A Treatment Programme For Complex PTSD PDF

DBT–PTSD: A Treatment Programme for Complex PTSD After Childhood
Abuse
Oxford Handbooks Online

DBT–PTSD: A Treatment Programme for Complex PTSD
After Childhood Abuse
Martin Bohus and Kathlen Priebe
The Oxford Handbook of Dialectical Behaviour Therapy
Edited by Michaela A. Swales
Subject: Psychology, Clinical Psychology Online Publication Date: Apr 2018

DOI: 10.1093/oxfordhb/9780198758723.013.48
Abstract and Keywords
In addition to the core posttraumatic symptomatology such as s trauma-related

intrusions, avoidance, and hyperarousal, patients with complex PTSD related to childhood
abuse often also exhibit distortions of emotion regulation, pervasive negative self-
concepts, and difficult interpersonal relationships. DBT-PTSD is a comprehensive
multicomponent treatment to specifically focus on the sequelae of childhood abuse with
and without borderline personality disorder. Based on the principles of DBT, it adds
trauma-specific cognitive and skills-assisted exposure-based techniques and interventions
to improve acceptance as well as compassion for self and others. It has been developed
for and tested in both a three-month residential treatment and a 12-month outpatient
programme. The first randomized controlled trial evaluated the treatment under
residential conditions, including borderline patients with ongoing self harm. The second
large multi-centre trial investigates DBT-PTSD under outpatient conditions, compared to
Cognitive Processing Therapy (CPT). This chapter reviews the principles and structure of
this new and highly promising DBT-adaptation.
Keywords: PTSD, childhood trauma, DBT-Stage II, Evidence-based treatments, borderline personality disorder
Key Points for Clinicians
• DBT-PTSD is a safe and highly effective multicomponent treatment programme for

complex PTSD.
• Thus far, there is no evidence that ongoing self-harm is a safety risk or negative
predictor for treatment outcome.
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• Borderline patients with co-occuring PTSD should search for a trauma-focused

treatment.
• In most cases, there is no need for patients with complex PTSD or PTSD and BPD to
complete standard DBT ahead of a specifically designed treatment programme for
treating trauma.
Psychological Consequences of Childhood

Abuse
Identifying the specific psychological consequences of sexual and/or physical abuse in
childhood presents several difficulties, not least because sexual and physical abuse
frequently occur together, often alongside other critical factors such as emotional abuse,
neglect, or violence between parents. Notwithstanding these challenges, the data from
prospective cohort studies and epidemiological studies fairly consistently establish that
sexuale abuse is associated with a multitude of psychological problems in adulthood and
is a nonspecific risk factor for psychopathology in general (Gilbert et al., 2009; Maniglio,
2009). In a New Zealand cohort study, 13% of mental disorders could be traced back to
sexual abuse (Fergusson, Boden, & Horwood, 2008). In an Australian cohort study,
individuals with a history of sexual abuse compared to those without were approximately
2.5 times more likely to exhibit an Axis I disorder (18.4% vs. 7.0%) and five times more
likely to exhibit a personality disorder (3.6% vs. 0.7%) (Cutajar et al., 2010). In a number
of studies, the incidence in people with a history of childhood sexual abuse was increased
for posttraumatic stress disorders (PTSD), depression, sleep disorders, substance-related
disorders, and borderline personality disorders (BPD) (Chen et al., 2010; Cutajar et al.,
2010; Maniglio, 2010). In addition to psychiatric diagnoses, those with a history of
childhood sexual abuse have increased risks for further psychological and psycho-social
problems, for example, dissociative symptoms, interpersonal difficulties, self-esteem
problems, self-harming behaviour, and suicidal tendencies (Chen et al., 2010; Paolucci,
Genuis, & Violato, 2001; Yates, Carlson, & Egeland, 2008; ). On the other hand, about
56% of individuals with BPD meet criteria for co-occuring PTSD, mostly after childhood
sexual abuse (Yen et al., 2002; Zanarini et al., 1998; Zlotnick, Franklin, & Zimmerman,
2002). There is ample evidence that these patients show exaggerated psychopathology
and are more likely to experience chronic problems (Harned, Rizvi, & Linehan, 2010;
Cackowski, Neubauer, & Kleindienst, 2016).
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Symptoms of Post-traumatic Stress Disorder

