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Dialectical Behavior Therapy: Stage I Treatment for Trauma. COMBAT Conference Kansas City, Missouri Ronda Oswalt Reitz, PhD Missouri Department of Mental Health. Helping people find lives worth living through relentless compassion and effective behavior change strategies.

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Dialectical behavior therapy stage i treatment for trauma
Dialectical Behavior Therapy: Stage I Treatment for Trauma

COMBAT Conference

Kansas City, Missouri

Ronda Oswalt Reitz, PhD

Missouri Department of Mental Health

Dialectical behavior therapy stage i treatment for trauma

Helping people find lives worth living through relentless compassion and effective behavior change strategies.

What is bpd
What is BPD?

  • Nine DSM Criteria—the only diagnosis that includes self-harm as a criteria.

  • Historically considered as an “excess of aggression” disorder.

  • Evolved into a disorder about which treaters became hopeless, burned out.

  • Now viewed as a relative of “mood disorders”

Bpd is common
BPD is Common

  • 11% of psychiatric outpatients meet DSM-IV criteria for BPD

  • 19% of psychiatric inpatients meet criteria

  • 33% of personality-disordered outpatients meet criteria

  • 63% of personality-disordered inpatients meet criteria

  • 74% of BPD population is female

Bpd is often lethal
BPD is often Lethal

  • 70-75% have a history of at least one self-injurious act

  • Suicide rates for BPD are 9%

  • Those with history of self-injurious behavior have at least double the risk of completed suicide

Bpd is expensive
BPD is Expensive

One Year Health Care Costs Per Patient

Estimated for Treatment as Usual (TAU)

Individual Psychotherapy 2,915

Group Psychotherapy 147

Day Treatment 876

Emergency Room Care 56

Psychiatric Inpatient Days 12,008

Medical Inpatient Days 1,094


Behavioral Tech, LLC 2003

How much overlap in bpd and ptsd is there
How Much Overlap in BPD and PTSD is There?



Golier et al, 2003 72/108 25%* 13%*

Yen et al, 2002 153/305 51%* 29%


Zanarini et al, 1998 379/125 56%* 22%

Does trauma cause bpd prospective research
Does Trauma Cause BPD?Prospective Research

Johnson et al., 1999, 2001:

636 youths ages 1-11 and mothers, followed into young adulthood, with Child Protective Services records and self-report assessment of maltreatment

Childhood Physical Abuse, Sexual Abuse, Verbal “Abuse, and Neglect predicted adulthood PBD criteria/diagnosis

Those with abuse or neglect were 4.5 to 7.7 times more likely to have BPD

Reconsidering the relationship between bpd and ptsd
Reconsidering the Relationship between BPD and PTSD

Trauma is associated with many psychiatric disorders other than BPD—almost all (Paris, 1998)

Only 25% of traumatized children develop adult psychiatric disorders (Werner and Smith, 1992)

Impact of abuse on psychiatric disorders depends on severity; only 25% of patients with BPD report severe trauma (Paris, 1997)

The association of BPD and Sexual Abuse across studies is not very strong (Fossati et al., 1999)

Physical Abuse, Sexual Abuse, and/or Severe Neglect are associated with childhood BPD (Goldman et al., 1992; Guzder et al., 1996) raising question of the direction of association in longitudinal research

Alternative explanations
Alternative Explanations

Gunderson & Sabo (1993)

BPD creates vulnerability to trauma, which leads to PTSD

Southwick et al. (1993)

Trauma leads to chronic PTSD which contributes to personality adjustment including BPD features

Trauma maintains bpd
Trauma Maintains BPD

Longitudinal study of adult patients with BPD (n=290) and other PDS (n=72) over 6 years;

BPD was associated with higher rates of verbal, emotional, physical, and sexual abuse

Rates of abuse declined over time

Continued presence of verbal, emotional, and physical abuse predicted non-remission of the BPD diagnosis

Zanarini et al, 2005

Combat trauma
Combat Trauma

Axelrod, Morgan, Southwick, 2005

Looked at Pre- and Post-combat veterans and found that BPD creates a vulnerability to the development of PTSD.

Trauma, particularly in individuals who were younger and who experienced more severe trauma, led to the development of BPD features.

If PTSD symptoms exist prior to trauma, then it increases the probability that an individual will develop BPD symptoms following additional trauma.

Dbt reduces symptoms
DBT Reduces Symptoms

When compared to TAU, DBT significantly reduced:

  • Frequency of self-harm behaviors

  • The severity of self-harm behaviors

  • Treatment drop-out

  • Inpatient psychiatric days

    (Linehan, Armstrong, Suarez, Allmon, & Heard, 1991)

Dbt reduces costs
DBT Reduces Costs


Individual Psychotherapy 2,915 3,885

Group Psychotherapy 147 1,514

Day Treatment 876 11

Psychiatric Inpatient Days 12,008 2,614

Medical Inpatient Days 1,094 360

17,609 8,610

The dialectical behavior therapy approach to treatment
The Dialectical Behavior TherapyApproach to Treatment

  • Applies research about emotions and their management to treatment.

  • Based heavily upon principles of behavior therapy, cognitive therapy, and Zen practices.

  • A “stages of treatment” model with hierarchies of targets at each stage.

Emotional vulnerability
Emotional Vulnerability

  • High Emotional Sensitivity

    • Immediate reaction

    • Low threshold for emotional arousal

  • High Emotional Reactivity

    • Extreme reaction

    • Hard to think clearly

  • Slow Return to Baseline

    • Long-lasting reactions

    • Sensitized before next event

A disorder of dysregulation
A Disorder of Dysregulation

  • Emotional Dysregulation

  • Interpersonal Dysregulation

  • Self Dysregulation

  • Cognitive Dysregulation

  • Behavioral Dysregulation

  • Rapidly shifting feelings and moods Problems with anger

  • Chaotic relationships fear of being left alone/abandoned

  • Fluctuating or absent sense of self sense of emptiness

  • Dissociation

    paranoid thinking/over-personalization

  • Self-harm behaviors

    impulsive behaviors

Bessel van der kolk complex trauma
Bessel van derKolkComplex Trauma

Adds a sixth area of dysregulation in complex trauma:

Somatic or physiological dysregulation

Inclusionary criteria
Inclusionary Criteria

Individuals with significant mood and behavioral dysregulation that would benefit from skill training in any of the following areas:

1. Attention/Concentration

2. Interpersonal Effectiveness

3. Emotion Regulation

4. Distress Tolerance

Four components of dbt
Four Components of DBT

  • Individual DBT-based treatment

    • One hour per week

  • Group Skills Training

    • Two hours per week

  • Skills Coaching

    • Limited by individual therapist

  • Consultation Team

    • Two hours per week

Five functions of a comprehensive treatment
Five Functions of a Comprehensive Treatment

  • Structuring the Environment

  • Enhancing client capabilities

  • Generalizing skills to the natural environment

  • Improving client motivation

  • Enhancing the capabilities and improving the motivation of staff

What makes dbt work
What Makes DBT Work?

Dialectics Helping clients find true balance in “Both…And” emotion, thoughts, and behavior and/or choices. Teaching them, as well as showing them how live in balance.

Validation Acknowledging another person’s reality, “Yes…And” noting that their thoughts, feelings, sensations, and responses are real, and are valid in their own right.

Practice, Practice, Practice

The fundamental dialectic
The Fundamental Dialectic




www. Behavioraltech.org

DBT in a Nutshell

Research Summary

Implementation Models