DBT-PTSD for treating cPTSD with complex dissociation

DBT-PTSD, also called DBT-PE, is a relatively new 12-week inpatient program designed to treat cPTSD with severe comorbid disorders like dissociation. It combines elements from classic DBT with Prolonged Exposure (PE) as trauma confrontation technique.

 

In a nutshell

Before starting:

You will be tested, if you meet the criteria. DBT-PTSD is aimed at people with childhood trauma and co-morbid disorders like borderline personality disorder, depression, self-harming behavior and severe dissociation. If you have a problem with addiction, a severe eating disorder, manic episodes, severe self-harming behavior, suicidal tendencies or severe risk-seeking behavior, you can’t take part. You need different therapy to gain more stability first.

 

Weeks 1-3:

You will look at all the things that might be in the way of successful trauma work. This includes your motivation and secondary gains, avoidance, depression, escape strategies like running away, dissociation etc. You will start with mindfulness, a Skills group and physical exercise to learn the coping skills you need for the exposure. You sign a contract where you promise not to use dissociation anymore. If you do it anyway, it is considered sabotage that will have consequences. You will be isolated from warm personal contact with the team until you have finished your behavior-chain-analysis about why you dissociated and how you can stop it in the future.

 

Weeks 3-10:

You will improve your DBT skills to avoid dissociation, learn discrimination, face difficult emotions like shame, guilt or disgust (2 weeks). Then you will start into the “skill-supported exposure” phase. You go through the details of your worst traumatic memory with your T while they keep you aware of the present reality. You will record this session and listen to the recording every day on your own.

It is called “skill-supported” exposure because you will struggle to stay within your window of tolerance and need to use DBT skills throughout every sequence to stay present. The exposure won’t work if you dissociate. After about 5-8 sequences the intensity of the suffering goes down and you have reprocessed this memory. There might be time to process another scene. It is possible to add imagery work to reduce nightmares, body work or other techniques specific to your problems in this phase as well.

 

Weeks 10-12:

You will look at the life you will return to after treatment. If there are problems in relationships or concerning work, avoidance or anxiety, you can work through them now.

 

6 weeks after treatment:

You will get homework to do during this time and a final appointment to reflect on your progress.

You need a T who will keep working with you afterwards.

 

 

---

 

A personal commentary

[please note that I am biased by my own experience with this approach]

 

The value of DBT for cPTSD

I took part in the classic DBT program twice. It taught me to sense my numbed emotions again (find out how), to identify and regulate them. I learn Skills for the body and mind that helped me to eliminate 98% of my self-harming behavior and a lot of depersonalization and derealisation. I was introduced to the window of tolerance that I consider key to proper trauma treatment, learned mindfulness, discrimination and work with cognitive errors, that can be crucial for helping parts stuck in trauma time. There is great value in these things.

 

Time frame

I needed 24 weeks of classic DBT and then another 6 years of practice to establish the tools throughout my DID system. I have a tested IQ of 132. It needs extremely special patients to learn all this within a few weeks like the program suggests.

I guess if it was designed to happen in intervals, 12 weeks of skill training, a break to establish it, then returning to the clinic for exposure, that might actually work for real, living patients.

 

 

View of dissociation

DBT-PTSD is built on the belief that all dissociation can be controlled. If you dissociate although you learned the “right technique” – DBT Skills – to avoid that, it will be seen as sabotage, as unwillingness to comply to the therapy process and you will be punished. This is an oversimplified view of dissociation and promotes DBT Skills as cure-it-all. They are not.

While DBT Skills are often helpful when it comes to depersonalisation and derealisation, they lose their edge as soon as we are dealing with structural dissociation. (Leading DID experts about the differences)

 

The problem of structural dissociation

We have yet to meet someone with cPTSD who did not show a personality structure of an ANP and at least one EP. The ANP will often enter dissociation to avoid the inner experience of the EP(s). Using DBT skills to remove this dissociation will force them into contact with the EP(s) and flooding with traumatic memories. Pulling down dissociative barriers might result in psychosis. More commonly the patient will dissociate, no matter what. The severe aversive stimulation might even provoke more dissociation. The avoidance of the inner experience needs to be approached differently and with great care. Establishing ego state work and inner communication will stop the dissociation that is based on avoiding EPs.

