DBT stages and Trauma

DBT is a stage-based therapy, with trauma processing typically introduced only after a period of stabilisation. While this structure is designed to ensure safety, research suggests that in practice many therapists remain focused on early-stage behavioural work, with some clients never progressing to trauma-focused interventions. This is problematic as some research suggests that at least 50% of people accessing DBT are likely to have co-occurring PTSD. Qualitative studies highlight that some individuals experience the stage-based approach as a delay —or even avoidance—of trauma work, with reports of being discouraged from discussing past experiences until they are considered “ready" or sufficiently stable.

DBT suggests that behavioural control remains the cornerstone of stage 1 of treatment. This includes a reduction of self-harm and suicidal behaviour and urges. In our experience, ensuring behavioural control (not acting on self-harm or suicidal urges for a significant period of time) is an important first step towards a trauma focused intervention. However, our experience is that the experience of urges (without acting on them) can provide an important pathway into trauma work. One of the approaches we adopt to do this is Eye Movement Desensitisation and Reprocessing (EMDR). There are a number of evidence-based DBT-trauma integrations (DBT-PTSD led by Bohus and colleagues or DBT-PE developed by Harned and colleagues) though these arguably align more readily to cognitive behavioural approaches. We believe that EMDR may offer an alternative, non-cognitive approach when integrated with DBT.  

Stage-1 of DBT also promotes a greater confidence, understanding and ability to experience emotions which is an essential prerequisite to trauma focused approaches. Gaining a greater emotional awareness, and ability to validate emotions as they arise further may help individuals become aware of the roots of where these emotions were first learned and experienced. These can translate in EMDR to potential targets. 

In summary, DBT offers a structured and effective framework for stabilisation, helping individuals build the safety, skills, and emotional awareness needed to engage in both therapy and building a life worth living. However, given the high prevalence of trauma among those accessing DBT, there is a risk that a strong focus on Stage 1 can inadvertently delay or limit access to trauma-focused interventions. While behavioural control and emotional regulation are important foundations, they do not in themselves automatically resolve the impact of past experiences. A more flexible, individualised approach—where readiness is assessed collaboratively and trauma work is introduced at the appropriate time—may help ensure that stabilisation becomes a bridge to, rather than a barrier against, meaningful trauma processing.

​We aim to write more about our formulation of a DBT based trauma framework in the coming weeks and to further explore and research an integration with EMDR.