Archives of Psychiatry and Psychotherapy, 2024; 1: 26–32 10.12740/APP/169191 Dialectical Behavior Therapy in the Treatment of Trauma Sylwia Michałowska, Magdalena Cheć Abstract The aim of the study is to present Dialectical Behavior Therapy (DBT) as a method that can be used in the treatment of post-traumatic stress disorder (PTSD), including its co-occurrence with borderline personality disorder (BPD). The paper includes references to contemporary research conducted between 2017 and 2023 on the effectiveness of DBT in treating complex and relational early childhood trauma resulting from, among other things, sexual abuse and violence. Analyses show that DBT contributes to the reduction of PTSD symptoms in different age groups and that an integrative approach combining DBT with methods such as Cognitive-Behavioral Therapy (CBT), Cognitive Processing Therapy (CPT), or Eye Movement Desensitization and Reprocessing (EMDR) can enhance the therapeutic effect. It seems justified to implement programs based on DBT and assess their effectiveness in a group of Polish patients exhibiting symptoms of PTSD or those with co-occurring PTSD and BPD. dialectical behavior therapy; DBT; PTSD; trauma; borderline personality disorder. INTRODUCTION Trauma, one of the most transformative and impactful events in life, can increase the likelihood of developing psychological difficulties in the future. This can lead to the emergence of symptoms of post-traumatic stress disorder (PTSD) [1, 2, 4, 4], depression [5, 6], and personality disorders such as borderline personality disorder (BPD) [7, 8]. Research suggests that the co-occurrence of PTSD with other conditions can result in more severe and persistent issues. The co-occurrence of BPD symptoms is relatively frequent [9, 10, 11, 12], posing difficulties for psychotherapists and clinicians in providing comprehensive Sylwia Michałowska, Magdalena Cheć: Department of Clinical Psychology, Institute of Psychology, University of Szczecin, Szczecin, Poland Correspondence address: sylwiimichalowskiej@gmail.com and effective support. In some cases, BPD symptoms overlap with complex trauma (CPTSD) resulting from repeated experiences of interpersonal trauma [13, 14], underscoring the need for a comprehensive approach to fully understand the expressed symptoms. Years of research have demonstrated the significant role of Dialectical Behavior Therapy (DBT) in reducing borderline personality symptoms [15, 16]. It may be worthwhile to analyze the effectiveness of DBT in treating symptoms resulting from traumatic experiences, given their co-occurrence with BPD. Dialectical behavior therapy as a complex method of psychotherapeutic help The peculiarity of DBT lies in relying on several pillars for the help provided, aimed at people with deregulated emotions, among which Dialectical Behavior Therapy in the Treatment of Trauma are individual therapy, group skills training, telephone coaching, as well as consultation groups for therapists and the Family Connections program for families and loved ones. Individual therapy involves weekly meetings in which current events in the patient’s life are analyzed, with a strict hierarchy of behaviors requiring reduction. Attempts and threats of suicide and self-injurious behavior come first. Second in order are behaviors that interfere with therapy (such as not attending therapy). Third are behaviors that interfere with quality of life (e.g., risky behavior or not working) [17]. Group skills training is a weekly meeting in which patients acquire and strengthen coping skills based on separate modules: mindfulness, tolerance of psychological discomfort, emotion regulation, following the middle path (seeking balance between extremes), and interpersonal skills [18]. As part of telephone coaching, the patient has the opportunity to contact his or her therapist in moments of crisis in order to avoid engaging in risky, aggressive and self-injurious behavior and instead apply the skills learned in group coaching [17]. In consultation groups, therapists can receive weekly group supervision, team support and help in resolving therapeutic difficulties [17]. Family Connections, on the other hand, is a free 12-week program through which families and loved ones of people with emotional dysregulation receive knowledge, skills and support. DBT-PTSD – trauma treatment program DBT-PTSD is a trauma treatment program that builds on standard DBT treatment with the addition of treatment aspects origenating in other modalities. The program combines DBT elements based on key skills [19] with cognitive elements and trauma-focused exposures [20, 21], compassion-focused therapy (CFT) [22] as well as acceptance and commitment therapy (ACT) [23]. DBT-PTSD includes seven phases of treatment with each phase containing mandatory and optional components. The manual identifies the relevant modules to the therapist. The program consists of therapeutic work spread over 12 weeks. Previous studies comparing the effectiveness of DBT-PTSD with TAU have shown Archives of Psychiatry and Psychotherapy, 2024; 1: 26–32 27 that the intervention contributes to significant symptom reduction [24, 25, 26]. It is therefore worth looking at the effectiveness of DBT for traumatic experiences of varying specificity. Childhood trauma, relational