behavior therapy (DBT), Seeking Safety, and eye movement desensitization and reprocessing (EMDR). Dialectical Behavior Therapy Marsha Linehan (2014; 2020) originated DBT, which borrows from CBT and mindfulness meditation practices, as a treatment protocol for clients diagnosed with borderline personality disorder. This therapy has since been used to help clients with a variety of other diagnoses—including those with a history of trauma—learn to self-regulate, self-soothe, and improve their interpersonal relationships (Lineman, 2020). DBT is a type of CBT that combines a dialectical worldview (i.e., two or more conflicting or opposing thoughts or ideas can both be true) with basic behavioral principles. A dialectical worldview stresses the fundamental interrelationships of reality that comprise internal and external parts and remains aware that the nature of reality involves change and process. This therapeutic worldview also incorporates a biosocial theory that describes emotion dysregulation as the interaction between an invalidating environment and an internal biological process. DBT seeks to address the impact of traumatic stress on functioning. The general goal is to “learn and refine skills in changing behavioral, emotional, and thinking patterns . . . that cause misery and distress” (Linehan, 2014, p. 6). The therapy works to address the interpersonal and intrapsychic dysregulation frequently experienced by survivors of chronic trauma. DBT has four main components (Linehan, 2020). ● Core mindfulness skills are skill sets employed to balance the “emotional mind” (when thinking and behavior are governed by current emotional states) and “reasonable mind” (when knowledge or action is approached solely from an intellectual standpoint, ignoring other salient aspects of a situation). The synthesis of these two, known as the “wise mind,” offers skills to help an individual stay grounded in the present moment, even while thinking of a frightening past or potential future. ● Distress tolerance skills relate to tolerating affect, accepting life as it is in the moment, and tolerating crises without a loss of functioning. These skill sets improve coping and increase resilience. ● Emotion regulation skills include being able to identify primary and secondary emotional responses in a nonjudgmental manner and learning skills to self-soothe and stay within the window of tolerance. The goal here is to learn to modulate feelings and not become overwhelmed by them. ● Interpersonal effectiveness skills include effective strategies for being in relationships that are acquired by learning to set appropriate limits and to ask for what one needs. Coping effectively with interpersonal conflict by negotiating solutions to problems, while maintaining and protecting relationships, is also stressed. Based upon the recognition that “a history of trauma is the norm rather than the exception among individuals receiving dialectical behavior therapy” (Harned, 2022, p. 3), the DBT Prolonged Exposure Protocol (DBT PE) was developed. DBT PE (Harned, 2022) is an effective option for individuals who would benefit from the skills and stabilization of DBT while simultaneously receiving trauma-focused treatment. Similar to recent approaches of concurrent substance use and trauma treatment, DBT PE can allow clients to alleviate their symptoms of PTSD at an earlier stage rather than waiting to complete full stage 1 DBT prior to trauma processing. Seeking Safety Seeking Safety is an integrated, evidence-based, present- symptom-focused, manualized counseling model designed to help people attain safety from trauma and/or substance abuse simultaneously (Litt et al., 2019). Developed by Lisa Najavits in 2002, Seeking Safety directly addresses both trauma and addiction, but without requiring clients to delve into the trauma narrative, thus making it relevant to a broad range of clients and easy to implement. It is an extremely safe and flexible model in
which clinicians can modify the sessions based on client needs. This therapy can be conducted in group or individual formats, for men and women, adults or adolescents, any length of treatment, any level of care (e.g., outpatient, inpatient, residential), any type of trauma, and any type of substance. Clients do not have to meet formal criteria for PTSD or substance abuse; the therapy is often used as a general model to teach coping skills. Seeking Safety has been successfully implemented for many years across vulnerable populations, including people who are homeless, people caught up in the criminal justice system, people involved in domestic violence, people who have severe mentally illness, veterans and military personnel, and others (Cook et al., 2006; Najavits et al., 2016; Najavits et al, 2018; Tripodi et al., 2019). Seeking Safety offers 25 topics that can be conducted in any order and as few or many as time allows: Introduction to Treatment/Case Management, Safety, PTSD: Taking Back Your Power, When Substances Control You, Honesty, Asking for Help, Setting Boundaries in Relationships, Getting Others to Support Your Recovery, Healthy Relationships, Community Resources, Healing from Anger, Compassion, Creating Meaning, Discovery, Integrating the Split Self, Recovery Thinking, Taking Good Care of Yourself, Commitment, Respecting Your Time, Coping with Triggers, Self-Nurturing, Red and Green Flags, Detaching from Emotional Pain (Grounding), Life Choices, and Termination. The key principles of Seeking Safety are (Najavits, 2001): ● Safety as the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions) ● Integrated treatment (working on both trauma and substance abuse at the same time) ● A focus on ideals to counteract the loss of ideals in both trauma and substance abuse ● Four content areas: Cognitive, behavioral, interpersonal, and case management ● Attention to clinician processes (clinicians’ emotional responses, self-care, and so on) Eye Movement Desensitization and Reprocessing Eye movement desensitization and reprocessing (EMDR) is a therapeutic approach based on the theory of Adaptive Information Processing and focuses on the processing of information in order to reduce posttrauma symptoms and distress (Shapiro, 2017). The theory suggests that when PTSD occurs, an individual has inadequately processed traumatic events and that memories of these events are stored in a state- specific form with the original distress and are not integrated with other memories (Beauvais et al., 2021). In this approach, the therapist has the client focus on a visual image related to a traumatic memory, a negative thought about the self, and any related bodily sensation while concurrently providing bilateral stimulation in the form of eye movements, taps, or tones. The client is instructed to notice whatever emerges during this process and then to consider identified positive thoughts and beliefs. Francine Shapiro (2017) theorizes that this protocol allows the client to more fully process traumatic memories in a more adaptive way through a focus on both internal (i.e., distressing thoughts) and bilateral (i.e., eye movements) stimuli. Overall, EMDR combines several therapeutic approaches, including brief exposures to traumatic material and mindfulness regarding the various sensations and thoughts that emerge during the exposure process—with the goal of creating less psychic reactivity to traumatic stimuli, thoughts, or other sequelae. Focusing on traumatic memories may be uncomfortable, but EMDR appears to be effective in reducing PTSD symptoms. Inconsistent practice and lack of specialized training can, however, reduce the efficacy of EMDR (Cusack et al., 2016). In its early years, EMDR was considered somewhat controversial; however, many randomized controlled trials have supports its efficacy and EMDR is now considered a strongly recommended treatment by the Department of Veterans Affairs (Management for Posttraumatic Stress Disorder Work Group, 2017).
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