Treating Trauma in Dialectical Behavior Therapy The DBT
Prolonged Exposure Protocol (DBT PE)
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Library of Congress Cataloging-in-Publication Data
Names: Harned, Melanie S., author.
Title: Treating trauma in dialectical behavior therapy : the DBT prolonged exposure
protocol (DBT PE) / Melanie S. Harned.
Description: New York : e Guilford Press, [2022] | Includes bibliographical references
and index.
Identifiers: LCCN 2021031113 | ISBN 9781462549122 (paperback) | ISBN
9781462549139 (cloth)
Subjects: LCSH: Post-traumatic stress disorder—Treatment. | Dialectical behavior
therapy.
Classification: LCC RC552.P67 H373 2022 | DDC 616.85/21—dc23
LC record available at https://lccn.loc.gov/2021031113
To my children
May you be happy, fulfilled, and free from suffering
About the Author
Melanie S. Harned, PhD, ABPP, is Coordinator of the DBT Program at the
VA Puget Sound Health Care System and Associate Professor in the
Department of Psychiatry and Behavioral Science and Adjunct Associate
Professor in the Department of Psychology at the University of Washington.
She previously served as Research Director of the Behavioral Research and
erapy Clinics at the University of Washington, Director of Research and
Development for Behavioral Tech, and Director of Behavioral Tech
Research. Dr. Harned’s research focuses on the development and evaluation
of the DBT Prolonged Exposure protocol (DBT PE), as well as methods of
disseminating and implementing this and other evidence-based treatments
in clinical practice. She regularly provides training and consultation
nationally and internationally in DBT and DBT PE, and has published
numerous articles and book chapters.
Acknowledgments
Development of the DBT Prolonged Exposure protocol would not have been
possible without the groundbreaking work of Marsha Linehan and Edna Foa
who have spent their careers developing and disseminating the two highly
effective treatments on which DBT PE is based. I am truly privileged to be
able to stand on the shoulders of such giants and to have had their support
as I worked to create DBT PE. I am also particularly indebted to my original
DBT PE treatment development team—Katie Korslund, Annie McCall, Bob
Goettle, and Julia Hitch—for agreeing to enter this uncharted territory with
me before I really had any idea what I was doing. It is an unusual breed of
therapist who says “yes” to treating posttraumatic stress disorder in highly
suicidal clients when there is no evidence base to support this. I am also
grateful to the many other therapists and consultants who have worked with
me on my research over the years and helped to develop DBT PE’s evidence
base: Sara Schmidt, Samantha Yard, Trevor Schraufnagel, Dan Finnegan,
Andrea Neal, Elizabeth Hembree, Tony DuBose, and the teams at Project
Transition, COMHAR, Carson Valley Children’s Aid, and Community
Treatment Teams. Perhaps most importantly, I want to thank the clients who
participated in this research, as well as those I have had the good fortune to
work with in other contexts. Your courage and resilience inspire me to do
this work, and the lessons you have taught me have helped to make this
treatment better and more available to other people who need it.
e Behavioral Research and erapy Clinics at the University of
Washington was my professional home in the years that I was developing
and starting to research DBT PE, and I am grateful to the many colleagues,
students, and postdoctoral fellows who enriched my thinking and my life
while I was there. Katie Korslund was especially helpful in keeping me going
over those years with her combination of validation, wisdom, and quirky
humor. To my current colleagues at the Seattle VA, thank you for welcoming
me so warmly and for providing me with such a validating environment in
which to move DBT PE forward.
Many expert trainers have helped me to disseminate DBT PE to
therapists around the world and I greatly appreciate their contributions to
this mission (and to making me a better teacher). anks are also due to the
courageous therapists who have attended these trainings and are using DBT
PE with some of the most challenging clients in the world. Without them,
my work to develop DBT PE would be pointless.
Writing this book has been quite an undertaking that I sometimes
thought would never end. I want to thank Kitty Moore at e Guilford Press
for believing in me and for being such a steady guide and comforting
presence throughout the process. Annie McCall read every word of this
book more than once and her thoughts are reflected in many of them. She
made sure the human element of this treatment didn’t get lost in translation,
allowed me to steal all her metaphors, and helped me to find my wise mind
more times than I can count. I am especially grateful that she pushed me to
become my own voice while writing this book even (and especially) when I
was scared to do this. Lorie Ritschel also volunteered her time to read this
entire book and it is undoubtedly better as a result. She helped me sharpen
my thinking and tighten up my writing and provided support in numerous
other ways (even when it required her to do exposure). I am also
appreciative of the many other people who read portions of this book and
gave valuable feedback: Sara Schmidt, Jill Rathus, Emily Cooney, Samantha
Yard, Laura Meyers, Katie Smith, Vibh Forsythe Cox, Trevor Coyle, Natalia
Garcia, Charlotte Brill, Colleen Sloan, David Pantalone, and Aaron Brinen.
Finally, thank you to my family and friends for supporting me through
the many years I have been doing this work and the many challenges I
encountered along the way. I could not have done it without you.
Author’s Note
All of the case material in this book is fictional, disguised, or a composite of
many cases. I have made every effort to use gender-neutral pronouns
(they/their/them) throughout the book. e exceptions are examples that
refer to specific individuals.
Contents
Cover
Title Page
Copyright
Dedication
About the Author
Acknowledgments
PART I. Background
1. The Development and Foundations of DBT PE
2. The Target Population
PART II. Stabilization and Preparation
3. Setting the Stage for DBT PE in Pretreatment
4. Achieving Safety, Stability, and Skills in Stage 1
5. Building Motivation for DBT PE
6. Determining Readiness for DBT PE
7. Preparing to Start DBT PE
PART III. The DBT PE Protocol
8. Session 1
9. Session 2
10. Joint and Family Sessions
11. Session 3
12. Intermediate Sessions (Sessions 4+)
13. The Final Session
PART IV. Troubleshooting and Tailoring Treatment
14. Troubleshooting Problems
15. Targeting Specific Trauma-Related Emotions
16. Working with Different Trauma Types
17. Treating Diverse Populations
PART V. Next Steps
18. Stage 3 and Beyond
APPENDIX A. DBT PE Client Handouts
APPENDIX B. Therapist Forms
APPENDIX C. Session Checklists
APPENDIX D. Potential Screening and Outcome Monitoring
Measures
References
Index
About Guilford Press
Discover Related Guilford Books
Purchasers of this book can download and print copies of the handouts
and forms in Appendices A–C at www.guilford.com/harned-forms for
personal use or use with clients (see copyright page for details).
Part I
Background
