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Integrating Dialectical Behavior Therapy Into Exposure Therapy
for Complex Posttraumatic Stress Disorder
Reprinted from Eating
Disorders Review
March/April 2002 Volume 13, Number 2
©2002
Gürze Books
Posttraumatic
stress disorder (PTSD) is a common comorbidity in eating
disorders patients. Patients who present with both PTSD
and an eating disorder are often considered challenging
to treat, and are frequently considered poor candidates
for exposure therapy. Yet we have found it is sometimes
easier to treat PTSD symptoms first via exposure than
to treat the eating disorder in the presence of full-blown
PTSD. Thus, identifying strategies to improve patient
tolerance and to broaden the range of patients deemed
appropriate for exposure therapy is a crucial next step
for those of us who advocate the use of exposure for
PTSD.1 Although
considerable evidence supports the effectiveness of
exposure therapy for PTSD, recent discussions with colleagues
indicate that many therapists are "giving up" on this
treatment. In particular, clinicians argue that exposure
does not meet the needs of highly comorbid PTSD patients,
some of whom also have eating disorders. Exposure
therapy involves exposing patients to anxiety-provoking
stimuli for prolonged periods to reduce associated fears.
Repeated trials are typically used to enhance between-session
habituation. In the case of exposure for PTSD, patients
are exposed to memories of traumatic events (i.e., imaginal
exposure) and to stimuli that remind the patient of
the trauma (i.e., in vivo exposure).
Dialectical
Behavior Therapy
In an attempt to identify strategies to facilitate exposure,
we turned to the literature on borderline personality
disorder (BPD). Individuals with complex PTSD are similar
to those with BPD in that they are often considered
to be very difficult to treat. One reason for this is
the global nature of their emotional distress. In addition
to chronic anxiety, persons with PTSD experience significant
sadness/depression, shame, guilt, and anger. Many have
chaotic lives and are involved with legal battles, abusive
relationships, or may be unemployed. Dialectical
behavior therapy was designed by Linehan to address
the impulsive behaviors, life chaos, and emotional deregulation
associated with BPD and thus is useful for treating
these same problems in individuals with PTSD. The increasing
use of DBT in the treatment of eating disorders by many
clinicians suggests possible utility in this area as
well.
'Modified
DBT'
Patients with complex PTSD have a spectrum of problems
dealing with emotions, ranging from full-blown BPD to
difficulties specifically related to individual trauma
histories. When patients exhibit chronic and severe
suicidal behavior and a lack of basic skills for self-regulation,
we refer them to comprehensive DBT programs. Most of
the patients who enter our program, however, exhibit
more circumscribed difficulties in these areas. While
these patients are frequently considered "exposure-intolerant"
by other clinicians, we have found that they are often
able to complete exposure treatment with more limited
"doses" of DBT. We refer to this more limited dosing
as "Modified DBT."
DBT
Biosocial Theory
The biosocial theory states that difficulties associated
with BPD are produced when a person with temperamental
vulnerability is raised in an invalidating environment.2
Linehan designed the biosocial theory to improve therapists'
ability to maintain a positive attitude towards their
patients. Linehan's research suggests that maintaining
a noncritical stance towards BPD patients is highly
important,3 and we believe the same is true for patients
with PTSD. Although working with trauma survivors is
emotionally draining for therapists, we have found that
using the biosocial theory improves our ability to like
our patients. Individuals
with complex PTSD frequently experience significant
invalidation during their lives and, as a result, often
find the invalidating environment concept helpful. Discussion
of invalidation may focus around others' reactions at
the time of the trauma (e.g., telling the patient to
put the experience behind him or her); others' reactions
to PTSD symptoms; or events not directly related to
the trauma that adversely influenced him or her during
childhood. In addition, explaining that self-invalidation
can perpetuate distress improves understanding and in
some cases helps to correct dysfunctional beliefs. Patients
often say, 'I shouldn't feel this way' or 'I should
be over this.' Yet, we have been surprised at how often
these patients spontaneously begin to alter their beliefs
once such beliefs are identified as examples of self-invalidation.
The
Dialectic of Acceptance and Change
Recently much has been written about the need to balance
acceptance and change- based strategies.5 Linehan, however,
was among the first to recognize the wisdom of balancing
behavior therapy's historic focus on change with explicit
attention to acceptance. The dialectic of acceptance
and change is critical for both PTSD and eating disorders and exists on two levels, that of the patient and that
of the therapist. For
the complex PTSD patient, balancing the dialectic entails
admitting that there are things about oneself and one's
life that cannot be changed. No matter how much patients
may wish things were different, they cannot undo past
traumas, mistakes, or failures by themselves or others.