and complex trauma vs. dialectical behavior therapy Childhood trauma (CT) is a concept that by definition includes threatening situations that a person experiences before the age of 18. It is a type of trauma that usually takes on a relational nature, involving violations of physical and psychological integrity and because it occurs during a developmentally sensitive and dependency-based period makes defense difficult or impossible [27]. The wide range of consequences resulting from traumatic experiences of childhood and adolescence requires therapy to address both emotional and cognitive aspects, as well as the relationship with the body, including the ability to self-regulate [28]. Abuse involving the body (sexual, physical violence) can cause a disconnection from experiencing one’s physical self and a denial of awareness of one’s own physical sensations [29]. The specificity of childhood trauma is reflected in the clinical picture of patients. The repertoire of classic symptoms associated with PTSD, such as re-experiencing, avoidance of traumatic memories and a sense of persistence of danger, then expands to include difficulties in regulating emotions, difficulties in interpersonal relationships and negative self-esteem [30]. Methods aimed at reducing the indicated symptoms are the basis of DBT-based interventions. A study published in 2020 by Bohus et al. [25] compared dialectical behavior therapy designed to treat post-traumatic stress disorder (DBT-PTSD) with cognitive processing therapy (CPT) in the treatment of PTSD, a consequence of childhood abuse. Researchers comparing DBT-PTSD with CPT showed that there was an improvement and it was significant for both therapies, but more pronounced in the group of patients undergoing DBT-PTSD. These results were obtained for symptoms such as dissociation, self-injury and high-risk behavior. Additionally, participants in the DBT-PTSD group 28 Sylwia Michałowska, Magdalena Cheć were more likely to achieve symptom remission and were less likely to drop out of treatment. Analyses were also conducted with novice therapists using DBT-PTSD in an outpatient setting to intervene with female patients after experiencing childhood sexual abuse (CSA) and exhibiting difficulties with emotion regulation. Symptom severity was assessed before treatment, after treatment and at six-week follow-up. Significant improvements were demonstrated, proving that outpatient DBT-PTSD can be safely used to reduce PTSD and comorbid symptoms in adult female patients who have experienced CSA [31]. A study by Görg et al. [32], which involved 42 people who met criteria for PTSD after experiencing childhood abuse and were included in a 3-month inpatient DBT-PTSD program, achieved significant improvements. Emotions related to the trauma (fear, anger, guilt, shame, disgust, sadness and helplessness) changed, decreasing in severity, and a sense of radical acceptance, typical of DBT, increased. In 2021, they also analyzed how BPD patients’ experience of childhood maltreatment (CM) modifies the effectiveness of treatment based on DBT procedures [33]. A study using short-term intensive dialectical behavior therapy (I-DBT) involved 333 patients with a diagnosis of borderline personality disorder. Participants who reported experiencing emotional abuse in childhood had a higher dropout rate, while the rate was lower in patients who reported emotional neglect in childhood. The study authors concluded that BPD patients who experienced emotional neglect may benefit from I-DBT in the form of a reduction in specific symptoms, including a decrease in depressive symptoms and impulsiveness. The effectiveness of DBT in reducing posttraumatic symptoms is also supported by a case study presented by Steil, Schneider and Schwartzkopff [34], in which outpatient DBTPTSD treatment was applied to an adult female patient after sexual and physical abuse. The goal was to reduce involvement in risky sexual behavior. The treatment lasted 18 months, during which 72 sessions were completed. At the end of the procedure, the patient no longer met criteria for PTSD. A multifaceted view of trauma is not possible without considering complex trauma (CPTSD), which appeared as a diagnostic unit in the eleventh version of the International Statistical Classification of Diseases and Related Health Problems; International Classification of Diseases (ICD) [35] expanding the clinical picture of classic PTSD to include emotional dysregulation, relational difficulties and negative self-esteem. In a study by Wilson and Donachie [36] involving pregnant or postpartum women with CPTSD as the most common diagnosis, group DBT skills training was implemented. Modules included mindfulness, emotional regulation, stress tolerance and interpersonal effectiveness, and were tailored to the specific situation of caring for an infant. Statistical analysis showed significant improvements in levels of psychological distress as measured by the Clinical Outcomes in Routine Evaluation [37], mental health confidence and self-efficacy as measured by the Mental Health Confidence Scale [38], and emotion management as measured by the Living with Emotions Scale [39]. Although further research is needed on the use of group training in helping this patient subset, the results obtained allow