DBT for PTSD
Sometimes the danger is over, but your nervous system hasn’t gotten the message. PTSD can make everyday experiences feel threatening long after a traumatic event has passed. Dialectical Behavior Therapy (DBT) offers a different kind of support: rather than asking you to revisit the trauma itself, it teaches skills for tolerating difficult emotions and responding to what’s happening in the present. Explore the role DBT can play in PTSD treatment and how its skills may help with trauma-related symptoms.
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Overview of DBT for PTSD
Post-traumatic stress disorder can develop after exposure to a life-threatening or deeply distressing event, and its symptoms tend to cluster in a few recognizable ways: intrusive memories or nightmares that resurface uninvited, avoidance of anything that resembles the trauma, a shift toward negative beliefs about oneself or the world, and a nervous system that stays on alert long after the actual danger has ended. These symptoms can persist for months or years, disrupt daily functioning, and often travel alongside chronic anxiety, depression, or substance use. Underneath much of this sits intense, hard-to-name emotion, fear, shame, guilt, and a diminished sense of safety or trust that can make even ordinary interactions feel effortful.
Dialectical Behavior Therapy (DBT) is a skills-focused psychotherapy developed by psychologist Marsha Linehan in the 1990s to treat chronic suicidality and borderline personality disorder. It's organized around four skill areas, mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, taught and practiced directly rather than explored primarily through conversation. PTSD wasn't the original target population, but DBT's skills framework has increasingly been applied to trauma-related distress as well, particularly where intense emotion, not just the traumatic memory itself, is what's driving the daily disruption.
Part of the reason has to do with what tends to sit underneath PTSD in the first place. A systematic review examining emotional dysregulation and post-traumatic stress symptoms found consistent evidence linking difficulty regulating emotion to the onset, severity, and persistence of PTSD, independent of trauma type or time since the event. DBT's four modules were built almost entirely around that same difficulty, teaching people concrete ways to notice, tolerate, and act on intense emotion rather than being run by it. Here's how each of the four modules meets a nervous system still stuck in survival mode:
- Mindfulness interrupts the flashback loop. Trauma tends to collapse the past and present into the same moment, a smell, a sound, a certain kind of silence, and the body reacts as if the danger is happening right now rather than years ago. Mindfulness skills teach the difference between a memory surfacing and being pulled back inside it, which is often the first real foothold someone gets to stay present at all.
- Distress tolerance covers the moments a flashback or panic spike doesn't leave room to think through. Not every trauma response arrives with space for reflection. This module supplies fast, physical tools for getting through acute hyperarousal, dissociation, or panic without making the moment more dangerous or overwhelming than it already is.
- Emotion regulation addresses the intensity that builds around triggers. PTSD rarely stays contained to the instant a memory surfaces; shame, guilt, and fear tend to accumulate around it and color everything nearby. This module works on that buildup directly, along with the avoidance that keeps the nervous system locked on alert long after it needs to be.
- Interpersonal effectiveness rebuilds a sense of safety with other people. Trauma often damages trust in ways that make closeness itself feel risky, so people withdraw or stay guarded even with those who mean them no harm. This module gives people concrete ways to ask for what they need, hold a limit, and let people back in without it feeling unsafe to do so.
PTSD rarely shows up as a single, isolated problem, which is part of why these four modules aren't meant to be used strictly one at a time. Someone might pair a mindfulness skill with an emotion regulation one in the same moment, noticing a trigger and then working the physiological spike it produces, rather than treating each module as a separate toolkit reached for in sequence.
This page covers each of the four modules in more depth along with what the research says about why the approach holds up for PTSD specifically, not just for the conditions DBT was originally designed to treat. Together, they give someone a way to work with a trauma response from more than one angle at once, steadying the nervous system in the hardest moments while also addressing the avoidance and disconnection that tend to keep PTSD entrenched over time.
DBT vs. Other Treatments
The trauma field's default first-line treatments, Cognitive Processing Therapy, Prolonged Exposure, and EMDR, work by helping someone sit with a fear-based memory long enough for the brain to relearn that it's no longer dangerous. For PTSD that shows up on its own, without heavy dissociation, chronic self-harm, or overwhelming emotion dysregulation, that approach tends to work well. The picture changes for what's often called complex PTSD, where childhood abuse or repeated trauma has left someone with a harder time regulating emotion, a persistently negative sense of self, and a tendency to dissociate under stress. Pushing straight into exposure with that kind of history can backfire, triggering shutdown or emotional flooding instead of the gradual habituation exposure is supposed to produce, which is part of why dropout from standard trauma-focused therapy in these populations can climb well past 35 percent.
