Journal of Traumatic Stress, Vol. 24, No. 1, February 2011, pp.

102106 ( C
2011)
B R I E F R E P O R T
Dialectical Behavior Therapy for Posttraumatic Stress
Disorder Related to Childhood Sexual Abuse: A Pilot
Study of an Intensive Residential Treatment Program
Regina Steil, Anne Dyer, Kathlen Priebe, Nikolaus Kleindienst, and Martin Bohus
Central Institute of Mental Health, Mannheim, Germany
Dialectical behavior therapy for posttraumatic stress disorder (DBT-PTSD) is tailored for adults with PTSDfrom
childhood sexual abuse (CSA). It uses principles from DBT and trauma-focused cognitivebehavioral approaches.
To evaluate acceptance and safety, the authors treated 29 women with chronic CSA-related PTSD plus at least
one other comorbid diagnosis. The Posttraumatic Diagnostic Scale (PDS), Symptom Checklist 90-Revised, Beck
Depression Inventory, and State Trait Anxiety Inventory were administered prior to, at the end of, and 6 weeks
after 3 months of intensive residential treatment. An effect size of 1.22 on the PDS was found between baseline and
follow-up. Effect sizes for secondary outcomes ranged from medium to large. The results suggest that DBT-PTSD
has promise for reducing severe and chronic PTSD after CSA.
We developed a 3-month residential dialectical behavior ther-
apy for posttraumatic stress disorder (DBT-PTSD) specically tai-
lored to patients suffering from chronic PTSD related to child-
hood sexual abuse (CSA). Dialectical behavior therapy for post-
traumatic stress disorder is based on principles and methods of
DBT (Linehan, 1993) and integrates methods of trauma-focused
cognitivebehavioral therapy (CBT) as described by Ehlers (Ehlers
& Clark, 2008), or Foa (Foa, Hembree, & Rothbaum, 2007).
Standard DBT was designed to treat disorders related to dif-
culties in emotion regulation. Typical PTSD dysfunctional be-
haviors can be understood as strategies to avoid or escape from
trauma-associated emotions like powerlessness, anxiety, or disgust.
Corroborated by dysfunctional cognitions, escape behaviors such
as self-injury, suicidal ideation, dissociation, and dysfunctional
secondary emotions like shame, guilt, or self-hatred, develop into
inappropriate self-concepts, strongly impairing quality of life.
Dialectical behavior therapy strategies have been successfully
used to treat PTSD in victims of interpersonal violence (Becker &
Zayfert, 2001; Cloitre, Koenen, Cohen, & Han, 2002; Harned &
The rst two authors contributed equally.
Regina Steil, Anne Dyer, Kathlen Priebe, Nikolaus Kleindienst, and Martin Bohus, Central
Institute of Mental Health, Mannheim, Germany.
The authors thank Kerstin Stickel and Sina Baumgaertner for their contributions.
Correspondence concerning this article should be addressed to: Regina Steil, Department of
Clinical Psychology and Intervention, Institute of Psychology, Goethe University, Frankfurt
Postfach 11 19 32, Fach 120 60054, Frankfurt Main, Germany. E-mail: steil@psych.uni-
frankfurt.de.
C
2011 International Society for Traumatic Stress Studies. View this article online at
wileyonlinelibrary.com DOI: 10.1002/jts.20617
Linehan, 2008; Levitt &Cloitre, 2005; Wagner &Linehan, 2006;
Wagner, Rizvi, & Harned, 2007). Cloitre and her workgroup have
developed a treatment combining an initial preparatory phase of
skills training in affect and interpersonal regulation followed by
exposure, which shows highly promising results. Harned and Line-
han have published case reports adding prolonged exposure pro-
tocols to ongoing standard DBT. In contrast to these programs,
DBT-PTSD is a completely structured DBT residential program
as described by Swenson, Witterholt, and Bohus (2007). The pro-
gram includes DBT basic assumptions, treatment rules, strate-
gies and methods, dialectical therapeutic relationship, all based on
mindfulness-based skills.
Dialectical behavior therapy for posttraumatic stress disorder
aims to help patients (a) reduce their fear of trauma-associated
primary emotions, (b) question secondary emotions like guilt and
shame, and (c) radically accept trauma facts.
To successfully reduce fear of trauma-associated emotions,
exposure-based techniques giving control over escape strategies
are required. Accordingly, patients learn to identify their typical
escape behaviors and use DBTskills to control these. The exposure
protocol (weeks 610) allows the patient to control the intensity
of memory activation and balances the vividness of trauma mem-
ories with the awareness of being in the (nondangerous) present
(moderated exposure), by using skills during exposure sessions and
exposure homework. Finally, treatment focuses on radical accep-
tance of trauma-related facts and on relevant psychosocial aspects
including work and partnership.
Individual and group intervention targets major treatment is-
