It is okay to use skills to process and manage the grief, seek support, and allow grief to come because after grief comes, there is acceptance.
One of the things that sit with me about prolonged exposure without the DBT component is that it’s a very risky intervention. The results and research are somewhat controversial. Many people, especially from the DBT camp, disagree and feel that prolonged exposure is highly effective. It has the highest efficacy rate of any of the interventions. Still, we have a lot of anecdotal evidence talking about how painful/difficult it is, which is why it is somewhat problematic.
Prolonged exposure has a high attrition rate, meaning people drop out of this frequently because we expose them to something incredibly painful and activating. For many people, that can increase avoidance to the point where they can’t continue the therapy.
This could mean that we started with an exposure that was too high or intense, but the prolonged nature of it and how we are having the client engage in it can also activate that. This has the potential to get people out of their window of tolerance quickly and actually activate a re-traumatization.
By adding DBT, the retention rate is higher, people can hang with it longer, and they can remain a little more regulated, but it is still considered to be a really intense intervention.
DBT Trauma Therapy
DBT trauma therapy, even without prolonged exposure, can be a powerful intervention for healing trauma.
What I like about DBT trauma therapy is that it teaches us very concrete skills on how to manage really painful, uncomfortable symptoms. It also teaches us how to reengage in our life and mindfully focus on what matters to us. We can do that without actually having to engage in any trauma processing.
We might choose to do that down the road, but you don’t have to do any trauma processing to recover from trauma and feel a change.
If you have any experiences with DBT trauma therapy, let me know in the comments. I’d love to hear them!
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