After Childhood Abuse
Post-traumatic stress disorder (PTSD) is characterized by the re-experiencing of the
traumatic event(s) accompanied by symptoms of increased arousal and by avoidance of
stimuli associated with the trauma. The DSM-IV conceptualized PTSD mainly as a fear
condition and required the experience of fear, helplessness, and horror during the
traumatic event. However, for those with PTSD after sexual abuse, the traumatic
experience and the memories are often associated with emotions of disgust and a sense
of being dirty, as well as shame and guilt, alongside the feelings of fear and helplessness (
Görg et al., 2017). Unlike traumatization in the context of uncommon experiences (such
as traumatization by natural disaster, war experiences, or accidents), sexual abuse is
often associated with everyday stimuli, so that affected persons encounter triggers for
memories everywhere. Thus, the experience of human proximity, intimacy, and sexuality—
a source of joy and happiness for healthy people—is a typical trigger for distressing
memories. Accordingly, the avoidance behaviour relates to precisely these everyday
things such as partnership, intimacy, and sexuality, as well as physical care and medical
visits (mainly gynaecologists, cardiologists, and dentists). From a behavioural
perspective, multiple dysfunctional behaviours (e.g., non-suicidal self harm (NSSI),
suicide ideations, aggressive outbursts, high-risk behaviour, drug and alcohol intake) can
be conceptualized as escape strategies from distressing intrusions or severe dissociative
states.
Patients with PTSD related to childhood sexual abuse often exhibit addional problems
such as emotion dysregulation, dissociative symptoms, and interpersonal difficulties.
Many of them have negative self-concepts, characterized by persistent thoughts of being
inferior, worthless, and unlovable. This rejection often also pertains to their own body,
which they perceive as dirty and disgusting. They find it hard to trust other people or feel
close to others. Against the backdrop of the belief that they are not worthwhile and do
not deserve a loving relationship, sufferers may often remain in dysfunctional
relationships and experience violence again.
This complex picture of PTSD has been described under the terms Disorders of Extreme
Stress Not Otherwise Specified (DESNOS) and Complex PTSD (cPTSD). Both the DSM-5
(APA, 2013) and the upcoming ICD-11 modified the diagnostic criteria of PTSD to
accommodate these more complex presentations. The DSM-5 added symptoms to the
PTSD diagnosis that have frequently been viewed as symptoms of cPTSD, such as
distorted beliefs about self and others, and reckless behaviour, and introduced a
dissociative subtype of PTSD. The ICD-11 proposes a distinct cPTSD diagnosis that
comprises the three core symptoms of PTSD along with enduring disturbances in the
domains of affect, self, and interpersonal relationships (Maercker et al., 2013).
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Data for the Treatment of Post-traumatic