Read more about DID-specific struggles with DBT Skills in Why DBT skills don’t work

DBT-PTSD assumes that dissociated parts can be controlled and their behavior shut down at will. I want to share a personal experience we had because of this assumption. This is triggering. Don’t read it if you are not fully grounded and able to keep a distant position.

I told the T about X, who got involved in unsafe behaviors. The T said that I need to “stop following the old patterns and start to walk new paths“. She said that I need to take X and “cut off her hands and feet, push in her eyes and sew shut her mouth and place her on the top of the bookshelf to forget about her“. X panicked in fear of death. She had witnessed situations where hands and feet were removed from corpses. Stuck in trauma time she was not able to understand that this was a figure of speech. Shortly after the session ended she switched to the front and ran away from the clinic. She ran until the body was too exhausted to keep moving. We came to in an unsafe neighborhood miles away from the clinic. When we finally made it back we were asked to write a behavior chain analysis about the dissociation, amnesia, escape behavior and getting into a dangerous situation, to find out the reasons why we couldn’t prevent X from running away and what we could have done to stop her. We were taught how to make it difficult for her to front (it turned out to be impossible to stop her altogether), not how to reduce her fear. The trauma-connection was fully ignored, the behavior confronted out of context.

(About 3 years later and with different treatment it turned out that X was stuck in trauma time and didn’t have crucial information about today. When she learned about the present she dropped her tricky behavior within a day)

I believe that DBT-PTSD is a dead-end for patients with structural dissociation. It treats structural dissociation as an unwillingness, not an inability. Not making a distinction here will result in abuse. Control is the wrong tool.

We have adapted the DBT behavior chain analysis to DID by adding ego state aspects, changing the focus from control to inner relationships. You can find it over here.

 

 

Isolation

I believe that the other major flaw in this treatment program is the repeated isolation patients will experience.

 

DBT and isolation

This behavioral therapy approach is heavy on reinforcing wanted behavior and discouraging unwanted behavior through social interaction and emotional warmth. If you show unwanted behavior, warm contact with the team with be removed. You will be left alone to write an analysis about your problematic behavior and how to do better next time. While this might provide valuable insight, it also repeats traumatic relationship patterns that we learned in our childhood: that warmth will be removed and we have to stay alone with our pain. This procedure will reinforce trauma patterns even more than teaching the patient to dissociate less. Compliant behavior might be the attempt to avoid more emotional trauma and abandonment.

 

DID and isolation

The program sees uncontrolled switching, and especially child parts popping out, as part of the dissociation that „can be controlled“ and as attention seeking behavior that needs to be discouraged. The therapeutic tool used is withdrawal of relational warmth and connection. Most systems I personally know don’t switch, especially not to child parts, unless they face a serious crisis they cannot handle. Being abandoned in this situation is terrible. A system might even create a new, compliant part just for the treatment team, to avoid being punished and isolated. There is also a chance that DBT skills, strong aversive stimulation, will be used on child parts to force a switch back to an adult. This is abusive.

 

Prolonged exposure and isolation

PE means one recording session with the support of a T and then having to expose yourself to it all by yourself. The trauma relief will happen somewhere between the 5-8 exposure, not in the session with your T. Especially with childhood and relational trauma the presence of a caring and safe other is key to healing. Not to the reprocessing of memory, that works well enough with PE, but to rewrite the history of relational trauma. „Relational trauma requires relational repair“. cPTSD is a lot more than just trauma memories. Leaving a patient alone during exposure means that relational trauma patterns will be reinforced at the same time as memories are processed.