DBT-PTSD was built around that specific gap. Before any trauma memory work begins, the protocol trains people in anti-dissociative skills, sensory grounding tools meant to keep someone inside a workable emotional range instead of checking out entirely once exposure starts. A randomized clinical trial comparing DBT-PTSD against Cognitive Processing Therapy in women with severe, abuse-related PTSD and overlapping borderline traits found that both treatments produced large reductions in PTSD severity, but DBT-PTSD pulled measurably ahead, reaching 58 percent diagnostic remission compared to 41 percent for CPT, a gap that held, and even widened, at nine-month follow-up rather than fading once treatment ended.
Standard DBT itself, the four-module program without a trauma-processing component, tells a different part of the story. It was built to stop suicidal behavior and self-harm, not to resolve trauma memories directly, and PTSD remission after standard DBT alone has historically stalled around 33 to 35 percent. That's the gap DBT PE was designed to close. Once someone completes standard DBT and reaches a baseline of safety, meaning no suicide attempts or severe self-harm for a set stretch, the protocol layers prolonged exposure on top of ongoing DBT sessions and phone coaching rather than replacing them. A pilot randomized trial testing DBT with and without the DBT PE protocol in suicidal, self-injuring women with PTSD and borderline personality disorder found that adding exposure lifted completer remission rates to 71 to 80 percent, cut suicide attempts by more than half, and reduced self-injury as well, without the spike in crisis behavior clinicians often worry exposure work might provoke in this population.
That safety profile holds up outside controlled trials, too. A pilot effectiveness study testing whether the DBT PE protocol could be transported into public mental health agencies found comparable gains in real-world community clinics, with no increase in crisis service use or self-injury among patients who started trauma exposure. The main obstacle wasn't the treatment itself; it was clinician turnover, which accounted for more than half of the cases where an eligible patient never got to start the protocol. Taken together with a meta-analysis pooling 13 clinical trials of PTSD-specific DBT interventions, the evidence points toward a fairly specific role for DBT within PTSD treatment: less a replacement for exposure-based therapies than a way of making exposure survivable, and effective, for people whose trauma history includes the kind of emotion dysregulation that standard protocols weren't built to handle.
Psychoeducation as a Starting Point for PTSD
Psychoeducation means teaching someone the actual mechanics of what they're living through: why an intrusive memory can surface with no warning while doing something as ordinary as loading the dishwasher, why a car backfiring two blocks away can send a body into full alarm months after the actual danger has passed, why avoiding a highway exit or a certain smell feels protective in the moment even as it slowly shrinks a person's world down to what feels safe to touch.
For PTSD specifically, understanding that mechanism does something the symptoms themselves rarely allow for on their own: it reframes a nervous system that won't stand down as one that did exactly what it was built to do in response to something genuinely dangerous, just still firing on a threat that's no longer there. That reframe doesn't resolve trauma by itself, but it tends to loosen the shame and self-blame that keep a lot of people from seeking any further help at all, the sense that they should be over it by now, that reacting this way means something is wrong with them specifically.
It's worth being direct about what the research actually shows here rather than overselling it. A systematic review and meta-analysis of randomized trials testing psychoeducational interventions for PTSD symptoms in adults pooled eight studies and found a small effect on symptom reduction that wasn't statistically significant or clinically meaningful on its own.
A randomized trial comparing a brief mindfulness program to a psychoeducation group for veterans with PTSD found something similar from a different angle: the mindfulness group produced significantly larger reductions in PTSD symptoms than the psychoeducation-only group, along with bigger gains in stress management and a stronger sense of not being run by symptoms. Information on its own, in other words, tends to help someone understand what's happening to them without reliably changing how often it happens.
That's a large part of why TheraHive doesn't stop at explanation. Sessions pair the psychoeducational piece with direct skills practice, mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness, on the premise the research above actually supports: understanding a trauma response is a starting point, but practicing something different to do with it in the moment is what tends to move outcomes.
TheraHive's groups are psychoeducational, not a clinical treatment for PTSD on their own, which means they're built to sit alongside trauma-focused therapy, medication, or other care a person already has in place rather than substitute for it. That distinction carries more weight here than it does for some other conditions, since trauma-focused approaches like prolonged exposure, cognitive processing therapy, and EMDR remain the treatments with the strongest evidence for addressing PTSD directly, and nothing here is meant to compete with that.
