DBT-Prolonged Exposure Protocol for PTSD and Complex PTSD in Washington state
Are you trapped between overwhelming trauma symptoms and intense emotions you can't control?
You need more than standard trauma treatment—you need an approach that addresses both
Maybe you've been told you have PTSD and need trauma-focused therapy. Or perhaps you've already tried trauma treatment but couldn't stay in therapy because your emotions became too overwhelming. The flashbacks, nightmares, and constant fear are destroying your life, but when you try to address the trauma, you become flooded with emotions so intense you feel like you're drowning.
You might dissociate and lose time. You might have panic attacks that feel like you're dying. You might engage in self-harm, substance use, or other behaviors just to survive the emotional intensity. Standard trauma treatments ask you to confront your trauma memories, but they don't teach you how to manage the tidal wave of emotions that comes with it.
You're stuck: you can't heal from trauma without facing it, but you can't face it without the skills to manage what it brings up.
Are your trauma symptoms making it impossible to function?
The trauma won't leave you alone. Intrusive memories hijack your day without warning—a smell, a sound, a certain time of day, and suddenly you're back there, heart pounding, body frozen, reliving the worst moments of your life. Or maybe you can't remember clearly, but your body remembers—the panic, the terror, the overwhelming sense of danger that never goes away.
You avoid anything that reminds you of what happened. Certain places, people, conversations, even thoughts—your world has gotten smaller and smaller as you try to stay safe from triggers. But despite all this avoidance, the trauma still controls everything. The nightmares still come. The hypervigilance never stops. You can't relax, can't trust, can't feel safe anywhere.
You're exhausted from being on constant high alert, but you don't know how to turn it off. Sleep is either impossible or filled with nightmares. You startle at every sound. You scan every room for exits. Your body won't believe the danger is over, even though logically you know you're safe now.
Do your emotions become so intense they feel dangerous?
When trauma memories surface or emotions arise, they don't feel manageable—they feel catastrophic. Anger explodes into rage. Sadness becomes unbearable despair. Fear turns into paralyzing panic. Shame feels so toxic you'd do anything to make it stop.
You might cope by self-harming, or maybe you use substances to numb everything, binge and purge, or engage in risky behaviors that let you feel something other than the trauma.
When emotions spike, you might dissociate—spacing out, feeling unreal, losing time, or feeling disconnected from your body. Or you might have emotional breakdowns that last for hours or days, where you're completely overwhelmed and unable to function. People might tell you you're "too sensitive" or "too reactive," but you're not choosing these responses—your nervous system is genuinely overwhelmed.
Standard trauma treatments like Prolonged Exposure or CPT expect you to sit with intense emotions while processing trauma, but if you don't have skills to manage emotional overwhelm, these treatments can feel impossible or even dangerous.
Have you been told you're "not ready" for trauma treatment?
Maybe a therapist told you that you need to "stabilize" before you can do trauma work. Maybe you tried trauma-focused therapy and had to stop because the emotional intensity became unmanageable. Maybe you've been in therapy for years working on "coping skills" but still feel stuck because no one will actually help you process the trauma.
Or perhaps you've been told you need to stop self-harming, get your substance use under control, or improve your emotion regulation before trauma treatment is safe. So you're caught in limbo—the trauma symptoms drive your unhealthy coping behaviors, but you're told you have to fix those behaviors before addressing the trauma. It's a catch-22 that keeps you stuck.
You need both at the same time: trauma processing and emotion regulation skills. You shouldn't have to choose between healing from trauma and learning to manage your emotions—you need treatment that does both simultaneously.
We understand that for many individuals, trauma recovery requires more than exposure alone—it requires skills to manage the intense emotions that trauma processing brings up. We offer DBT Prolonged Exposure (DBT PE), a treatment specifically designed for people with PTSD and emotion dysregulation. This integrated approach teaches you the skills you need to manage overwhelming emotions while also helping you process your trauma so it stops controlling your life.
How DBT Prolonged Exposure works
DBT PE combines two powerful, evidence-based treatments: the emotional regulation and distress tolerance skills from Dialectical Behavior Therapy with the trauma processing techniques from Prolonged Exposure therapy. This gives you both the tools to manage intense emotions and the structured approach to face trauma memories safely.
You'll meet individually with a specialized trauma therapist and participate in skills training at the same time, ensuring you have the regulation skills you need before, during, and after confronting trauma memories.
How the treatment process works
We begin by building your emotional regulation toolkit. Before we ask you to face trauma memories, we make sure you have skills to manage what comes up. You'll learn mindfulness techniques to stay grounded in the present moment when trauma memories pull you into the past. You'll develop distress tolerance skills—concrete strategies to get through emotional crises without self-harm, substance use, or other destructive behaviors. These aren't just concepts; they're practical tools you'll use throughout treatment and beyond.