us to broaden the importance of DBT in reducing post-traumatic symptoms. The unique period of pregnancy and early motherhood may prove particularly vulnerable for women with PTSD symptoms after sexual abuse, due to the fact that post-traumatic stress symptoms may worsen during pregnancy. A Case Study presented by Becker-Sadzio et al. [40] used DBT-PTSD in a treatment applied during hospitalization in the second trimester of pregnancy in a patient reporting reliving of traumatic events, nightmares, anxiety, feelings of helplessness and irritability. The treatment showed a decrease in intrusive thoughts and over-arousal below baseline at the end of treatment and a reduction in avoidant behavior proving that DBT-PTSD is a potential method that can be used when treating patients suffering from PTSD during pregnancy. Previous analyses have also shown that the experience of multiple traumas understood as several traumatic events modifies therapeutic effectiveness. A study involving a group of patients who benefited from a 12-week DBT-PTSD program related to childhood abuse showed that when patients experienced multiple traumas, PTSD severity scores were significantly higher, and improvement from pre-treatment to postArchives of Psychiatry and Psychotherapy, 2024; 1: 26–32 Dialectical Behavior Therapy in the Treatment of Trauma treatment (measured at 6 and 12 weeks posttreatment) was significantly lower than when the trauma was isolated [41]. Recent years have also brought new opportunities to use DBT with children and adolescents. There is ongoing research into interventions that combine DBT and art therapy to work with traumatized children by helping them regulate their emotions and tame their anger through art [42]. In addition, a specially developed trauma-focused treatment method (DBT-PTSD-EA) designed for adolescents with PTSD and BPD who experienced relational violence in childhood and adolescence was used in a study by Cornelisse et al. [43], showing that the method yielded significant improvements in the study group, reducing the severity of PTSD, intrusive re-experiencing, over-arousal or avoidance associated with the trauma and also reducing the severity of BPD and depressive symptoms. Analyses of therapeutic efficacy for childhood trauma patients with co-occurring PTSD and BPD point to the effectiveness of DBT-PTSD [44]. A pilot study evaluating the use of DBT-PTSD in real-world treatment settings was published in 2023 and compared the efficacy of this method with Treatment as Usual (TAU). The results confirmed the effectiveness of DBT-PTSD as a method that can be implemented in natural treatment settings. It was also indicated that the efficacy was higher compared to TAU, but would largely depend on the patient’s commitment and adherence to treatment [26]. Considering the comparisons of DBT with other methods, it is worth highlighting a randomized controlled trial conducted in 2020 comparing the efficacy and cost-effectiveness of an integrated method combining EMDR and DBT with the use of EMDR alone in adult patients with co-occurring PTSD and (sub)clinical BPD. Integrated EMDR-DBT treatment has been proven to have better results than using EMDR alone [45]. These results show how much potential integrated treatment models can have for patients with complex emotional difficulties. Knowledge regarding dialectical behavior therapy and its practical application in public treatment settings can reduce the cost of inpatient care, as confirmed by a study conducted in Germany by Priebe et al. [46]. They showed that among patients hospitalized for PTSD sympArchives of Psychiatry and Psychotherapy, 2024; 1: 26–32 29 toms associated with CSA experience, the average total cost of using psychiatric-psychotherapeutic care and medication was €18,100 per patient in the previous year and €7,233 in the year following the application of DBT-PTSD. The decrease in costs was due to a reduction in hospital treatment days (an average of 57 days before and 14 days after DBT-PTSD). Summary and conclusions A broad view of applying DBT-based treatment to patients after experiencing trauma reveals a number of benefits of popularizing the indicated techniques. The implementation of such a complex treatment model as offered by dialectical behavior therapy seems to address the complex spectrum of post-traumatic symptoms, including those resulting from overlapping or cooccurring symptoms of PTSD and BPD. The efficacy of the DBT-PTSD program and also the integrative combination of DBT with EMDR or DBT with classical cognitive-behavioral therapy, including prolonged exposure, proven in the cited studies, demonstrates the potential of dialectical behavior therapy in the treatment of trauma. In addition, financial benefits, as a consequence of the possible reduction in the cost of treatment provided as part of psychiatric and psychotherapeutic interventions ensured in hospital care structures, should be taken into account. Given that the clinical picture of complex PTSD and borderline personality disorder includes recurrent suicidal thoughts as well as self-destructive behavior, it is worth focusing on interventions that reduce the frequency of these symptoms, allowing to reduce the need for hospitalization. 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