Eye Movement Desensitization and Reprocessing (EMDR) and Dialectical. Behaviour Therapy (DBT) are very different psychotherapies. Theoretically they differ in their principle of their working mechanisms of change significantly however, they do overlap in some ways.
Both EMDR and DBT are used with people with Complex PTSD, BPD and those with emotion regulation issues. It is important to note that there is not an agreed upon gold standard of psychotherapy treatment for CPTSD, however there is an emerging evidence base of the effectiveness of both EMDR and DBT for treatment for people with Complex Trauma and Emotion Regulation.
They focus on different outcomes- DBT works to decrease suicidality and increase emotion regulation, whereas EMDR focuses on healing PTSD and improving positive self worth.
I believe the DBT and EMDR can be effectively used in tandem to help improve the quality of life in individuals with CPTSD, including those with Borderline Personalty Disorder and Substance Use.
DBT
DBT is considered a third wave cognitive behavioural therapy, that was developed at a similar time to other third wave Cognitive Behavioural Therapies (CBT) like Acceptance and Commitment Therapy (ACT) and MBSR (Mindfulness Based Stress Reduction) and MBCT (Mindfulness Based Cognitive Therapy).
What is third wave Cognitive Behavioural Therapy?
The “first wave” of CBT therapy was purely Behaviour therapy and relied on principles such as operant and classical conditioning (eg. rewards and punishments), B.F. Skinner was one of the most known theorists and developer of this therapy. The “second wave” emerged with the combination of behaviour therapy with cognitive therapy with its primary developer being Albert Ellis and Aaron Beck. They shifted the focus to changing thinking as the primary mode of changing emotional states.
The third wave of CBT shifted the focus from the content of a person’s thoughts and behaviours to focus more broadly on the context, processes and functions of a behaviour. This resulted in integrating an emphasis on values, mindfulness, acceptance, metacognition and spirituality. These new emphases do not supplant the traditional emphasis on changing thoughts and behaviours but build upon them and work alongside them.
More about DBT
DBT founder Marsha Linehan has explained in various publications and videos that she added an emphasis on acceptance and validation based on how invalidating her clients with emotion regulation and suicidality felt (primarily those with Borderline Personality Disorder) when she solely focused on the change based strategies from CBT. However when she only focused on acceptance and validation strategies she noted that her patients were frustrated with the lack of emphasis on change in therapy.
One of the main strategies for decreasing emotional reactivity in DBT is to developing acceptance strategies including validation, self-compassion and mindfulness. Minddfulness is developed through practice both in and outside of therapy- in DBT therapy clients are encouraged to practice mindfulness daily and each DBT group begins with a mindfulness exercise. In DBT participants are not asked to adopt lengthy meditation practices but are encouraged to practice mindfulness in a bite-sized manner.
One key change strategy in DBT is examining behaviour without judgement and adopting alternative behaviours and decreasing problematic behaviours. Alternative behaviours are taught in the form of DBT skills but they can be any skill that is effective for someone and not harmful to themselves or their relationships.
DBT therapists are trained to help clients understand how problematic behaviours are maintained and also taught how to find ways to change these behaviours in a non-judgemental and mindful way.
This is most often done through the practice of chain analysis where we examine the links (events, context, actions, feelings, thoughts, etc) that led up to the problem behaviour and the aftereffect of this behaviour. For example if a person ends up in an explosive argument with their partner while drinking, we look at what led them to drinking, the environment, the thoughts, actions, and then the after effects of the drinking or fighting and then look to find solutions to help avoid similar patterns in the future (solution analysis).
What are the limitations of DBT therapy as a treatment for Complex PTSD?
The main limitations for DBT therapy to treat complex PTSD is that although it can help with improving relationships, and decreasing emotional reactivity, the first stage of DBT (using skills) is not proven to decrease PTSD symptoms in a significant way (flashbacks, nightmares). In theory DBT therapists have three stages of treatment and the second stage is set aside for treating trauma.
There are adaptions of DBT including DBT-PE (Prolonged Exposure) and DBT-PTSD (Bohus) that have addressed this issue and have integrated PTSD treatment into their protocol and has shown promising research results for those with CPTSD.
What are the benefits of DBT therapy as a treatment for PTSD?
