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How Dialectical Behavior Therapy Treats PTSD in Adolescents

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT Meet The Team >

Post-traumatic stress disorder (PTSD) is a serious psychological disorder that develops in some teens after they’ve been through something traumatic. Traumas can include neglect or abuse (physical, sexual, or emotional). Family violence. A car accident, death of a loved one, or natural disasters. War. School shootings. Terrorist attacks like 9/11, or even just exposure to media coverage of traumatic events.

Experiencing trauma can negatively impact all areas of a person’s life. Flashbacks, nightmares, emotional dysregulation, and frequent anxiety are just a few of the painful symptoms. If left untreated, PTSD can significantly impact teens’ ability to concentrate, sleep, and function normally. It can cause substance abuse issues, relationship problems, and other mental health or behavioral concerns. Teens who experience trauma find it very difficult – if not impossible – to relax and have fun. PTSD essentially robs teens of joy. Some traumatized teens find it a struggle to even live, and they consider risky behavior (even suicide) as a way to escape the pain.

NOTE: If you or someone you know is considering suicide, call 911 immediately.

If your teen has experienced a traumatic event, it is important to get help as soon as you can. Early treatment can help prevent PTSD from developing, and/or reduce the severity of symptoms if it already has.

DBT as a Treatment for PTSD

So how does Dialectical Behavior Therapy actually treat the symptoms of post-traumatic stress disorder?

DBT targets, in hierarchical order:

  1. Life-threatening behaviors (self-injurious behaviors, suicide attempts).
  2. Treatment-resistant behaviors (running away, not participating in therapy).
  3. Quality-of-life interfering behaviors (reducing anxiety, nightmares, avoidance, etc.).

All three types of behaviors are those commonly seen in victims of trauma and adolescents with PTSD.

Let’s go over these in more detail.

DBT Targets Suicidal, Self-Injurious, and Other Life-Threatening Behaviors

Teens who find it hard to deal with the pain of trauma may consider hurting themselves to escape their pain. They may cut, scratch, attempt suicide, and engage in other self-harming behaviors. The primary focus of DBT, in Stage 1 (residential treatment), is to reduce and eventually eliminate these life-threatening and treatment-threatening behaviors. These behaviors must be addressed first before any other symptoms (like flashbacks, anxiety, etc.)  In this stabilization phase, teens learn necessary Distress Tolerance and Emotion Regulation skills to safely and quickly deal with their pain instead of acting on urges to hurt themselves.

These skills include intense physiological exercises such as:

  • Ice-cold face splashes
  • Quick exercise
  • Deep breathing
  • Progressive muscular relaxation

This phase may also include distraction skills, such as:

  • Watching a movie
  • Going out in the rain or snow,
  • Calling a friend
  • Listening to very loud music

DBT’s first priority is helping teens stay alive, which means stopping behaviors that jeopardize their lives or threaten treatment. Once these behaviors stop, then theapists can target PTSD symptoms using a formal exposure treatment (such as PE or EMDR).

DBT Directly Targets PTSD Symptoms

After focusing on removing life-threatening and treatment-resistant behaviors in teens, the next stage in DBT is helping eliminate trauma-related anxiety, avoidance, and other intrusive symptoms in a teen’s life. This is when teens also receive exposure therapy for PTSD – a type of therapy that helps people learn how to gradually approach their trauma-related memories.

DBT skills help trauma-related anxiety.

Teens who experience trauma often have intrusive, unwanted thoughts or flashbacks. These flashbacks can be quite distressing and anxiety-provoking, especially when they intrude upon an otherwise normal or routine activity. What’s more, trauma-related cues and triggers can induce even more anxiety.

DBT helps reduce trauma-related anxiety by encouraging the use of grounding or distraction skills. For example, in DBT’s self-soothe skill, teens use their five senses to ground themselves in the present moment instead of ruminating on the past. (Touch a fuzzy blanket, sniff essential oils, observe the shapes of clouds in the sky, chew some minty gum, feel its texture on the tongue, etc.). The key is to focus intensely on an aspect of the physical, observable world instead of staying stuck in the recesses of your mind.

DBT challenges trauma-related beliefs.

When a child experiences a trauma, the memory imprints itself into the brain’s amygdala. This hijacks and alters the brain’s fight-or-flight response. Thereafter, everyday situations and events—even if they only slightly share a resemblance to the traumatic event—can cause the teen to experience hyperarousal. This happens because the adolescent interprets ordinary events as high-risk, threatening situations. For example, a teen who experienced parental neglect as a child may experience a disproportionate amount of melancholy when a friend doesn’t call them back right away. In their mind, the rejection of the parent is happening all over again.

In these cases, DBT asks teens to challenge the trauma-related beliefs causing these intense emotions. DBT teaches them to “check the facts” to see if the emotion fits with the reality (facts) of their current situation, or if they’re jumping to generalizations and assumptions.

In the case above, if the teen “checks the facts” when their friend doesn’t call them back, they realize that not calling back does not equal rejection. Perhaps the friend was busy with something important, or perhaps their phone was on silent. The friend never said outright that he/she was mad, so the emotion of sadness is inappropriate at this point.

DBT reduces avoidance.

If an adolescent experiences trauma in elementary school, just returning to the same town as their school (let alone their school) can induce a panic attack. This issue may, in turn, cause a teen to avoid a lot of people, places, and even experiences. The brain fears a repeat of the initial trauma, even when the present moment presents no danger.

