Research

 

The DBT PE treatment approach involves the integration of two evidence-based treatments that are considered gold standards for the problems they are designed to treat. Extensive research already provides strong support for Dialectical Behavior Therapy for the treatment of suicidal and self-injurious behavior, particularly among individuals with borderline personality disorder, and for Prolonged Exposure therapy for the treatment of PTSD. Thus, research on the integrated DBT+DBT PE treatment has focused on confirming the feasibility, acceptability, safety, and effectiveness of adapting and combining these two highly effective treatments.

Key Research Questions

Acceptability

A majority of clients (74-90%) report a preference for DBT + DBT PE compared to either DBT or PE alone. [1, 2]

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Feasibility

The DBT PE protocol is feasible to deliver for a majority of clients during one year of DBT. [3,4]

Key statistics

  • 60% of clients started the DBT PE protocol.

  • On average, the DBT PE protocol was started after 20 weeks of Stage 1 DBT.

  • Of those who started the DBT PE protocol, 73% completed it.

  • On average, the DBT PE protocol took 13 sessions to complete.

  • The primary barrier to starting the DBT PE protocol was premature dropout from Stage 1 of DBT.

Safety

  • Urges to commit suicide and self-injure rarely increase immediately after completing an exposure task. [3,4]

  • Adding the DBT PE protocol to DBT is likely to decrease the risk of suicidal and self-injurious behaviors. [4]

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Effectiveness for PTSD

PTSD outcomes at post-treatment are described below for the two studies conducted in academic research settings [3,4]. 

  • Rates of diagnostic remission from PTSD ranged from 71-80% among DBT PE treatment completers and 58-60% among all clients assigned to receive the DBT PE protocol (i.e., the intent-to-treat (ITT) samples).

  • Among treatment completers in the pilot RCT, PTSD remission rates were 2x higher in DBT PE than in DBT (80% vs. 40%).

Improvements in PTSD were maintained in the 3 months after treatment for clients in DBT PE. Of the clients in DBT who had remitted from PTSD at post-treatment, 100% relapsed in the three months after treatment.  

 
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Effectiveness for Comorbid Problems

DBT + DBT PE is associated with high rates of recovery (60-100%) for multiple comorbid problems. [4] 

  • Among DBT PE treatment completers, recovery rates were 60-100% across comorbid problems.

  • Among DBT treatment completers, recovery rates ranged from 0% (global functioning) to 20% (depression, trauma-related guilt, shame).

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Effectiveness in Community Practice Settings

DBT + DBT PE has been found to be effective among veterans receiving treatment in a VA medical center [5], adolescent girls receiving treatment in a residential or partial hospital program [6], and clients receiving treatment in diverse practice settings from clinicians who had attended DBT PE workshops [7]. Outcomes achieved in these settings are similar to those found in research settings. 

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Mechanisms of Action

Analyses of treatment mechanisms and the course of change in DBT PE indicate that:

  • PTSD does not significantly improve in DBT until Stage 2 when it is directly targeted via the DBT PE protocol. [8]

  • Changes in post-traumatic cognitions [9] and between-session habituation [10] predict improvements in PTSD.

  • Improvement in PTSD is, in turn, associated with subsequent improvements in suicidal ideation, dissociation, depression, global severity, borderline symptoms, social adjustment, and health-related quality of life [8, 9, 11].

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Ongoing and Recently Completed Research

A Hybrid Effectiveness-Implementation Trial of Treatments for Veterans with PTSD at Elevated Acute Risk for Suicide (Sept 2023 - Aug 2027)

Principal Investigator: Melanie Harned, PhD
Funding Agency: VA Office of Research and Development/HSR&D (SDR 22-185)
This  multi-site randomized controlled trial aims to evaluate the effectiveness of DBT + DBT PE vs. PE + suicide risk management among Veterans with PTSD at elevated acute risk for suicide, as well as evaluate barriers and facilitators to implementing both treatments in VA. Read more. 

Effectiveness and Implementation of PTSD Treatment for Suicidal and Multi-Diagnostic Clients in Community Practice Settings (September 2018 to September 2021)

Principal Investigator: Melanie Harned, PhD
Funding Agency: National Institute of Mental Health (R56MH117085) 
The aim of this project is to gather data and information to be prepared to conduct a future large-scale hybrid effectiveness-implementation trial of DBT with and without the DBT PE protocol in community practice settings.   Read more. 

Effectiveness of PTSD Treatment for Suicidal and Multi-Diagnostic Clients (April 2015 to March 2019)

Principal Investigator: Melanie Harned, PhD
Funding Agency: National Institute of Mental Health (R34MH106598) 
This  pilot project aims to evaluate the feasibility, acceptability, safety, and effectiveness of this intervention when implemented in community agencies, as well as develop and test the methods needed to successfully transfer the intervention into routine clinical practice.  Read more. 