Stress Disorder After Childhood Abuse
Numerous meta-analyses have demonstrated the effectiveness of trauma-focused
psychotherapies (Bisson, Roberts, Andrew, Cooper, & Lewis, 2013Bradley, Greene, Russ,
Dutra, & Westen, 2005; Watts et al., 2013;). The meta-analysis by Watts and colleagues
(2013) included 112 randomized controlled trials and reported a mean effect size of 1.1
for the post-traumatic symptoms, i.e., very effective. There were no significant
differences between treatments focusing on exposure and treatments focusing on
cognitive processing and EMDR (Eye Movement Desensitization and Reprocessing).
Exposure-based procedures include the repeated exposure to the distressing memories in
imagination, and to feared and avoided triggers. Cognitive procedures mainly focus on
identifying, challenging, and modifying unhelpful trauma-related cognitions, e.g., “I am to
blame for the abuse,” “Closeness means danger.” In EMDR, patients are asked to observe
their emerging thoughts, feelings, and body reactions during “bilateral physical
stimulation” (usually horizontal eye movements) without judgment. The results obtained
in the meta-analyses with PTSD-remission rates of about 50–60% indicate that these
treatments works well for many patients with PTSD. Prolonged Exposure (Foa, Hembree,
& Rothbaum, 2007), Cognitive Processing Therapy (Resick, Monson, & Chard, 2016) and
EMDR (Shapiro, 2018) are all well-studied treatment programmes demonstrating good
outcomes. Despite these promising results, there is room for improvement. Regardless of
which treatment programme is used, approximately 20% of patients terminate the
treatment prematurely (Imel, Laska, Jakupcak, & Simpson, 2013). While remission rates
of 50–60% are good, 40–50% of patients continue to suffer from PTSD after
psychotherapeutic treatment.
In addition, it is unclear to what extent the results of these meta-analyses apply to the
treatment of cPTSD, since many studies have excluded patients with symptoms like
suicidal ideation, self-harming behaviour, or substance abuse (Bradley et al., 2005). In a
meta-analysis of treatment studies on the psychotherapy of PTSD after sexual or physical
abuse in childhood, typically associated with more complex presentations, Ehring and
colleagues (2014) report an effect size of 0.72 for post-traumatic symptoms. Dorrepaal
and colleagues (2014) conclude, in their review on the treatment of PTSD following
sexual and physical abuse in childhood, that the studies with patients with cPTSD show
lower PTSD remission rates, higher post-treatment symptoms scores, and lower rates of
clinically significant improvement. In addition, it is still largely unclear whether the
additional symptom domains of cPTSD—that is, problems in the areas of the regulation of
emotions, self-esteem, and interpersonal relationships—improve with classic trauma-
focused treatments.
The absence of sufficient data on the psychotherapy of cPTSD has prompted the
International Society for Traumatic Stress Studies (ISTSS) to conduct an expert survey on
cPTSD (Cloitre et al., 2011). The majority of experts recommended a phase-oriented,
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multimodal treatment. Training in the regulation of emotions and exposure to the
traumatic memory were rated as the most effective interventions. In line with this,
several working groups developed treatment programmes that combine emotion
regulation skills and trauma-focused interventiones. Cloitre and colleages (2002, 2010)
have investigated such a two-phase treatment consisting of eight sessions of emotion
regulation training and subsequent eight-session exposure in two randomized-controlled
trials. In the first study, however, there were a number of exclusion criteria, for example,
BPD and dissociative disorders, and thus probably excluding most patients of cPTSD.
With Dialectical Behavioural Therapy plus Prolonged Exposure (DBT + PE, Harned,
Korslund, Foa, & Linehan, 2012; Harned, Korslund, & Linehan, 2014) and Dialectical
Behavioural Therapy for post-traumatic stress disorder (DBT-PTSD, Bohus et al., 2013Steil,
Dyer, Priebe, Kleindienst, & Bohus, 2011; ), there are now two treatment programmes
combining DBT and trauma-focused interventions. In DBT + PE, patients receive trauma-
focused exposure sessions in addition to standard DBT as soon as they have stopped self-
harming behaviour for at least two months. In an US pre-post study in 13 patients, there
was a significant improvement in post-traumatic symptoms with an effect size of 1.4
(Harned et al., 2012). In a randomized controlled trial (Harned et al., 2014), although
there were significant effects on the post-traumatic symptoms, only eight patients (less
than half) of the 17 patients included received the trauma-specific treatment.
In contrast to the previously highly linearly organized treatment programmes, DBT-PTSD

is based on a modular organization. This takes into account that a large number of
symptom presentations can be present in cPTSD, which are likely to require specific
interventions. In additions, the modular organization allows a more dynamic response to
the highly fluctuating symptoms and the many everyday problems. In the first pre-post
study, which was conducted under residential conditions with 29 females with PTSD
related to childhood sexual abuse, there was an effect size of 1.22 and no dropouts from
treatment (Steil et al., 2011). In a randomized controlled trial including 74 female
patients, also under residential conditions, DBT-PTSD resulted in significantly greater
reductions in post-traumatic symptoms at discharge and three months post-discharge
compared to treatment-as-usual (TAU). The intent to treat between group effect size for
the post-traumatic symptoms was 1.35. Only 5% of the patients (two out of 36)
discontinued the treatment prematurely. Individual analysis did not reveal any symptom
worsening in any subject treated with DBT-PTSD. About 50% of the patients in this study
met DSM-IV criteria for BPD. Patients with ongoing self-harm and severe dissociative
features and suicidal thoughts were not excluded. The last life-threatening suicide
attempt had to have been more than eight weeks past. Post-hoc analyses revealed that
neither the severity of BPD symptomatology nor the number of episodes of self-harm at
the beginning of the treatment influenced the outcome of the therapy. No increase in
suicidal thoughts or urges for self-harm occurred during the exposure phases (Krüger et
al., 2014). Long-term analysis of the data showed highly significant decreases in
admission rates and persistence of recovery one year after discharge (Priebe et al., 2017).
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Based on these highly promising data on safety, feasibility, acceptability, and efficacy
under residential conditions, the treatment programme was subsequently tailored for
outpatient conditions. Outpatient DBT-PTSD comprises up to 45 sessions of individual
therapy. For practical reasons we abstained from a skills group. A pilot study showed
excellent feasibility under outpatient conditions (Steil et al., 2018). Within the scope of a
multi-centre therapy study supported by the German Federal Ministry of Education and
Research (RELEASE project), we conducted a randomized controlled trial to investigate
feasibility, acceptance, and effectiveness of DBT-PTSD under outpatient conditions; 206
female patients suffering from cPTSD after childhood sexual or physical abuse were
randomized to either one year of DBT-PTSD or one year of Cognitive Processing Therapy
(CPT) as designed and supervised by the treatment developer, P. Resick. Data will be
published in 2019. However, thus far (2018), we have found no indications of high drop-
out rates or serious incidents such as suicide attempts in DBT-PTSD—otherwise, we
would not have published this chapter! Even without the final analysis of the outpatient
study, currently available data converge to suggest that DBT-PTSD has strong empirical
evidence for acceptability and effectiveness in the treatment of cPTSD after childhood
abuse.
Structure and Principles of DBT-PTSD