DBT is an ideal therapy to provide alongside or prior to beginning an evidence based PTSD therapy, such as EMDR. Research has shown that it is not absolutely necessary to adhere to a phase based model for PTSD and Complex PTSD treatment (Van Illet et al, 2021*).
DBT can provide excellent practical coping tools to navigate daily life including triggers and times when someone finds themselves outside of the window of tolerance in hyperarousal (fight or flight) or hypoarousal (freeze/collapse). It is a structured treatment that encourages practice outside of session.
EMDR
Eye Movement Desensitization and Reprocessing Therapy (EMDR) was developed by Francine Shapiro in the 1980’s. It is based on the Adaptive Information Processing(AIP) model. This model posits that the experiences we have had throughout our life, especially in our earlier years of life have shaped the way we face and react to our current life situations-they form the glasses that we wear everyday to interpret and understand life. This is especially true for people with CPTSD, who have faced multiple and repeated adverse events in life.
The trauma experienced in the past is encoded in our reactions and body sensations when we face situations or events that remind us unconsciously or consciously of our past negative experiences and shape our beliefs about ourself, others and the world.
According to AIP model, these are adaptions that are meant for survival but we have a hard time moving out of this survival mode after the trauma is over. Once this information (body sensations, thoughts, memories) are accessed and processed (unstuck) we naturally connect to the adaptive information we have that is empowering and helpful.
How is EMDR different from DBT?
EMDR does not have any homework involved. EMDR processing is done in session and as traumatic memories are accessed and processed people often find they are less reactive and do not find those previous memories disturbing any longer. After EMDR people with Complex Trauma are better able to navigate interpersonal situations that were previously very triggering. People also note feeling more confident and less worried about thoughts that plagued them previously.
EMDR can be a shorter therapy than DBT depending on the trauma that is being treated. There is not a prescribed amount of sessions and it can vary from person to person and depending on their treatment goals.
In contrast DBT in its traditional standard form is 6-12 months long and includes individual and group therapy for adequate benefit alongside phone coaching and the therapists join a DBT consultation team
What are the limitations of EMDR?
EMDR requires a certain level of stability to enter into the processing phase. EMDR therapists do teach stabilization but if a client is suicidal or in very active substance use it may mean that EMDR is not the right fit at this time- in that case a standard course of DBT may be useful. As well, some people with complex trauma can find it overwhelming to do past trauma work, and may be advised or prefer to do more stabilization before beginning trauma therapy. DBT is an ideal therapy for those wanting or needing further skills and stabilization prior to commencing trauma therapy.
How do you use DBT and EMDR together?
EMDR and DBT are an excellent combination of therapies when working with complex trauma and emotion regulation issues.
My preference is that clients with CPTSD and emotion regulation issues have the option to attend a DBT group alongside doing EMDR therapy. If working with clients individually I provide about 4-6 sessions of DBT individual therapy at the outset of our time together to learn mindfulness, and a few DBT skills that can help with them as well as introduce to core principles of DBT such as dialectics and chain analysis. We may use the diary card to encourage and monitor skills practice and mood outside of group.
When client is increasing in their stability and using DBT skills outside of group I may start EMDR treatment planning while reviewing the DBT concepts we have learned. Many of the DBT Distress Tolerance activities mirror or are included in preparation (Phase 2) of EMDR therapy.
I begin EMDR processing as soon as the client is stable enough (which can vary from person to person from a month to 6 months), pausing sessions as needed to attend to relational and interpersonal dynamics. DBT skills can be useful to navigate these challenges (for example if someone is experiencing suicidal urges or substance use issues) . I tend to return processing trauma as soon as possible after focusing on everyday skills use because processing trauma may reduce the overall level of emotion regulation issues and consequentially reduce the need to use as many DBT skills. Throughout the treatment we may alternate between processing trauma and reinforcing and learning and reviewing DBT skills to help navigate challenges outside of session.
Please let us know if you have any questions about Combining EMDR and DBT for effective treatment for Complex PTSD. If you would like to start therapy with any of our EMDR and DBT therapists at Emotion Wise Counselling, please reach out today.
*van Vliet NI, Huntjens RJC, van Dijk MK, Bachrach N, Meewisse M-L, de Jongh A. Phase-based treatment versus immediate trauma-focused treatment for post-traumatic stress disorder due to childhood abuse: randomised clinical trial. BJPsych Open. 2021;7(6):e211. doi:10.1192/bjo.2021.1057
コメント