DBT-PE for PTSD (Complex Trauma)

DBT-PE: Prolonged Exposure Protocol for Complex Trauma

Dialectical Behaviour Therapy – Prolonged Exposure (DBT-PE) is a specialised treatment protocol designed by Dr Melanie Harned to address Post-Traumatic Stress Disorder (PTSD) in individuals who also experience high-risk or complex mental health challenges. Building on the foundational skills of standard DBT, DBT-PE targets the underlying trauma that often fuels ongoing distress, self-harm, or suicidal behaviours.

What Is DBT-PE?

DBT-PE combines the principles of Prolonged Exposure therapy with Dialectical Behaviour Therapy. Prolonged Exposure techniques focus on reducing avoidance of trauma-related memories, thoughts, and situations – ultimately helping individuals to process traumatic experiences rather than push them away. By embedding these strategies within a DBT framework, clients are equipped with essential coping skills (e.g., Distress Tolerance, Emotion Regulation) to manage the intense emotions that can arise when confronting trauma.

Valerie Dunn McBee (LCSW) discusses what DBT-PE is with the University of Georgia School of Social Work

Why DBT-PE?

  • DBT-PE addresses PTSD in High-Risk Clients: Many people with PTSD also experience suicidal ideation, self-harm, or multiple diagnoses. DBT-PE is specifically designed to help these clients access trauma treatment safely and effectively often when other trauma focussed therapies have been ineffective or unsafe to consider.
  • It Builds on DBT Skills: After gaining a degree of behavioural control (e.g. managing self harm urges) and emotional stability in standard DBT, clients are typically more prepared to confront traumatic memories.
  • DBT-PE is Comprehensive & Collaborative: Clients continue receiving DBT support (individual sessions, skills groups, phone coaching if available) while undergoing targeted trauma work, ensuring no gaps in care.

How Does DBT-PE Work?

  1. Preparation & Readiness
    • Clients usually enter Stage 1 of DBT first, focusing on stabilising life-threatening behaviours and learning foundational DBT skills.
    • Readiness criteria often include a sustained period without suicidal or non-suicidal self-injury. For many, this means having not acted on any urges for at least two months, though exact requirements can vary.
  2. Prolonged Exposure Sessions
    • Sessions are 90 – 120 minutes weekly. While continuing with standard DBT, you’ll dedicate part (or all) of your individual therapy time to imaginal exposure (revisiting and processing the trauma memory in detail) and in vivo exposure (gradually confronting feared but safe situations in daily life).
    • This process typically unfolds across three phases:
      • Pre-Exposure (2–3 sessions): These sessions focus on building trust, setting goals, and planning exposure targets (specific trauma that the client wants to work on).
      • Prolonged Exposure (multiple sessions): Clients engage in imaginal and in vivo exposure exercises to address and reduce any distress they experience related to the target of therapy, depending on the type and complexity of the traumas being targeted the number of sessions needed will vary.
      • Consolidation & Relapse Prevention (1–2 sessions): As we conclude therapy we focus on solidifying gains, preparing for future challenges, and developing a long-term safety plan.
  3. Ongoing Support
    • Throughout DBT-PE, you’ll still have access to DBT Skills Groups (if actively enrolled), phone coaching (if offered by your therapist), and the broader DBT framework.
    • The aim is to ensure you have enough coping tools and emotional regulation skills to navigate the intense emotions that can surface during trauma work.

Who Is DBT-PE For?

  • Client who might be considered High-Risk or as having Multiple Problems: Particularly those who have found it difficult to access standard PTSD treatments because of chronic self-harm, multiple diagnoses, or severe emotional dysregulation.
  • Individuals with PTSD After DBT Skills: Typically I recommend DBT-PE once you’ve established behavioural stability – often after completing (or nearing completion of) our DBT Skills Group modules.
  • Case-by-Case Discussions: While the standard recommendation is to complete DBT Skills before starting DBT-PE, I can review individual needs to determine the best time to begin.

Typical Timeline

  1. Stage 1 – DBT Stabilisation
    • This involves attending a DBT Skills Group (Distress Tolerance, Emotion Regulation, Interpersonal Effectiveness, and Mindfulness) plus individual DBT sessions.
    • As part of Stage 1 people work towards crisis management, learning safe coping skills to manage day to day life, and decreased high-risk behaviours.
  2. Stage 2 – DBT-PE for Trauma
    • Once stage 1 behaviours are better managed we shift focus towards working on trauma exposure, employing imaginal and in vivo techniques which are evidence based methods of working with trauma.
    • Alongside DBT-PE work, people continue to receive and access core DBT modes for ongoing emotional support (e.g. DBT Skills Group, Individual Session and accessing phone coaching).
  3. Stage 3 – Post-Trauma Integration
    • Looks to address any remaining issues, such as building healthier relationships, finding meaningful work or activities, and fully integrating the trauma processing into a life worth living.

What to Expect

  • Imaginal Exposure
    You’ll revisit traumatic events in a controlled, supportive environment. Guided by me as your therapist, you’ll be asked to describe the memory we are working on in detail, the purpose of this is to decrease avoidance and reduce its emotional grip.
  • In Vivo Exposure
    You’ll gradually face real-life situations that you’ve been avoiding because they trigger memories or fears. Over time, these experiences become less distressing, restoring a sense of freedom in daily life.
  • Ongoing DBT Framework
    Alongside accessing DBT-PE sessions, people continue to use the skills that have been taught in the DBT Skills group like Distress Tolerance and Emotion Regulation. Which are essential for managing the high emotional arousal that can accompany trauma work. Combined with chain analysis in individual therapy, DBT-PE ensures you maintain the stability you’ve worked hard to achieve.

Ready to Begin DBT-PE?

  1. Complete (or Approaching Completion of) DBT Skills
    If you haven’t yet stabilised crisis behaviours, I can offer support regarding how to begin with standard DBT modules first.
  2. Arrange an Assessment
    Contact me to arrange an assessment where we can discuss your clinical history, current coping skills, and potential readiness for DBT-PE. This conversation helps us determine the optimal stage to begin trauma work.
  3. Start Prolonged Exposure
    Once stabilised, you’ll begin weekly 90–120 minute sessions, confronting past trauma with my support. You will also be expected to listen back to recordings of your sessions between appointments which form an important part of DBT-PE.
  4. Build a Life Worth Living
    As you process traumatic memories, you’ll reclaim a sense of safety and self-efficacy – setting the stage for Stage 3 of DBT, where any remaining life challenges can be addressed.

Take the Next Step

DBT-PE offers a specialised path to healing for individuals with PTSD who also face complex mental health challenges. By combining thorough trauma processing with the supportive framework of DBT, you can move beyond survival mode and genuinely thrive. If you’re interested in learning more about Prolonged Exposure therapy within a DBT context, reach out today to book an assessment.