DBT-PTSD was specifically developed for patients with complex PTSD with and without
co-occuring BPD. The overriding aim of DBT-PTSD is to help the clients to live a
meaningful life in accordance with their own values. Figure 1 provides an overview of the
sources of DBT-PTSD. In addition to trauma-specific cognitive and skills-based exposure-
based techniques, DBT-PTSD comprises a variety of interventions of the so-called “third
wave” of behavioural therapy with elements of DBT (Linehan, 1993a, b), Compassion
Focused Therapy (CFT, Gilbert, 2010) and Acceptance and Commitment Therapy (ACT;
Hayes, 2016). Patients affected by sexual and physical abuse in childhood often cannot
completely revise their cognitive-affective schemata developed early in life. Often
patients have to learn to deal with these problematic schemas and take goal-orientated
action in spite of their fears and their disturbing thoughts. According to DBT’s dialectical
principles, changing emotional and cognitive processing is balanced by a strong focus on
acceptance, metacognitive awareness (observing), and self-compassion. These aspects
play a central role in ameliorating the more persistent symptom areas of cPTSD—i.e.,
components of self-worth.
In addition to the treatment framework, the principles, and the therapeutic approach of
DBT, DBT-PTSD uses many DBT interventions to improve the regulation of emotions. The
identification and description of emotions and thoughts using mindfulness creates an
inner distance (in the sense of “I am not my emotion but I have an emotion.”). The
attitude of ACT that it is more helpful in the case of some thoughts and feelings (so-called
“bodyguards”), not to fight them but to accept them as old and once useful thoughts, has
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proved useful particularly in the case of basic assumptions (in the sense of “I have
learned and familiar thoughts, and I can decide whether I should act in accordance with
these thoughts.”). In addition, ACT provides many helpful interventions for recognizing
and implementing personal values and thus for improving the quality of life. The
strengthening of compassion towards oneself and towards others in accordance with CFT
has proved to be particularly helpful for treating issues in the areas of self-worth and
interpersonal relations.
Click to view larger