If you have structural dissociation you will be left alone with struggles that might arise with EPs and the only tool you were taught are DBT skills to shut them down instead of helping them in a compassionate way.

Trauma work for DID always means including all parts that were involved with a certain memory, so that you can put together the puzzle of all BASK components of the memory. You also need to keep all parts inside your window of tolerance, all by yourself. If you are supported by a nurse, she will help you with the Skills, not with your System.

I cannot see a DID system actually doing this successfully. I doubt that we could pull it off and we have 10 years of experience with DBT skills. PE is simply the wrong technique.

 

 

Trauma through treatment

The measures taken to avoid dissociation during PE are extreme. Sometimes they are humiliating. Please be aware of the triggering potential of the following example.

Y was close to the front. He is 5, autistic, scared and mute. The nurse made it her goal to make us speak. She asked us to step on a balance board and threw balls at us that we were supposed to catch but couldn’t. In between she made us smell ammonia and asked us to solve math problems. Y got scared by the math problems he couldn’t solve. Because he was stuck in trauma time he expected terrible punishment for not being able to obey. The intense sensory stimulation of the ammonia overwhelmed him and made him go into complete autistic shutdown. The dissociation got worse so that we fell off the balance board and onto our face several times. The situation was ended, after what seemed like eternity, by a switch and someone older fronting. Y is phobic of clinics and nurses to this day.

(We found out that he fronts when he gets very scared and that sitting him down to draw in a place with limited sensory stimulation helps him to calm down. He will then let go of the front all by himself and make room for older parts again.)

This was not even a PE situation, just something that happened during treatment. I believe that especially when it comes to traumatized patients, protecting dignity is crucial.

 

Trauma patterns

DBT-PTSD is training patients not to show their symptoms anymore. The way this is done, using withdrawal of social contact and aversive stimulation, is close to what some severely traumatized patients call their trauma experience: sadistic training by abusers. It doesn’t help to explain to the patient that this is “not punishment” and supposed to help them. Abusers use techniques from behavioral therapy to create certain behavior in their victims and the same tools, only a little less painful, are now used on the patient again. It will deepen the trauma pattern.

I am also concerned about the way dissociation and other coping strategies are condemned. The way isolation is used to discourage such behavior causes feelings of guilt and shame to arise in connection to our symptoms, and that includes switching and having parts. It doesn’t help, but now we are also ashamed of what we are.

DBT was developed for chronically under-controlled patients. Many survivors tend to be over-controlled and treating them with the aim of increasing control is not helpful. They need to be treated with the goal of safe connection.

 

 

Is it worth it?

This program needs an especially trained team to pull it off and it is very costly. It also seems to need a special kind of patient to make it work. It is severely painful, using the hardest tools out there for trauma work. All this for maybe working through one or two traumatic memories, while risking to be harmed in all kinds of ways if you have structural dissociation. You need to decide if this is worth it.

 

Research

Studies show that DBT-PTSD works. Memories can be processed this way.

Let me put it like this: You can look at your silverware and decide that you like the spoon. It is a great tool. You can then decide to use it to remove an appendix by sharpening the edges really well and perform surgery with it. Then you do research with appendix patients and compare those who had it removed with a sharp spoon with those who didn’t get any treatment at all and get scientific evidence that sharpened spoons can reliably be used to perform appendix surgery. Does that make a sharpened spoon the right tool? Or can we find other silverware that would be more appropriate for this job?

There is a growing number of Believers in spoon-surgery out there. It is my strong conviction that Believers, in any technique actually, don’t make good trauma Ts. All techniques fall short, but I believe that this one falls so short, it might become one of those chapters in the history of therapy that will cause future generations to shake their head in horror and disgust.

 

 

 

[Opinions are all mine. They are obviously “emotional” and based on experience, not science. If you want to prove me wrong, offer me a different experience]

Back to Phase 2: Trauma Work

How Integration of structural dissociation actually works