DBT & DBT PE: The Cutting Edge of Treating Trauma and Substance Use Disorders

Renowned as innovators in the treatment of substance use disorders, Freedom Institute and Veritus are now poised to begin treating trauma, which is often at the root of an individual's substance use disorder. Our clinicians have already or will be completing training in Dialectical Behavior Treatment Prolonged Exposure (DBT PE), the latest cutting-edge version of DBT, specifically created to address trauma. Our entire clinical team will be trained in this protocol in early 2023. 

Recent research states that 80% of people with substance use disorders have a trauma history. Freedom Institute's and Veritus's world-renowned Intensive Out Patient Programs (IOP) are the only fully model adherent DBT Substance Use Disorder IOPs in the country and trauma work is already embedded within DBT Skills Training in our 12-week IOPs. All of our clients undergo an initial assessment, and any potential trauma-processing candidates are additionally screened for PTSD, initially and then intermittently, throughout the course of the IOPs. Our IOPs work to stabilize the individual in terms of substance abuse before dealing with their trauma. Trauma treatment normally begins midway through the IOP, around week five or six, and every client has the full focus of our highly skilled and trained clinicians and their combined expertise from the initial assessment onwards.

April Tully, LCSW joined Freedom Institute & Veritus as Clinical Director in August 2022. With a professional background in trauma treatment, her training and expertise has led Freedom Institute & Veritus to expand treatment options to focus on trauma as an underlying cause of substance use disorders in certain clients. We sat down for a Q&A with April. Read on to learn more.

Tell us a little about your background?
My background is unique in that it is in trauma treatment unlike most substance use treatment professionals. Prior to joining Freedom Institute, I was the Military Sexual Trauma Coordinator at the Department of Veterans Affairs Healthcare System in NJ. I approach addiction from this perspective, because you can’t treat addiction without treating trauma and vice versa.

What is PTSD and how is it linked to substance abuse?
This is a larger discussion, but PTSD or Post-Traumatic Stress Disorder is a neurologically based disorder, which means that trauma has restructured the individual's nervous system. We usually think of PTSD in relation to veterans and combat, but PTSD may be caused by exposure to any traumatic or life threatening event, such as sexual assault, child abuse, domestic violence, car crashes, natural disasters as well as to a secondary trauma of having to bear witness to the loss of life, as in the case of an ER doctor or nurse whose work exposes them to such events, particularly though not exclusively during the Covid-19 pandemic.

Because the majority of people with substance use disorders have a trauma history, my firm belief is that until our field becomes more consistent in treating the underlying traumas that drive addictions or at the very least, strongly contribute to them, we, and most importantly our clients, will never see the lifelong treatment outcomes we want.

What are some of the modalities used to treat trauma?
As a trauma specialist, it was my mission to get trained in the best evidence-based trauma protocols available, beginning with EMDR (Eye Movement Desensitization and Reprocessing), Cognitive Processing Therapy (CPT), and standard Prolonged Exposure (PE), which was developed by Edna Foa, and of course DBT, which has now evolved to DBT PE and is specific to trauma. Of all these trauma treatment modalities, DBT PE has the most research behind it and is proven to be successful in healing individuals with trauma, leading to higher success rates for long-term, lifetime sobriety.

Freedom Institute’s and Veritus’ IOPs are world-renowned for integrating DBT in their substance abuse treatment protocols. How does DBT help treat trauma?
DBT was not originally designed to be an addiction protocol, but we are renowned for adopting the SUD version later created by Marsha Linehan through Behavioral Tech for use in our IOPS.

Nor was DBT designed specifically as a trauma-processing protocol, but DBT already has certain trauma-processing aspects built right into it, such as cognitive modification techniques, exposure, and contingency management.  It is therefore the treatment of choice to stabilize those who suffer from PTSD and other forms of emotional dysregulation before they begin the actual work of trauma processing. Research has shown that about 35% of people with PTSD who completed standard DBT training experienced remission from their trauma symptoms.  