Figure 1 Sources of DBT-PTSD.
DBT-PTSD basic assumptions
1. The overarching goal is to empower the clients to live a life according to their
values (life worth living).
2. Currently, trauma-related symptoms, cognitions, emotions, and behaviour hinder
clients in achieving their goals (or even to define their individual values and goals).
3. Thus, the treatment primarily focuses on reduction of trauma-related symptoms,
cognitions, emotions, and behaviour.
4. Most trauma-related symptoms are maintained by either escape or avoidance of
trauma-related primary emotions.
5. The key components of negative self-esteem have been developed as maladaptive
coping strategies to survive feelings of unescapable threat, powerlessness, irritation,
helplesseness, and loss of belonging.
6. The key components of DBT-PTSD are skills-assisted exposure; development of
compassion for self and others; radical acceptance of the past; and developing a life
worth living (in this order).
7. DBT-PTSD is a highly intensive treatment provided by highly trained experts.
8. DBT-PTSD is a treatment in a team.
DBT-PTSD Treatment Phases
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DBT-PTSD is divided into a pre-treatment phase and seven consecutive thematic
treatment phases (Figure 2), which extend over a period of 12 weeks in a residential
setting and comprise up to 45 therapy sessions in an outpatient setting. Each treatment
phase includes mandatory and optional treatment modules. The latter allow tailoring the
treatment to the many different symptom constellations that present in cPTSD. While one
patient in the third therapy phase is focused, for example, primarily on the reduction of
dissociative symptoms, the treatment of the feelings of guilt can be the focus of another
patient. In addition to the chronologically organized treatment process, DBT-PTSD is also
oriented to the dynamic treatment hierarchy as defined by the standard DBT. Whenever
present, therefore, life-threatening or crisis-generating or therapy-interfering behaviours
take precedence.
Pre-Treatment.
Prior to treatment,
diagnosis of PTSD and co-
occuring psychatric
disorders is required. We
recommend the Structured
Clinical Interview for
DSM-5 (SCID-5, First et
al., 2015) and the Clinican-
Administered PTSD Scale
(CAPS; Weathers et al.,
2013). We further require
Click to view larger
an overview of any current
Figure 2 Modular DBT-PTSD with dynamic treatment
hierarchy. crisis-generating
behaviour, including
ongoing self-harm behaviour, suicide attempts, high-risk behaviour, aggressive outbursts,
etc. We recommend the Severe Behavioural Dyscontrol Interview (SBD; Bohus, 2011) for
this purpose. In case of a life-threatening suicide attempt within the last six weeks, we
apply a short version of individual DBT in order to figure out the main reasons for this
suicide attempt and clarify whether the related problems are still of relevance, can be
solved, or can be coped with using specific individualized skills. Ongoing NSSI,
parasuicidal behaviour, suicidal ideation, or severe dissociative states are no reason to
exclude patients from this treatment. As a next step, we educate the client about the form
and function of the treatment and work on a non-suicidal contract. The latter includes a
promise, mostly in the form of a written contract, not to committ suicide during the
therapy phase and—under residential conditions—for six months after discharge from the
unit. In return, clients are offered telephone consultation to assist with managing suicidal
crises according to the standard DBT suicide crisis protocol.
Commitment phase.
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During this phase, we conduct a short biographical and medical history, explore the
individual’s PTSD presentation, and orientate our clients to the treatment and try to
understand the experience and potential problems with previous psychosocial treatments.
Clients are informed about the basic concept of mindfulness exercises and encouraged to
practise mindfulness daily for at least ten minutes, based on MP3 file mindfulness
instructions, read by their therapist.
Motivation and planning.

This second phase begins with a short overview of the circumstances of the major
traumatic events: “What happened to you? At which age did it happen? Who was
involved? Who was informed? Did you have any emotional support? When and why did it
end? And how did the perpetrator(s) frighten and intimidate you not to report to
anybody?” The focus in this early phase is not to elicit strong emotional responses, but
rather to encourage the clients in speaking openly about previously taboo subjects with
their therapists. A longer focus on motivational issues follows helping the clients to clarify
their personal values and to formulate specific, measurable, attainable, relevant, and
time-bound (SMART) treatment goals. The central question is: “How would you create
your life if you were not hindered by PTSD symptoms.” In order to avoid problems in the
therapeutic relationship based on replicating patterns in previous significant
relationships, we briefly assess the characteristics of significant others like the mother,
father, or siblings of the client. One further important topic is the development of an
individualized trauma-model including explanations of form and function of trauma-
networks (i.e., relative fixed associations of trauma-related thoughts, emotions, and
somatic experiences), initiating cues, maladaptive mechanisms of avoidance and escape,
including behavioural (e.g., self-harm), emotional (e.g., guilt, dissociation), and cognitive
strategies.
Skills Acquisition.
Due to lack of a group, in DBT-PTSD skills are taught by the individual therapist. We
selected a small number of essential skills: anti-dissociation skills (e.g., balance board,
ammonia, ice-packs), distress tolerance skills, emotion regulation of guilt, shame, anger,
and disgust.
Skills-assisted Exposure.
As a first step, the index-trauma (the currently most distressing and shameful memory) is
selected. Next, the patient’s concerns and apprehensions regarding the exposure are
thoroughly discussed and addressed. Central to the fourth treatment phase is in-sensu
exposure to the most distressing memory. In order to keep stress within a tolerable range
and to prevent dissociative symptoms, exposure is based on the principle of skills-assisted
exposure. Through the use of skills, a balance between the activation of trauma-
associated feelings and present relevance is established. This phase typically lasts for
about five to seven sessions per index trauma. After remission, we can process a second
or third traumatic memory.
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Radical Acceptance.
Linehan’s (1993 a, b) radical acceptance requires acceptance of the facts of the past, the
sequelae of past events, and the current emotional response to both of these. Accordingly,
we added a phase of intensively working on radical acceptance at the end of the exposure
phase.
Regain your Life.