sues. Dialectical behavior therapy for posttraumatic stress disor-
der follows principles and rules of established DBT residential
102
DBT-PTSD for PTSD Related to CSA 103
programs (Bohus et al., 2004). Life-threatening or crisis-generating
behavior is prioritized whenever it occurs, followed by therapy-
interfering behaviors (e.g., dissociation or substance abuse). Ter-
mination of non life-threatening self-harm is not required before
applying exposure techniques. We conducted anuncontrolled pilot
study to examine acceptance, safety, and efcacy of DBT-PTSD.
ME T H O D
Participants
Twenty-nine female patients were consecutively included. Patients
were referred to our PTSD residential treatment unit by their local
psychiatrists due to treatment resistance to at least one previous
in- or outpatient treatment. In most European countries, residen-
tial treatment programs are routinely offered to patients who lack
adequate local treatment opportunities or have not adequately re-
sponded to outpatient treatment (e.g., Bateman & Fonagy, 1999).
Inclusion criteria were a diagnosis of PTSD related to CSA
according to the Diagnostic and Statistical Manual of Mental Dis-
orders, Fourth Edition (DSM-IV; American Psychiatric Association
[APA], 1994), mean score of at least 1.4 on the German version
of the Posttraumatic Diagnostic Scale (PDS; Griesel, Wessa, &
Flor, 2006) plus a DSM-IV diagnosis of current major depression
and/or anorexia/bulimia nervosa, substance abuse/dependence, or
borderline personality disorder (BPD). Axis-I and II diagnoses
were assessed by trained clinicians. Child sexual abuse was dened
as sexual assault of a minor or sexual activity between a minor
and an older person with the older person using the dominant
position to coerce or force the younger person (APA, 2001). Ex-
clusion criteria were lifetime diagnosis of schizophrenia, mental
retardation, or severe acute psychopathology requiring immediate
treatment in a different setting (i.e., Body Mass Index <16, acute
suicidality). Previous participation in another DBT program was
not an exclusion criterion. The study was approved by the local
ethics group. Written informed consent was obtained. Figure 1
shows the patient ow.
DBT-PTSD Residential Program
Four trained clinical psychologists administered the two weekly
35-minute sessions of individual treatment plus weekly group
treatments: 90 minutes of skills training, 60 minutes of group
intervention focusing on self-esteem, three 25-minute mindful-
ness sessions, and 60 minutes of PTSD-specic psychoeducation.
Approximately one quarter of the individual sessions were dedi-
cated to exposure techniques. The mean treatment length was 82
(SD=20) days. The residential setting ensured that all patients at-
tended all interventions regularly. On average, patients attended 23
sessions of individual treatment, 11 sessions of skills training/self-
esteem intervention/psychoeducation, and 35 sessions of mind-
fulness training. Patients additionally attended three 90-minute
Figure 1. Flow diagram of study patients.
nonspecic weekly group interventions (musical therapy, art ther-
apy, and motion therapy). Therapists were supervised by the rst
author on a weekly basis.
If required, sleep disorders were treated with antidepressants
or prazosin. Major depressive episodes were treated with selective
serotonin reuptake inhibitors. No patient was treated with benzo-
diazepines.
Measures
The DSM-IV diagnoses were established before study intake by
trained and clinically experienced raters using the Structured
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
104 Steil et al.
Clinical Interview for DSM-IV (SCID-I, German version;
Wittchen, Wunderlich, Gruschwitz, & Zaudig, 1996) and the
Structured Clinical Interview for DSM-IV Axis II (SCID-II,
German version; Fydrich, Renneberg, Schmitz, & Wittchen,
1997). To assess interrater reliability, we followed a joint interview
method (Bruss, Gruenberg, Goldstein, & Barber, 1994; Zimmer-
mann, 1994). One rater interviewed one participant, while the
other raters observed and scored the interviews independently
( = 0.70).
Four questionnaires were administered at baseline (T0), end
of treatment (T1), and 6-week follow-up (T2): The PDS (Griesel
et al., 2006) yields a mean score representing overall PTSDseverity
(03). It shows good internal consistency and convergent valid-
ity (Griesel et al., 2006) and Cronbachs alpha in this sample
was .68. Secondary outcome included the Beck Depression In-
ventory (BDI; Hautzinger, Bailer, Worall, & Keller, 1995; =
.81), State-Trait-Anxiety Inventory Trait (STAI-Trait; Laux, Glanz-
mann, Schaffner, & Spielberger, 1981; = .71), and the Global
Severity Index (GSI) of the Symptom Checklist 90-Revised (SCL-
90-R; Franke, 1995; = .96).
