Individuals with PTSD often present to treatment with multiple, severe comorbid problems such as suicidal and self- injurious behavior, severe dissociation, substance use, and personality disorders. In fact, 66% of individuals with PTSD have two or more comorbid dis- orders and up to 30% attempt suicide. Unfortunately, these types of high-risk and multi-problem clients are often unable to access effective PTSD treatment. These individuals are often excluded from PTSD treatments due to their severity, and treatments designed for this population such as Dialectical Behavior Therapy (DBT)1 have not typically targeted PTSD. When not treated, PTSD increases the risk of suicidal and self-injurious behavior and is likely to interfere with achieving recovery.

The DBT Prolonged Exposure (DBT PE) protocol was developed by Dr. Melanie Harned specifically to treat PTSD among high-risk and multi-problem clients who are receiving DBT. The DBT PE protocol is based on Prolonged Exposure therapy2 and was adapted to fit the needs of this complex client population. DBT with the DBT PE protocol is a comprehensive treatment designed to help these tremendously suffering individuals recover from trauma and build lives worth living.

The DBT PE protocol is now an important part of standard DBT for clients with PTSD. All DBT clinicians need to learn how to deliver this new and highly effective protocol.

Dr. Marsha Linehan, DBT Treatment Developer

Special points of interest

  • DBT with the DBT PE protocol is a comprehensive treatment for high-risk, multi-problem, and difficult-to-treat clients with PTSD.
  • The treatment has been delivered and researched in outpatient, intensive outpatient, and residential settings with adults and adolescents.
  • Research indicates the treatment is feasible to deliver, acceptable to clients, safe, and effective in reducing PTSD, suicidal and self-injurious behavior, dissociation, shame, guilt, depression, and social impairment.

The treatment is delivered in 3 stages.

Stage 1

Stage 1 consists of standard DBT including weekly individual therapy, group skills training, therapist consultation team, and between-session phone coaching. The focus in Stage 1 is on helping clients achieve control over life- threatening and other severe behaviors, and increasing behavioral skills in the areas of emotion regulation, distress tolerance, mindfulness, and interpersonal effectiveness.

Stage 2

Once clients have achieved sufficient stability, Stage 2 focuses directly on treating PTSD. The DBT PE protocol is delivered in weekly 90-120 minute therapy sessions while clients continue to receive all modes of DBT.

Stage 3

Once the DBT PE protocol is complete, Stage 3 uses standard DBT to address any remaining problems in living. Often the focus of Stage 3 treatment is on improving relation- ships and increasing valued activities such as work or school.

Avoidance is a major factor that maintains PTSD and prevents recovery. There are two ways that people with PTSD typically avoid. The first is trying to push away memories, thoughts, and feelings about the trauma. The second is avoiding situations, people, and objects that are reminders of the trauma. Although avoiding trauma-related thoughts and situations works to reduce distress in the short run, it actually prolongs and intensifies post-trauma reactions in the long run. The DBT PE protocol aims to help clients stop avoidance and instead confront trauma- related thoughts and situations so that trauma can be effectively processed. To do this, the DBT PE protocol uses two types of exposure.

Imaginal Exposure

Imaginal exposure involves revisiting the traumatic experience in one’s imagination and describing it out loud during therapy sessions. Imaginal exposure to the traumatic memory is very effective in reducing trauma- related symptoms and helping to gain new perspective about what happened before, during, and after the traumatic events.

Imaginal Exposure

In vivo exposure means confronting avoided situations “in real life.” Clients are asked to gradually approach situations that they have been avoiding because they remind them of the trauma. In vivo exposure has been found to be very effective in reducing excessive fears and avoidance after trauma.

DBT+DBT PE has been evaluated as a 1-year outpatient treatment in an open trial (n=13)3 and a randomized controlled trial (n=26)4 conducted in a research clinic. Clients were recently suicidal and self-injuring adult women with PTSD and an average of 6 additional diagnoses including borderline personality disorder.
Pilot studies in community outpatient, intensive outpatient, and residential settings with men and adolescents have also shown promising results.

  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.
  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 Dialectical Behavior Therapy Prolonged Exposure protocol. Behaviour Research and Therapy, 50, 381- 386.
  4. Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014). A pilot randomized controlled trial of Dialec- tical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD. Behaviour Research 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.

Melanie Harned, Ph.D., ABPP
Research Director, Behavioral Research and Therapy Clinics Box 355915
University of Washington Seattle, WA 98195
Email: mharned@uw.edu Tel: 206.616.1542

Download The DBT PE Info Sheet