Most of our patients experience dramatic changes within a relatively short time frame.
This often revolutionizes the client’s perspective on his/her entire life: Partnership,
sexuality, friendships, supportive systems, occupational conditions—almost every aspect
has to be questioned and re-arranged. Making these behavioral changes requires time
and support.
Farewell.
After such an intensive and life-changing therapy saying farewell is not easy and so we
provide a structured approach to this process.
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DBT-PTSD Interventions
DBT-PTSD in general follows the principles and rules of standard DBT and adds in a set of
trauma-specific interventions such as exposure to the index-trauma. Some additional non-
trauma-specific interventions like “compassion for self and others” or “follow your
values” are in line with the DBT-principles as outlined by Linehan (Linehan, 1993a, b);
however, we elaborated on these concepts to enhance their relevance for this specific
patient group.
In general, the DBT-PTSD manual is designed as a comprehensive and detailed textbook

for therapists, including a set of handouts and worksheets for the patients. The entire
focus is on trauma, avoidance of trauma-related emotions, and related cues, as well as
trauma-related sequelae on self-esteem and self-concepts, including maladaptive guilt,
shame, disgust, self-contempt, and suspiciousness.
The key element of the programme is skills-assisted exposure. Therapists should

thoroughfully prepare these sessions by selecting the appropriate index-trauma(s) (the
currently most distressing and shameful event(s)). Furthermore, they should be familiar
with the key primary emotions (emotions that were experienced during the trauma),
mostly disgust, and other relevant cognitions and sensations, such as powerlessness,
threat, or sexual arousal. Emotions like guilt, shame, and self-contempt are seen as
secondary emotions and mostly function as escapes from primary emotions. Therapists
should actively guide their patients to experience and tolerate the primary emotions. ? We
do not apply classic prolonged exposure (PE) as proposed by Foa and colleagues (2007),
since most patients meeting criteria for cPTSD are highly prone to dissociative features
under stress conditions, and the level of activated dissociative features negatively
correlates with treatment-outcome (Kleindienst et al., 2016). The neural mechanisms
underlying dissociative features are not completely understood. There is ample evidence,
however, that during dissociation the functions of amygdala and hippocampus are blunted
(Krause-Utz et al., 2017; Winter et al., 2015), and therefore emotional learning is
attenuated if not completely inhibited (Ebner-Priemer et al., 2009). Therapeutic in-sensu
or in-vivo activation of traumatic memories induces stress, stress induces dissociative
features, and dissociative features inhibit emotional learning. To facilitate emotional
learning during stressful in-sensu exposure, therapists apply anti-dissociative skills. Any
kind of strong sensory input can be used as anti-dissociative skills: loud noise, pain
(ammonia), cold temperature (ice-cubes), eye-movement, as well as proprio-sensoric
stimuli as balancing boards, or even juggling. Most patients are rather creative and
quickly learn to find their own techniques to also inhibit dissociative symptoms when
listening to the audiotaped exposure-sessions at home.
In most cases, five to seven exposure sessions should be sufficient to reduce the
frequency and the distress of index-related intrusions and nightmares. Secondary trauma
related emotions like guilt, shame, and self-contempt or self-hatred need more specific
interventions. We use a combination of psycho-education, meta-cognitive training and
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compassion-based interventions to address these issues. The results for this approach are
quite convincing: the three-month residential programme resulted in a strong decrease of
guilt, shame, and disgust. By the end of the intervention 82% of the patients had achieved
a level of trauma-related guilt (shame 67%; disgust 51%) that resembled the level of a
healthy control group (Görg et al., 2017, Görg et al., in prep).
The standard DBT manual provides no specific interventions for changing habits or
creating a life worth living. Chain—or behavioural analyses—are helpful tools to
understand and modify maladaptive behaviour such as self-harm, suicidal thoughts, or
aggressive outbursts. However, when it comes to modify your patient’s sexual sensitivity,
to encourage seeking a nicer partner, or applying for a better job—chain analyses are of
little help. We found a useful and practical solution in a recently developed ACT tool—the
Matrix (Polk, Schoendorff, Webster, & Olaz, 2016). The Matrix is a simple-to-use format
developed initially for groups, but subsequently utilized with individuals. Based on an
original idea by Kevin Polk, the Matrix discriminates between direct experiencing with
the senses and indirect experiencing in the mind encouraging clients to sort behaviour
into two categories, broadly described as “Towards” whom or what is important to us,
and “Away” from what we want to avoid feeling or thinking. Therapists orientate clients to
the difference between five-sense experiencing and observable behaviour—which is the
immediate experience we have of the world outside, and inner experiencing—which is the
world of the mind and emotions. Using a diagrammatic format, the Matrix helps clients
rapidly develop clarity about these differences and move toward valued living, also known
as psychological flexibility.
The focus of the Matrix is more on dragging out new behaviour than on analysing
hindering cognitions and emotions. DBT skills can be used as both mental reminders and
motivators as well as functional behaviour.
Summary
With DBT-PTSD, a treatment programme is available that is specifically tailored for the
needs of patients with complex PTSD and/or borderline patients with co-occuring PTSD.
The treatment has proved to be effective and safe under residential and outpatient
treatment conditions. Training in DBT-PTSD requires four days, plus one supervised case
for therapists who are already experienced in standard DBT.
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Page 16 of 17