The DBT skill “Opposite Action” is a way of reversing one’s emotions by doing the exact opposite of what you feel like doing in the middle of an unjustified negative emotion. So, for example, if you are feeling unreasonably shameful when something happens even though you did nothing wrong (which you know because you checked the facts), DBT’s Opposite Action tells you to hold your head up high, walk straight, and try to feel confident. Likewise, if you were invited to a party in a certain town that is associated with negative past memories, your gut instinct is to stay home and under the covers. Instead, DBT tells you to go out there and face the music. 

DBT works with CBT, Prolonged Exposure Therapy, and EMDR.

When it comes to teens with PTSD, there are a number of traditional methods that professionals use to deal with the direct symptoms of trauma. These modalities include CBT, prolonged exposure (PE) therapy for PTSD, and EMDR (Eye Movement Desensitization Reprocessing). Therapists typically conduct these treatments on the outpatient level (such as in a partial hospitalization or intensive outpatient program for teens).

Often, therapists integrate these treatments into DBT. Dr. Melanie Harned and Dr. Katherine Korslund, along with DBT creator Dr. Marsha Linehan (all of whom are colleagues at the University of Washington-Seattle), joined together to study DBT’s effectiveness on PTSD, both alone and combined with the traditional PTSD treatment of exposure therapy. Their study participants were females with PTSD who engaged in self-harming behavior and also met the criteria for borderline personality disorder.

According to Dr. Melanie Harmed:

[T]herapists were instructed to address PTSD by using DBT skills to manage anxiety (e.g., self-soothing), challenge trauma-related beliefs (e.g., check the facts), and reduce avoidance (e.g., opposite to emotion action).

The research team found that DBT reduced the patients’ suicidal ideation, trauma-related guilt, shame, anxiety, depression, and social difficulties. At least 70% of the patients no longer met the criteria for PTSD at the end of the one-year study. Additionally, the combination of DBT with Prolonged Exposure therapy reduced self-harming and suicidal tendencies by 80%.

DBT for PTSD is Evidence-Based

In another study, researchers studied women who were sexually abused as children. The 74 participants met the criteria for PTSD. They were divided into a DBT group or a control group. The former group members received DBT while in residential treatment for 12 weeks. The latter received treatment as usual—which the researchers permitted to be any therapy other than DBT (PE, EMDR, etc.) The DBT group had a significantly greater improvement in PTSD symptoms than the control group. Thirty-nine percent of the participants improved so much in their PTSD symptoms that they were classified as “in remission.” In the control group, only 11% were classified as such. (Bohus, 2013).

And yet in another study, 79% of the patients showed remission in PTSD when being treated with DBT in an outpatient setting. These patients had severe emotion dysregulation issues in addition to the symptoms of trauma.

As you can see, the evidence-based on peer-reviews scientific studies – proves that Dialectical Behavior Therapy for PTSD works.

Where to Find DBT Treatment for Your Teen

Individual therapists usually run adolescent DBT-skills groups in their outpatient practice. This is coupled with weekly individual sessions and coaching, over the course of a year. If your child’s PTSD is more severe, an immersive program (RTC) is necessary for stabilization.

Our teen treatment centers offer options at three levels of care. Depending on the level of your teen’s trauma, you may need a Residential (RTC), Partial Hospitalization (PHP), or Intensive Outpatient (IOP) program.

Residential Treatment

In residential treatment, the priority is on eliminating life-threatening, treatment-resistant behaviors, including suicidal attempts and self-injurious behaviors. If your child needs PTSD treatment in a teen residential facility, he or she will stay at a non-hospital treatment facility that will care for them 24/7. The focus of DBT at this point in time is stabilization and removal of life-threatening behaviors. The goal is to keep the teen alive and teach them the emotion regulation and distress tolerance skills they need to later tolerate a formal exposure treatment (like PE or EMDR). Residential treatment often lasts between 30 to 60 days, depending on the severity of PTSD.

Partial Hospitalization Program

Partial Hospitalization (PHP) is an effective alternative to residential or inpatient treatment when a teen does not need 24/7 monitoring for life-threatening behaviors. In this level of care, the focus is on directly treating the symptoms of PTSD (reducing anxiety, avoidance, etc.) using DBT skills in combination with exposure therapy (such as prolonged exposure therapy for PTSD, or PE) or EMDR therapy (Eye Movement Desensitization and Reprocessing). PHP may be appropriate for those transitioning from an RTC or those who need to step up from an intensive outpatient program. In a Partial Hospitalization Program, teens attend programming at least five hours per day, five days a week. Teens receive a full-day of treatment, but continue to live at home.

Intensive Outpatient Program

An Intensive Outpatient Program (IOP) for PTSD is a less intensive option than PHP. At the intensive outpatient level of care, teens receive a half-day of professional treatment. Most teens in IOP are able to attend school and live at home. IOP is an effective alternative to residential or partial hospitalization programs. It may be appropriate for teenagers who need more structure than private-practice psychotherapy for their PTSD. The number of hours and frequency of treatment in an Intensive Outpatient Program may vary. Generally, IOP programs offer 3-4 hours of DBT for up to four days a week. On the IOP level, teens learn how to move on from their traumas using DBT skills in combination with exposure therapy for PTSD or EMDR.

Whether it’s a DBT therapist or residential treatment, IOP, or PHP, get in touch with a DBT program for your teen’s PTSD today. Let your child start building, as they say in the DBT world, “a life worth living.”

To read more about post-traumatic stress disorder, check out our Parent Guide to PTSD.  

Our Behavioral Health Content Team

We are an expert team of behavioral health professionals who are united in our commitment to adolescent recovery and well-being.

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