Next, we teach you about trauma and how exposure works. You'll understand why you're experiencing PTSD symptoms, why avoidance keeps trauma active, and how gradually confronting what you've been avoiding actually reduces its power over you. Knowledge reduces fear—when you understand what's happening and why, the process feels less overwhelming.
Then we start in vivo exposure—facing situations you've been avoiding. Together, we'll create a list of safe situations, places, or activities you've been avoiding because they remind you of your trauma. Starting with moderately difficult items (not the hardest ones), you'll gradually begin approaching these situations while using your DBT skills to manage anxiety. You might start by driving past a location, then parking nearby, then eventually going inside. Between sessions, you'll practice these exposures repeatedly, teaching your brain that these reminders aren't actually dangerous. Your skills keep you regulated while exposure teaches your brain the trauma is over.
We integrate imaginal exposure with emotion regulation skills. This is where you'll revisit the trauma memory itself by describing it aloud in detail to your therapist, including sensory details and emotions. You record these sessions, and you'll listen to the recording daily at home. This sounds terrifying—and it's natural to feel scared—but here's the crucial difference from standard PE: you have DBT skills to use before, during, and after exposure. If emotions become too intense, you pause and use skills to regulate. If you start to dissociate, you use grounding techniques. If urges to self-harm arise, you have distress tolerance strategies. The skills make trauma processing possible when it otherwise wouldn't be.
We process what comes up and reinforce your skills. After each exposure, you'll work with your therapist to process what emerged—emotions, beliefs, insights. You'll identify any stuck points (beliefs like "I'm permanently damaged" or "I can't trust anyone") and challenge them using cognitive techniques. Over time, the trauma memory loses its emotional intensity, your avoidance decreases, and you build confidence in your ability to handle difficult emotions without falling apart or engaging in destructive behaviors.
Why choose DBT Prolonged Exposure at our clinic?
We specialize in complex trauma presentations. Our therapists are trained in both DBT and PE, and we've successfully treated people with complex PTSD, histories of self-harm, suicidal ideation, substance use, eating disorders, and severe emotion dysregulation. We help you build stability while processing trauma, because that's what actually works.
Our integrated approach addresses what other treatments miss. Standard PE is highly effective but wasn't designed for people with severe emotion dysregulation. Standard DBT is excellent for emotion management but doesn't always adequately address trauma. DBT PE gives you both: you learn to regulate emotions while also directly processing the trauma that drives those emotions. Research shows that DBT PE is safe and effective even for people who would typically be excluded from standard PE due to complexity.
We provide comprehensive support throughout treatment. Beyond your individual sessions, you have access to phone coaching between sessions when you need real-time skill support. We monitor your safety closely and adjust the pace of exposure based on what you can handle. Your therapist is part of a consultation team that ensures you're receiving the best possible care. You're never alone in this process—we're with you every step of the way, providing both structure and flexibility to match your needs.
Frequently Asked Questions
How is DBT PE different from regular Prolonged Exposure therapy?
DBT PE explicitly integrates emotion regulation and distress tolerance skills throughout trauma processing. In DBT PE, we actively teach and reinforce skills to manage overwhelming emotions, prevent dissociation, and reduce urges to self-harm or use substances. This makes trauma processing accessible and safe for people who couldn't tolerate standard PE.
What if I dissociate or have panic attacks during exposure?
This is exactly why we teach you skills first. Before starting exposure work, you'll have grounding techniques, breathing strategies, and other tools specifically designed to prevent or interrupt dissociation and manage panic. During exposure, we monitor closely for signs you're becoming too dysregulated, and we'll pause to use skills if needed. The goal is to stay in the "window of tolerance"—emotionally activated enough for learning to happen, but not so overwhelmed that you dissociate or shut down. Your therapist is trained to help you stay in this optimal zone.
What if I have multiple or chronic traumas—can DBT PE help with that?
Yes, DBT PE was designed for individuals who are faced with this reality. Your therapist will help you identify the first index event to focus on, often based on careful assessment of what is causing the most distress or impairment in your current life, and we focus on processing that trauma first. Many people find that once they've processed one trauma using DBT PE, they have both the skills and confidence to address other traumatic experiences if needed. The emotion regulation skills you learn apply across all traumatic memories. Some clients choose to process multiple traumas sequentially in treatment, while others find that processing their most distressing trauma significantly reduces symptoms related to other events as well.
How do I know if I need DBT PE versus regular PE or CPT?
If you have PTSD with significant emotion regulation difficulties—such as self-harm, substance use, eating disorder behaviors, frequent emotional crises, dissociation, or if you've been told you're "not ready" for trauma treatment—DBT PE is likely a better fit than standard trauma therapy. If your PTSD is relatively straightforward without these complicating factors, standard PE or CPT might be sufficient. During your initial intake, we'll help you determine which approach best matches your needs.