References

  1. Harned, M. S., Tkachuck, M. A., & Youngberg, K. A. (2013).   Treatment preference among suicidal and self-injuring women with borderline personality disorder and PTSD.   Journal of Clinical Psychology, 69,749-761.

  2. Harned, M. S. & Schmidt, S. C. (2019). Perspectives on a stage-based treatment for posttraumatic stress disorder among Dialectical Behavior Therapy consumers in public mental health settings. Community Mental Health Journal., 55, 409-419.

  3. Harned, M. S., Korslund, K. E., Foa, E. B., & Linehan, M. M. (2012).   Treating PTSD in suicidal and self-injuring women with borderline personality disorder: Development and preliminary evaluation of a Dialectical Behavior Therapy Prolonged Exposure protocol.   Behaviour Research and Therapy, 50, 381-386.  

  4. Harned, M. S., Korslund, K. E., & Linehan, M. M. (2014).   A pilot randomized controlled trial of Dialectical Behavior Therapy with and without the Dialectical Behavior Therapy Prolonged Exposure protocol for suicidal and self-injuring women with borderline personality disorder and PTSD.   Behaviour Research and Therapy, 55, 7-17.

  5.  Meyers, L., Voller, E. K., McCallum, E. B., Thuras, P., Shallcross, S., Velasquez, T. & Meis, L. (2017). Treating veterans with PTSD and borderline personality symptoms in a 12-week intensive outpatient setting: Findings from a pilot program.   Journal of Traumatic Stress, 30, 178-181.

  6. Kaplan, C., Aguirre, B., & Galen, G. (October, 2015). Targeting PTSD in an adolescent BPD population: Pilot data using the DBT PE protocol. Presented at the McLean Hospital DBT Training Seminar, Belmont, MA.

  7. Harned, M. S. & Schmidt. S. C. (2017, September). Can workshop training change community clinicians' practice? A non-randomized comparison of two workshop lengths for training clinicians in the DBT Prolonged Exposure protocol for PTSD. Poster presented at the 4th Biennial Conference of the Society for Implementation Research Collaboration, Seattle, WA. 

  8. Harned, M. S., Gallop, R. J., & Valenstein-Mah, H. R. (2016).   What changes when? The course of improvement during a stage-based treatment for suicidal and self-injuring women with borderline personality disorder and PTSD.   Psychotherapy Research. DOI: 10.1080/10503307.2016.1252865.  

  9. Harned, M. S., Wilks, C., Schmidt, S., & Coyle, T. (2018). Improving functional outcomes in women with borderline personality disorder and PTSD by changing PTSD severity and post-traumatic cognitions. Behaviour Research and Therapy, 103, 53-61.

  10. Harned, M. S., Ruork, A. K., Liu, J., & Tkachuck, M. A. (2015).   Emotional activation and habituation during imaginal exposure for PTSD among women with borderline personality disorder.   Journal of Traumatic Stress, 28, 253-257.

  11. Harned, M. S., Wilks, C., Schmidt, S. & Coyle, T. (2016, October). The impact of PTSD severity on treatment outcomes in DBT with and without the DBT Prolonged Exposure protocol. In C. Wilks (Chair), The how and the why: Mechanisms and change processes of DBT. Symposium presented at the 50th Annual Convention of the Association for Behavioral and Cognitive Therapies, New York, NY. 

  12. Tully, I. A., Schmidt, S. C., & Harned, M. S. (2019, November). Symptoms of post-traumatic stress, but not global disease burden, are associated with suicidal behavior in multi-diagnostic individuals with PTSD. Poster presented at the 53rd Annual Convention of the Association for Behavioral and Cognitive Therapies, Atlanta, GA.

  13.  Harned, M. S., Fitzpatrick, S., & Schmidt, S. C. (2020). Identifying change targets for posttraumatic stress disorder among suicidal and self-injuring women with borderline personality disorder. Journal of Traumatic Stress, 33, 610-616.

  14. Harned, M. S., Schmidt, S. C., Korslund, K. E. & Gallop, R. J. (in press). Does adding the Dialectical Behavior Therapy Prolonged Exposure (DBT PE) protocol for PTSD to DBT improve outcomes in public mental health settings? A pilot nonrandomized effectiveness trial with benchmarking. Behavior Therapy.

  15. Harned, M. S., Ritschel, L. A., & Schmidt, S. C. (in press). Effects of workshop training in the Dialectical Behavior Therapy Prolonged Exposure protocol on clinician beliefs, adoption, and perceived clinical outcomes. Journal of Traumatic Stress.