Data Analysis
To test whether the severity of (a) PTSD-symptomatology (pri-
mary outcome), and (b) depression, anxiety, and symptoms of
general psychopathology (secondary outcome) were reduced after
DBT-PTSD, the change in these variables over time was analyzed
using an hierarchical linear growth model as specied in Singer
(1998, Equation 9a). No predened structure was dened for the
diagonal blocks of the variancecovariance matrix. All parame-
ters were estimated using restricted maximum likelihood (REML)
estimates. To increase the t of the hierarchical linear models,
all analyses were corroborated after shifted log transformations
(ln(1 +Y
i j
)) of the dependent variables. To account for a po-
tentially confounding effect of change in medication (including
change in dosage) and psychological treatment after discharge,
additional analyses incorporating these dichotomous variables as
covariates were carried out.
Cohens d for pre- and posttest data was used as the effect-size
measure. The signicance level was set at p < .05 (two-tailed).
To ensure that change was outside the range easily explained by
measurement unreliability, reliable change (based on PDS and its
test-retest reliability according to Griesel et al., 2006) was calcu-
lated as described by Jacobson, Roberts, Berns, and McGlinchey
(1999). Accordingly, pre- and posttest differences in PDS scores
of 0.565 (corresponding to a Reliable Change Index [RCI] >
1.96) were indicative of reliable change. Remission rates based
on observer-based DSM-criteria could not be calculated, as di-
agnostic status had only been assessed via clinician rating at
baseline.
R E S U L T S
Sample Characteristics
All patients were White aged 20.0 to 51.0 years (M = 35.4,
SD = 9.1). Eighteen were single, six married, and ve divorced.
Nine had completed their school leaving certicate, six their
university-entrance diploma, 13 their apprenticeship, and one held
a university degree.
Time between the start of CSA and treatment intake ranged
from 9 to 44 years (M =27.4, SD=9.8). Patients had an average
of 3.8 DSM-IV Axis-I or II diagnoses (SD = 1.6). The most fre-
quent diagnoses were major depressive disorder (90%), personality
disorders (45%, including 24% bipolar disorder), eating disorders
(38%), other anxiety disorders (38%), and substance-related dis-
orders (14%).
Upon admission, 19 patients (62%) reported a history of at
least one suicide attempt; 11 patients (38%) reported a history
of multiple suicide attempts. Eighteen patients (62%) reported
a history of nonsuicidal self-injury. Six patients (21%) exhibited
current nonsuicidal self-injury. All participants had previously re-
ceived psychological treatment for PTSD; 27 (93%) in the form
of outpatient and 26 (90%) in the form of inpatient treatment.
Sixteen patients (55%) were receiving antidepressants at T0
and 19 (66%) at T1. Ten patients (34%) received antipsychotics
at T0 and 10 (34%) at T1. None received benzodiazepines. After
discharge (between T1 and T2), 12 patients returned to their
previous outpatient psychological treatment, 7 patients started new
outpatient psychological treatment, and 10 received no further
treatment.
All patients completed the treatment program and no patient
showed deterioration on the PDS. No patient exhibited acute
suicidality, life-threatening self-harm, high risk behavior or other
forms of crisis, which would lead to a change of the therapeutic
setting. Four patients did not complete measures at T2 .
Treatment Outcome
For the primary outcome (PDS) the linear growth model indicated
a signicant reduction over time, F (1, 28) = 33.83, p < .001.
Additional analyses including change in medication and psycho-
logical treatment after discharge as covariates fully conrmed this
result. Again, a signicant reduction of PDS scores was observed,
F (1, 26) = 14.54, p < .001; however, the covariates were not
related to the level or course of PDS scores (all p-values ns).
Growth models for all predened secondary outcomes further
conrmed these ndings. The hierarchical linear models indicated
signicant reductions for the BDI, F (1, 28) = 18.55, p = .002,
Global Severity Index of the SCL-90-R, F (1,27) = 8.98, p =
.006, and trait anxiety, F (1, 28) = 9.49, p = .005. Pre-and
posttest effect sizes, Cohens d, for these outcome measures were
1.04, 0.36, and 0.61, respectively. All results were fully conrmed
Journal of Traumatic Stress DOI 10.1002/jts. Published on behalf of the International Society for Traumatic Stress Studies.
DBT-PTSD for PTSD Related to CSA 105
Table 1. Means, Standard Deviations, t-Values, and Cohens d for Outcome Measures
Baseline End 6 Weeks Post Baseline vs. 6 weeks Post Baseline vs. End End vs. 6 weeks Post
Outcome M SD M SD M SD t d t d t d
PDS 2.13 0.40 1.66 0.69 1.38 0.77 6.24