Patients must also address this dialectic in relation
to their emotions. Patients enter therapy wanting to
escape their painful emotions, a goal that presents
a paradox for therapy since the amelioration of emotional
suffering requires acknowledging their negative emotions
so one may respond effectively. The
therapist must also maintain a balance between acceptance
and change. Behavior therapy is a change-oriented treatment.
With it, we help patients to change their maladaptive
behaviors, dysfunctional thoughts and, by the first
two methods, their negative emotions. Even acceptance
is reached via change. For example, acceptance of weight
in bulimia nervosa is often achieved via cognitive restraint
(CR), a change procedure. As
Linehan notes, approaches that focus on change are clearly
necessary, and a therapist who unconditionally accepts
the patient without focusing on change is likely to
do little good because new behavior and skills are neither
taught nor learned. Acceptance techniques such as repeated
and explicit validation, however, are also critical
since PTSD patients often feel misunderstood when they
are asked to make changes that seem impossible. When
therapy overemphasizes the need for change relative
to acceptance, patients may re-experience the invalidation
that occurred at the time of the trauma. This is particularly
true for survivors of abuse, who often experienced invalidation
from legal and social systems as well as from family
and friends. Making therapy "invalidation-free" is crucial
to achieving a safe setting in which to address traumatic
experiences. Reducing
invalidation in exposure therapy can be quite difficult.
For example, a very articulate group of patients once
informed us that simply by teaching exposure we were
invalidating their primary coping strategy. In essence,
the whole notion of exposure implied to these patients
that their use of avoidance to cope was somehow wrong.
We now explicitly encourage patients to discuss the
benefits of avoidance, which validates its use as a
coping strategy, before beginning to examine the negative
consequences associated with avoidance. Feedback from
patients about this change in focus has been uniformly
positive and we find that patients are more committed
to engaging in exposure therapy as a result.
Exposure
and Mindfulness
After conducting exposure with many "unsuitable" patients,
we have become aware of the extent to which exposure
is not merely a technique but also a skill that a patient
must acquire. In complex PTSD patients, trauma-related
stimuli often trigger a range of emotions, such as anger,
guilt, or shame. For exposure to be successful in facilitating
habituation of anxiety responses, however, the patient
must learn to selectively focus attention on the anxiety
associated with the stimuli. Selective focusing of attention
requires patients to scan the range of their affective
responses and then selectively attend to sensations
of anxiety to the exclusion of other emotions. As several
patients have noted, this is not a skill that they necessarily
bring to treatment. Mindfulness
enables patients to observe and label their emotional
reactions to traumatic memories. Thus, they learn to
identify the sensations associated with anxiety (versus
shame, guilt, anger) and selectively attend to them.
A number of our patients have reported that once they
learn to focus on their anxiety, they can "shelve" other
emotional reactions in order to complete the exposure
task at hand.
Dangers/Pitfalls
Although modified DBT is a useful tool for helping patients
complete exposure therapy, it is important to point
out potential problems that may arise from its use.
First, it is clear that many PTSD patients can complete
exposure therapy without the addition of DBT. Second,
while current treatment manuals donÕt fully address
the needs of clinicians, there is an ever-present danger
that merging interventions may "water-down"
efficacious treatments. Similarly, use of modified DBT
may decrease the therapist's attention to the core components
of exposure-based treatment, thus resulting in inadequately
administered or incomplete exposure.
The
Future
While DBT has been scrutinized as an intervention for
parasuicidal and impulsive behaviors, its routine use
to enhance exposure therapy has not been empirically
studied. We believe that integrating DBT-based therapy
leads to improved tolerance of exposure therapy for
PTSD. Systematic clinical investigations, however, are
needed to demonstrate this effect and to examining the
underlying mechanisms of this approach.
Suggested
Reading
1. Becker CB and Zayfert C. Integrating DBT-based techniques
and concepts to facilitate exposure treatment for PTSD.
Cognitive Behavioral Practice 2001; 8:107.
2.
Foa, EB and Rothbaum, BO. Treating the trauma of rape:
A cognitive-behavioral therapy for PTSD. New York: Guilford
Press, 1998.
3.
Sherain EN, Linehan MM. Dialectical behavior therapy
for borderline theoretical and empirical foundations.
(Acta Psychiatr Scand 1994; 89:61)
4.
Linehan MM. Cognitive Behavioral Treatment of Borderline
Personality Disorder. New York: The Guilford Press,
1993. (end)
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American Psychiatric Association Practice Guidelines
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Anorexia Nation
Anorexia Nervosa: 11 Areas of Advancement
Assessing Readiness and Motivation for Change: Challenges and Practical Advice
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