How Does Dialectical Behavior Therapy For PTSD Work?

Dialectical behavior therapy (DBT) is a type of psychotherapy used to treat various mental health conditions, including borderline personality disorder (BPD) and other personality disorders, eating disorders, depression, and anxiety. DBT may also be an effective treatment option for post-traumatic stress disorder (PTSD) and complex PTSD (c-PTSD), as evidenced by a growing body of findings from various randomized clinical trials.

What is PTSD?

Posttraumatic stress disorder is a serious mental health condition that can develop after a person has experienced or witnessed a traumatic event. Common examples of traumatic events that may lead to PTSD symptoms include surviving a violent crime, experiencing an accident, surviving a natural disaster, or living in a war zone as a civilian or soldier. Surviving violence like physical or sexual assault or experiencing childhood abuse are some other events that could lead to post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) symptoms can vary over time and from one person to the next. One person may experience completely different symptoms from another, even if they have had similar or the same traumatic experiences. Symptoms of PTSD include physical and emotional components and can significantly harm a person’s relationships and overall functioning. Treatment usually consists of therapy—like cognitive processing therapy or dialectical behavior therapy—sometimes in combination with medication.

Common symptoms of PTSD

Below are some of the most common physical and behavioral symptoms of post-traumatic stress disorder (PTSD): 

• Flashbacks

• Recurring memories of the event 

• Reckless or risky behavior

• Self-destructive or self-harming behavior

• Difficulty with concentration or memory involving the traumatic event 

• Nightmares

• Insomnia 

• Avoiding thoughts, memories, or feelings associated with the traumatic event

• Holding negative beliefs about oneself or the world, such as “I am fundamentally flawed and damaged” 

Below are common emotional symptoms of post-traumatic stress disorder (PTSD): 

• Intense feelings of distress caused by memories or thoughts related to the event

• Loss of interest in previously enjoyed activities 

• Feeling detached from relationships with others

• Difficulty experiencing happiness or satisfaction

• Persistent feelings of fear, horror, anger, guilt, or shame

• Irritability, which can result in verbal or physical aggression

• An exaggerated startle response

• Feelings of guilt, often related to self-blame for the event or feeling that one could have acted differently to prevent it 

The four key components of dialectical behavior therapy

Dialectical behavior therapy (DBT) for PTSD is an evidence-based type of therapy based on the concepts in cognitive behavioral therapy with an emphasis on helping individuals learn to better control and tolerate their emotions. 

Dialectical behavioral therapy focuses on developing four key coping skills for processing intense emotions: mindfulness, emotion regulation, interpersonal effectiveness, and distress tolerance. 

Because involuntary and distressing emotions are a hallmark of PTSD, these four skill areas may be useful for individuals with this condition. For example, findings from a randomized clinical trial published in JAMA Psychiatry in 2020 suggests that DBT treatments may reduce PTSD symptoms in survivors of childhood sexual abuse. Below are some of the theories and techniques involved in each module of DBT. 

1. Mindfulness

The mindfulness module of DBT involves learning to focus on the present moment instead of ruminating on the past or fixating on the future. Mindfulness practices often highlight ways to connect your mind to your body through deep breathing exercises, meditation, yoga, or labeling emotions.

Mindfulness may be a key component of coping with PTSD, as one of the most common symptoms associated with the condition is a feeling of disconnection from one’s body, emotions, and relationships. People with PTSD may also believe they are “stuck in the past” and unable to move forward into the future. Mindfulness may help a person let go of the past and experience the present moment, reducing the perceived threat of the past and future.

2. Emotion regulation

The emotion regulation module of DBT builds on skills you can develop through mindfulness practice. Emotion regulation is the process of recognizing and identifying the source of your emotions, focusing on more distressing emotions like shame or anger. 

Emotion regulation can also involve learning to differentiate between a primary emotion, which is an initial reaction, and a secondary emotion, which is often the “reaction to the reaction.” For example, you might experience sadness first, with embarrassment about your sadness following. 

Emotion regulation is not necessarily about identifying your emotions to dismiss or suppress them. Rather, emotion regulation aims to help clients fully feel their feelings while understanding that their feelings do not have to determine their thoughts or behaviors. Emotions can be intense but can be separated from your mind. 

Practicing emotion regulation may help with two of the most persistent symptoms commonly associated with PTSD: experiencing recurring and involuntary distressing emotions and intentionally avoiding aspects of one’s life that may recall emotions associated with the traumatic event. Learning to fully feel your emotions after experiencing trauma can seem overwhelming, but it may be a valuable step toward feeling more in control of yourself. 

3. Interpersonal effectiveness

In the interpersonal effectiveness model, an emphasis is made on better understanding your interactions with other people. Developing solid interpersonal effectiveness skills can mean learning about and practicing the components of healthy relationships, including open and assertive communication, understanding and respecting yourself and others, and knowing the value of setting and holding boundaries. Implementing interpersonal effectiveness may lead to stronger and healthier relationships. 

When it comes to relationships, a healthy and resilient support system can be helpful for individuals with borderline personality disorder symptoms or PTSD symptoms—particularly those associated with negative self-beliefs and guilt. Connecting with others can help you gain a new perspective, make new memories, find joy in the present, and cultivate hope for the future. That’s why some DBT sessions may be held in a group format, allowing individuals to connect with others with similar symptoms or concerns. 

4. Distress tolerance

Distress tolerance is one of the key areas of resilience that dialectical behavior therapy focuses on developing. Distress tolerance involves increasing a person’s ability to successfully navigate intense or stressful situations and the emotions one may experience as a result. A component of distress tolerance is learning to recognize which aspects of a situation you have control over and which are beyond your control. 

Increasing distress tolerance skill knowledge may help a person reduce their PTSD symptoms over time. Some aspects of PTSD—including hypervigilance, startling easily, or seeking distractions through risky behaviors—may be related to the trauma survivor’s desire to anticipate and avoid intense emotions. Developing the ability to process such emotions instead of avoiding them could allow a person with PTSD to re-engage in activities they have been avoiding. 

Finding support for PTSD

Post-traumatic stress disorder is a complex mental health condition that can be immensely difficult to navigate independently. Without treatment, symptoms are unlikely to resolve on their own. That’s why it’s recommended that you seek professional support from a licensed mental health counselor if you’re experiencing symptoms of post-traumatic stress. 

If you have difficulties with flashbacks or intense feelings of fear that make it difficult to leave the house or commute to a new setting, online therapy for posttraumatic stress through a platform like BetterHelp may be an effective treatment option. Through an online therapy platform, you can meet with a therapist remotely from the comfort of your home or anywhere you have an internet connection. Research from clinical trials suggests that online therapy can be as effective as in-person therapy in addressing symptoms of post-traumatic stress disorder in many cases.