So far in this series, you’ve been introduced to DBT and trauma. Now let’s connect the dots and explain why trauma-focused DBT is a great starting point for trauma work. In the previous section, you learned how trauma affects the nervous system. This explanation is called the polyvagal theory, and it provides the theoretical basis for trauma-focused DBT.
According to the polyvagal theory, trauma has an impact on both branches of the ANS. The SNS—the accelerator—is associated with physical and emotional activation (such as increased fear, anger, breathing, and heart rate); in the case of danger, this means fight or flight.
In contrast, the PNS—the brake—is associated with physical and emotional relaxation. In addition, the PNS has two branches of its own. One part (ventral) is associated with social engagement; the other part (dorsal) is responsible for rest-and-digest functions—and, in the case of extreme threat, freeze. Freeze occurs when the organism starts to physically shut down or mentally dissociate, or both.
When presented with danger, the various branches of the ANS are affected in a specific order. The first branch to be affected is the social engagement system. In other words, when presented with a threat, functions related to social connectivity—laughter, smiling, empathy, attunement, the ability to provide validation—go offline. This is like letting up on the brake. If the danger persists, the accelerator is applied, which results in fight or flight. When neither fight nor flight can mitigate the threat, the brake is activated, resulting in freeze. The following actions summarize this sequence in slightly more technical language (Porges 2011):
- Danger is sensed.
- Social engagement goes offline (ventral PNS). This is like releasing the brake.
- Danger persists.
- Fight or flight is triggered (SNS). This is like slamming on the gas.
- Danger cannot be mitigated through fight or flight.
- Freeze response activates (dorsal PNS). This is like slamming on the brake while your foot is still on the accelerator.
When we drive, we need both the brake and accelerator to get to our destination safely. If the drive is smooth, sometimes we will gently accelerate and sometimes we will gently brake. The same process applies to our physical, mental, and emotional functioning. If the “drive” is smooth, our mind and body enjoy a gentle oscillation between accelerating and braking.
This flow is even reflected in our heart rhythm. A healthy rhythm is indicated by a consistently alternating repetition of fast-slow, fast-slow, fast-slow. The reason for this gentle pattern is so that the entire organism, at a moment’s notice, can either accelerate further or brake further, as needed. A heartbeat that is either consistently fast, or consistently slow, or unpredictably fast and slow, is not a healthy rhythm.
Let’s return to the driving analogy. If you are driving down the highway and a truck carelessly swerves right in front of you, you will probably demonstrate all of the reactions represented by the polyvagal theory. You may swear and flip a finger at the driver (social engagement goes offline); you may suddenly accelerate; or you may slam on the brakes. But after the danger is averted, you will most likely return to your baseline of gently oscillating between accelerating and braking as needed…until the next threat again requires more extreme action.
Now let’s assume you have experienced so many highway hazards that you decide never to let down your guard. You are poised at every moment to yell and scream at other drivers, unpredictably accelerate, and unpredictably brake. If you are really frazzled, you may even attempt to accelerate and brake at the same time! Eventually, this becomes your new default driving style, regardless of the driving conditions: curse at everyone, suddenly accelerate, and suddenly brake. Do you see how this will lead to a wild ride? Even if the driving conditions would otherwise have been relatively smooth, they won’t be anymore. And even if no danger would otherwise have been present, now there is.
This driving metaphor describes what happens to people who have experienced chronic trauma: too much accelerating, too much braking, and loss of social engagement. These dramatic shifts in the nervous system precipitate a long, complicated cascade of reactions in the brain and body, but here’s the bottom line: The end result of this domino effect is a variety of responses that are either too much or too little, resulting in a host of complications. This tendency toward too much or too little especially affects five domains: awareness, thoughts, emotions, reactions, and relationships. For each of these domains, it is possible to have either too much (overuse of the accelerator) or too little (overuse of the brake).
DBT is all about reconciling dialectical dilemmas (binary extremes resulting in dysfunction) by teaching specific behavioral skills to forge a middle path between those extremes. In particular, DBT teaches these five skill sets: mindfulness, distress tolerance, emotion regulation, dialectical thinking, and interpersonal effectiveness. These skill sets provide the middle path between each of the dialectical dilemmas mentioned above.
| Domain Affected by Trauma | Too Much | Too Little | Middle Path |
|---|---|---|---|
| Awareness | Hypervigilance | Dissociation | Mindfulness |
| Thoughts | Rumination | Impulsivity | Dialectical Thinking |
| Emotions | Overwhelm | Numbness | Emotion Regulation |
| Reactions | Hysteria | Paralysis | Distress Tolerance |
| Relationships | Aggression | Passivity | Interpersonal Effectiveness |
By practicing these skills, you learn to find a middle path in life, a path between the extremes. That’s the essence of DBT…or what I like to call “developing balance therapy.” The dialectical behavior in DBT is simply a really fancy way of saying developing balance.
Once a person has stabilized by learning each of these middle paths, many, if not most, trauma symptoms will start to resolve. The purpose of these middle paths is to restabilize the nervous system, which is a huge feat in and of itself. But there’s a caveat here: even after the nervous system has restabilized, it is quite possible for the brain and body to still have those memory fragments that the thalamus never integrated. Standard, traditional DBT was not designed to deal with those intrusive memories and recurring nightmares. But trauma-focused DBT is!
As long as people are existing and operating at the extremes of life, it is extremely difficult for them to do even basic counseling— much less trauma work (or the rest of life, for that matter). That is why DBT as a treatment model is entirely skills focused. In particular, trauma-focused DBT teaches the foundational skills you need to optimize counseling, stabilize for trauma work, and then thrive in life—“building a life worth living,” in the words of Dr. Linehan (2020).
