An interventional study of Dialectical Behavior Therapy and Dialectical Behavior Therapy Prolonged Exposure protocol in Self-directed Violence and Post-traumatic Stress Disorder (PTSD), sponsored by VA Office of Research and Development. Recruiting at 4 sites in United States. Open to participants aged 18 Years and older. Per ClinicalTrials.gov, last updated 2026-07-16.
Sponsored by VA Office of Research and Development · Not applicable, Interventional, and Treatment
Posttraumatic Stress Disorder (PTSD) is a significant driver of suicide risk among Veterans, but there is a critical knowledge gap about how to treat PTSD among people at elevated risk for suicide. Although evidence-based treatments for PTSD reduce suicide risk, Veterans at high risk for suicidal behavior rarely receive these potentially life-saving treatments. Prior research suggests that a treatment that combines Dialectical Behavior Therapy (DBT) with the DBT Prolonged Exposure protocol (DBT PE) for PTSD improves both PTSD and suicide-related outcomes. This study will evaluate whether DBT + DBT PE improves these outcomes more than Prolonged Exposure plus suicide risk management, the gold standard VA care for this population. The proposed study will also examine factors that make it easier and harder to implement these treatments in VA settings. The results will help to inform treatment guidelines for this high-priority Veteran population.
Background: Posttraumatic stress disorder (PTSD) is a significant risk factor for suicide among Veterans. Evidence-based psychotherapies (EBPs) for PTSD reduce suicide risk, but Veterans at elevated acute risk for suicide, such as those who have engaged in self-directed violence (SDV), rarely receive these treatments. This is largely due to the historical exclusion of high-risk individuals from PTSD treatment trials, which has resulted in a lack of evidence-based guidance about indicated treatments for this population. Without such guidance, clinicians are often reluctant to use EBPs for PTSD with suicidal individuals. A treatment that combines Dialectical Behavior Therapy (DBT), a suicide-focused EBP, with the DBT Prolonged Exposure (DBT PE) protocol for PTSD has been developed for this high-risk population and shows promise in reducing both SDV and PTSD while being feasible, acceptable, and safe to deliver. However, a large-scale randomized controlled trial (RCT) is needed. This study will compare the effectiveness of DBT + DBT PE to the current VHA gold standard of care for this population, Prolonged Exposure therapy augmented with suicide risk management (PE + SRM), while also examining the potential for implementation of both interventions in VHA.
Significance: There is a critical gap in knowledge about how to treat PTSD among individuals at high risk for suicidal behavior. As a result, VA/DoD Clinical Practice Guidelines do not specify indicated treatment strategies for this population. Experts have recommended two approaches to facilitate the safe and effective use of EBPs for PTSD with individuals at elevated acute suicide risk, including combining these treatments with suicide-focused EBPs or augmenting them with suicide risk management strategies. This project will help to fill this critical gap by rigorously evaluating these two approaches among Veterans with SDV. The results will provide important information to inform guidelines about indicated treatments for this high-risk population.
Innovativeness: This will be the first large-scale RCT to evaluate treatments for PTSD among Veterans who have engaged in SDV, an HSR\&D high priority group. The DBT + DBT PE intervention is the first treatment designed to address both SDV and PTSD, and results will indicate if this novel treatment improves outcomes compared to the current VHA gold standard of care. To facilitate more rapid implementation of these findings into clinical practice, implementation barriers and facilitators for both treatments will also be evaluated.
Specific Aims: This study will randomize 125 Veterans with PTSD, recent and repeated SDV, current suicidal ideation, and emotion dysregulation to DBT + DBT PE (intervention) or PE + SRM (control). Aim 1 will test the hypothesis that DBT + DBT PE will be superior to PE + SRM in improving clinical outcomes and engagement in trauma-focused treatment. Exploratory analyses will examine Veteran characteristics that may predict better engagement and outcomes in DBT + DBT PE versus PE + SRM. Aim 2 will examine barriers and facilitators to implementation of both treatments.
Methods: This is a multi-site hybrid type 1 effectiveness-implementation trial. Veterans will be treated in outpatient settings at four VA sites and assessed at 5 points over 16 months. A mixed-methods approach will be used to evaluate barriers and facilitators to implementation, including conducting interviews with 45 key stakeholders (Veterans, providers, and leadership).
Primary Outcomes/Endpoints: Primary outcomes will be reductions in SDV episodes at 16-month follow-up and reductions in PTSD severity at post-treatment.
Implementation/Next Steps: This project will provide much-needed information about how to safely and effectively treat PTSD among Veterans at elevated acute risk for suicide. If one or both treatments are found effective, Aim 2 will provide vital information about how to maximize future implementation success. Future implementation activities would be coordinated with the investigators' national operational partners.
2,682 studies on the registry are indexed under Stress Disorders, Post-Traumatic; 601 are open to participants now.
This study's planned enrollment of 125 is above the median of 69 across 2,196 interventional studies indexed under Stress Disorders, Post-Traumatic.