1.22 4.36

0.83 3.16

0.38
BDI 29.92 9.47 18.72 12.00 19.08 11.26 4.94

1.04 4.71

1.04 0.22 0.03

STAI trait 56.64 8.35 50.78 10.83 49.27 12.10 3.15

0.71 2.73

0.61 0.57 0.13

SCL-90-R 1.46 0.64 1.16 1.00 1.08 0.80 3.03

0.52 1.52 0.36 0.51 0.09

Note. Analyses include all patients (N = 25) who completed assessments at baseline, end, and 6 weeks posttest. PDS = Posttraumatic Diagnostic Scale; BDI = Beck
Depression Inventory; STAI trait = State-Trait-Anxiety Inventory Trait; SCL-90-R = Symptom Checklist-90-R.

p < .05.

p < .01.

p < .001.
after a shifted log transformation was applied to the outcome
variables (all p-values < .005).
As shown in Table 1, patients showed signicant improvement
on all measures frombaseline to follow-up. Signicant decreases in
PDS, BDI, and STAI scores were observed from T0 to T1 as well
as from T0 to T2. SCL90-R scores decreased signicantly from
T0 to T2 and PDS scores decreased signicantly from T1 to T2.
All other pairwise comparisons were not statistically signicant.
Based on the PDS, 15 patients (51%; 60% of the 25 providing
T2 data) showed reliable change at T2 according to the RCI.
D I S C U S S I O N
The program shows excellent acceptance: No patient dropped
out of treatment. Because treatment did not exacerbate PTSD or
other symptoms in any of the patients or cause any form of crisis,
it appears to be safe. Strong pre- and posttest changes were found
on PDS and BDI, indicating a strong treatment effect. The PDS
scores decreased further after discharge. Patients initially reported
severe PTSD, as indicated by a mean PDS score of 2.13.
Analyses including potential confounders (change in medica-
tion during DBT-PTSD and participation in outpatient psycho-
logical treatment following discharge) showed no indication that
these might have accounted for the observed treatment efcacy.
However, our sample was too small to completely rule out a mod-
erating effect of these variables.
The current design does not allow for the determination of
whether or howDBTcomponents contributed to treatment effects
over and above what the CBT components contributed. Improve-
ments are greater than those found among CSA-related PTSD
patients receiving no treatment, with McDonagh and colleagues
(2005), for example, reporting a pre- and post effect size (Cohens
d) for the waitlist group of 0.36. However, controlled data are
needed to rule out unspecic effects. Results are limited by the
lack of diagnostic status after treatment, and of measures of symp-
toms that might be indicative of severe CSA-related PTSD (i.e.,
dissociation, self-harm, shame, etc.).
Our ndings indicate that DBT-PTSD might represent a
promising treatment for severe CSA-related chronic PTSD.
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