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Martin Bohus
Prof. Dr. Martin Bohus, Central Institute of Mental Health; Medical Faculty
Mannheim; Heidelberg University; Germany
Kathlen Priebe
Kathleen Priebe, Dipl Psych, Institute of Psychiatric and Psychosomatic

Psychotherapy; Central Institute of Mental Health, Mannheim, Heidelberg University,
Germany
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What psychological consequences are associated with childhood abuse?

What psychological consequences are associated with childhood abuse?

What treatment programme is described for complex PTSD?

What treatment programme is described for complex PTSD?

DBT–PTSD: A Treatment Programme for Complex PTSD After Childhood

Oxford Handbooks Online

Subject: Psychology, Clinical Psychology Online Publication Date: Apr 2018

Abstract and Keywords

In addition to the core posttraumatic symptomatology such as s trauma-related

Key Points for Clinicians

• DBT-PTSD is a safe and highly effective multicomponent treatment programme for

Subscriber: Tufts University; date: 28 July 2018

• Borderline patients with co-occuring PTSD should search for a trauma-focused

Psychological Consequences of Childhood

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Symptoms of Post-traumatic Stress Disorder

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Data for the Treatment of Post-traumatic

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In contrast to the previously highly linearly organized treatment programmes, DBT-PTSD

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Structure and Principles of DBT-PTSD

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DBT-PTSD basic assumptions

DBT-PTSD Treatment Phases

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Motivation and planning.

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Regain your Life.

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In general, the DBT-PTSD manual is designed as a comprehensive and detailed textbook

The key element of the programme is skills-assisted exposure. Therapists should

Subscriber: Tufts University; date: 28 July 2018

Subscriber: Tufts University; date: 28 July 2018

Bohus. M. (2011). Checkliste zu schweren Störunegn der Verhaltenskontrolle (SBDI). In:

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Gilbert, P. (2010). Compassion focused therapy. New York: Routledge.

Görg et al. in prep. Changes in Trauma-related Emotions following Treatment with

Subscriber: Tufts University; date: 28 July 2018

Linehan, M. M. (1993a). Cognitive Behavioral Treatment of Borderline Personality

Subscriber: Tufts University; date: 28 July 2018

Shapiro, F. (2018). Eye movement desensitization and reprocessing (EMDR) therapy,

Zlotnick, C., Franklin, C. L., & Zimmerman, M. (2002). Is comorbidity of post-traumatic

Subscriber: Tufts University; date: 28 July 2018

Kathleen Priebe, Dipl Psych, Institute of Psychiatric and Psychosomatic

Subscriber: Tufts University; date: 28 July 2018

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