Browse Stress Disorders, Post-Traumatic studies →VA Office of Research and Development is the lead sponsor of 1,771 studies on the registry; 392 are open to participants now.
Of its 213 completed or terminated interventional studies of FDA-regulated products, 185 (87%) have results posted.
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Exclusion Criteria:
This condition combines one year of standard Dialectical Behavior Therapy (DBT) with the DBT Prolonged Exposure (DBT PE) protocol for PTSD.
Behavioral: Dialectical Behavior Therapy · Behavioral: Dialectical Behavior Therapy Prolonged Exposure protocol
This condition provides up to 18 sessions of Prolonged Exposure therapy (PE) for PTSD augmented with suicide risk management (SRM).
Behavioral: Prolonged Exposure therapy · Behavioral: Suicide risk management
Standard Dialectical Behavior Therapy (DBT), including DBT individual therapy (1 hour/week), DBT group skills training (2 hours/week), between-session coaching (as needed during business hours), and therapist consultation team (1-1.5 hours/week).
Also known as: DBT
DBT PE is designed to be integrated into DBT to formally treat PTSD once patients meet standardized readiness criteria. The core procedures are in vivo and imaginal exposure with processing that are delivered in individual therapy sessions (1.5 hours/week).
Also known as: DBT PE
Standard PE is delivered in individual therapy sessions (1.5 hours/week) and uses the core procedures of in vivo and imaginal exposure with processing.
Also known as: PE
Standard VA suicide risk management procedures, including comprehensive suicide risk assessment and safety planning.
Also known as: SRM
Self-Injurious Thoughts and Behaviors Interview - Revised Short Form (SITBI-R-SF)
Number of self-directed violence episodes
Time frame: Baseline to 16 months
Clinician-Administered PTSD Scale for DSM-5 Revised (CAPS-5-R)
Total Severity Score (range = 0 - 200, higher is worse)
Time frame: Baseline to 16 months
Columbia - Suicide Severity Rating Scale (C-SSRS), Suicide Ideation subscales
Total Score (range = 0 - 5, higher is worse)
Time frame: Baseline to 16 months
PROMIS Global Mental Health
Total Score (range = 4 - 20, higher is better)
Time frame: Baseline to 16 months
Difficulties in Emotion Regulation Scale-16 (DERS-16)
Total Score (range = 16 - 80, higher is worse)
Time frame: Baseline to 16 months
World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0)
General Disability Score (range = 12 - 60, higher is worse)
Time frame: Baseline to 16 months
Self-Injurious Thoughts and Behaviors Interview Revised Short Form (SITBI-R-SF)
Non-suicidal self-injury frequency and remission; Suicide attempt frequency and remission
Time frame: Baseline to 16 months
Clinician-Administered PTSD Scale for DSM-5 Revised (CAPS-5-R)
PTSD diagnostic status
Time frame: Baseline to 16 months
Treatment History Interview (THI)
Non-VA psychotherapy, psychiatric crisis services, and psychotropic medications
Time frame: Baseline to 16 months
VA Service Use Form
VA mental health service use and psychotropic medications
Time frame: Baseline to 16 months
Credibility Expectancy Questionnaire (CEQ)
Total score (range = 1 - 7, higher is better)
Time frame: Baseline to 16 months
Client Satisfaction Questionnaire (CSQ)
Total score (range = 8 - 32, higher is better)
Time frame: Post-treatment (4 months in PE + SRM, 12 months in DBT + DBT PE)
Dissociative Experiences Scale - Taxon (DES-T)
Total score (range = 0 - 80, higher is worse)
Time frame: Baseline to 16 months
Trauma-Related Shame Inventory (TRSI)
Total score (range = 0 - 72, higher is worse)
Time frame: Baseline to 16 months
Self-Compassion Scale (SCS)
Total score (range = 1 - 5, higher is better)
Time frame: Baseline to 16 months
Borderline Symptom List - Behavioral Supplement (BSL-BS)
Total score (range = 0 - 44, higher is worse)
Time frame: Baseline to 16 months
PTSD Checklist for DSM-5 (PCL-5)
Total severity score (range = 0 - 80, higher is worse)
Time frame: Baseline to 16 months
Post-Traumatic Cognitions Inventory-9 (PTCI-9)
Total score (range = 9 to 63, higher is worse)
Time frame: Baseline to 16 months
PROMIS Sadness
Total score (range = 8 - 40, higher is worse)
Time frame: Baseline to 16 months
PROMIS Fear-Affect
Total score (range = 7 - 35, higher is worse)
Time frame: Baseline to 16 months
PROMIS Anger-Affect
Total score (range = 5 - 25, higher is worse)
Time frame: Baseline to 16 months
Plan to share: Yes — De-identified, anonymized data that underlie results in a publication may be shared.
Supporting information: Study protocol, Statistical analysis plan, Analytic code
Time frame: Starting after publication of relevant data
Access criteria: Data may be shared in response to written requests submitted to the PI by other researchers. Such data sharing will take place under a written agreement that prohibits the recipient from identifying or re-identifying (or taking steps to identify or re-identify) any individual whose data are in the dataset.
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