However, this leaves 65% of individuals with PTSD who do not achieve remission in substance abuse disorders from undergoing treatment using standard DBT alone. Studies have demonstrated that PTSD, like most chronic conditions, if left untreated will become worse over time. 

Marsha Linehan, who developed DBT, correctly stipulates (with other experts in the field) that patients cannot and should not undergo trauma processing until they are no longer considered to be in stage 1 (where they are subject to extreme emotional dysregulation, which may include self-injurious and life-threatening behaviors). In DBT, there were no criteria to establish when a person had attained the necessary level of stabilization to be ready to begin trauma processing, and what trauma-processing methods should be employed.

When and how was DBT adapted to treat trauma?
In 2009, Dr. Melanie Harned, a student of Linehan’s while receiving her doctorate at the University of Washington, asked: “How do you determine when in the course of DBT someone is ready to begin trauma processing, and what modality do you use?”

Linehan’s response was that Melanie should conduct some research to find out. It took Dr. Harned at least 10 years of clinical trials and study (she learned standard PE from Edna Foa, the founder of that protocol), but the end result is DBT PE. Dr. Harned did not simply graft standard PE onto DBT, she reframed some of its basic assumptions and refined it.

Dr. Harned’s training manual was published and made available to the public in the spring of 2022. Standard PE was, and remains, a phenomenal trauma-processing tool. It has been the most studied of the evidence-based trauma treatments and yields the best results of all of them. Dr. Harned dramatically enhanced and improved the protocol by reimagining PE through the lens of DBT, so that it now has even greater efficacy and precision with less risk, which is why all of us at Freedom Institute and Veritus will undergo the training. We are tremendously excited about DBT PE’s potential to treat both the addicted and traumatized populations.

How do Freedom Institute/Veritus use DBT PE in our IOP to treat trauma?
Because PTSD is a neurologically based disorder and often at the root of a person’s substance use, successful treatment needs to be targeted at the neurological level. DBT PE is specifically designed to treat PTSD. DBT helps to stabilize the functioning of newly abstinent patients and teaches them the tools they need to regulate their fluctuating mood states, which in turn helps to support their sobriety. Once the clinical team determines that the clients are no longer at imminent risk for serious self-harm or suicidal behavior, we can initiate trauma-processing, which should occur about midway through the IOP.

From the assessment and then every week, clients undergo a PTSD screening. The base score for this screening is monitored and our clinical team works with the client to reduce this score. The PTSD scoring scale varies according to which test we choose to administer (there are several), but most have a range of 17-20 questions.

As explained in Bessel van der Kolk's groundbreaking book, The Body Keeps the Score, PTSD is sustained by avoidance, which is both a symptom of the disorder as well as a strategy people utilize, often unconsciously, to escape from feeling overwhelmed. They will also turn to drugs and alcohol to help numb themselves, since the intensity of these symptoms is pretty unbearable. Research has discovered that the brain has neuroplastic capabilities, which means that the circuitry can rewire by undergoing certain forms of therapeutically driven controlled episodes of re-experiencing the avoided traumatic memories through two types of exposure -- imaginal and in vivo.  We work with our clients to experience both.

Imaginal requires the patient to recount his/ her trauma narrative over and over again with the goal of transforming it from an experience that the person is forced to relive on a physical as well as an emotional level, to something that is a bad memory, which he can choose to think about, or not, but which no longer hijacks them when s/he is exposed to environmental triggers. In vivo exposure requires someone to face those environmental triggers in current day, real life experiences, since their brains now confuse feeling uncomfortable with actually being unsafe, and the only way to correct this misperception, which is happening at a neurological level, is to have the individual acquire the new learning that their avoidance has prevented -- i.e., that being uncomfortable is not the same thing as being in actual physical danger.

This is the first in a series of article from Freedom Institute & Veritus on the underlying causes of and the innovative technics we use to treat substance use disorders. Stay tuned for more.