Meeting virtually also removes a specific kind of friction for PTSD that it might not for other conditions. A commute that passes near a triggering location, a crowded waiting room, a schedule that leaves no room to reschedule around a bad week, all of these can quietly function as their own reminders. A shift toward virtual delivery tends to matter more here, since avoidance is so often the very symptom standing between someone and the care that could help.
Mindfulness: Anchoring in the Present
Intrusive memories and flashbacks share a common feature: they pull attention out of the present moment and into the past, sometimes so convincingly that the body reacts as though the danger is happening right now. Mindfulness is the DBT module built to counter exactly that pull, not by suppressing the memory, but by strengthening a person's ability to notice where they actually are.
Grounding is often where this starts in practice. A simple exercise, naming five things you can see, four you can hear, three you can feel, works by deliberately redirecting attention to present-moment sensory information, which makes it harder for the nervous system to stay locked onto a memory. For someone with PTSD, this kind of practice doesn't erase the intrusive thought, but it interrupts its momentum, offering a foothold back into the here and now before a flashback fully takes hold.
The research on mindfulness for trauma is measured but genuinely encouraging. A multisite randomized clinical trial of mindfulness-based stress reduction in veterans with PTSD found that participants who received MBSR showed significantly greater improvement in self-reported PTSD symptom severity than those in an active present-centered comparison therapy, with the gap widening at two-month follow-up. The effect was described as clinically meaningful, even if gradual, which fits how DBT frames mindfulness generally: less a quick fix than a practice that compounds. Within DBT groups, mindfulness is treated as the foundation the other three modules build on, since the ability to notice and accept a difficult moment without being swept into it is what makes the later skills usable in the first place.
Try one of our brief and calming mindfulness exercises below. For the full playlist of free mindfulness exercises, visit our YouTube channel.
Distress Tolerance: Getting Through Triggers
PTSD produces its own category of crisis moments: a trigger that arrives without warning, a wave of panic tied to a trauma anniversary, a flashback that hijacks an otherwise ordinary afternoon. Distress tolerance is the module DBT built specifically for these situations, when the goal isn't to solve anything but simply to get through the next several minutes without doing something that makes the aftermath harder.
For someone with PTSD, these tools matter because the alternative, reaching for substances, self-harm, or other high-risk coping during an intense trigger, tends to compound the original problem rather than resolve it.
The TIP skill works on the body directly rather than asking the mind to reason its way out of a spike it isn't in a state to reason through: cold water against the face, a few minutes of intense movement, or paced breathing with a longer exhale than inhale can bring a flooded nervous system back down fast enough to make the next choice a safer one.
When the crisis is less a physical spike and more a pull toward a specific decision, say, calling in sick to avoid a trigger at work, or ending a relationship in the middle of a flashback, the Pros and Cons skill gives someone a concrete way to weigh acting on the urge against tolerating it before doing either.
Self-Soothe works by deliberately engaging the senses, a warm object, a familiar scent, quiet music, to remind an overwhelmed nervous system that the present moment holds more than the crisis it's currently fixated on.
Wise Mind ACCEPTS offers a related but distinct set of tools: shifting attention to an activity, a memory of gratitude, or a counting exercise long enough for the acute wave of distress to pass on its own, since intense emotion, however unbearable it feels in the moment, does eventually crest and recede.
Radical Acceptance sits underneath both of these and tends to be the hardest to practice: acknowledging, without minimizing, that a triggered reaction is happening right now, so the energy that would otherwise go into fighting the fact of it can go toward actually getting through it.
Emotion Regulation: Working With Difficult Emotions
Few conditions produce emotional swings quite like PTSD does. Someone can move from numbness to sudden rage to overwhelming shame within a single afternoon, often without a clear sense of what set the shift in motion. Emotion regulation is the module built to slow that process down enough to actually work with it, starting from the basic step of identifying what's being felt in the first place.
Observing, Describing, and Naming Emotions supplies that starting point directly: pausing to name what's present, tension, dread, humiliation, rather than collapsing it all into a single undifferentiated "bad," and noting what specifically triggered it. Practiced consistently, this turns what once felt like random misery into something a little more predictable, a particular sound, place, or time of year that reliably precedes a spike, and therefore something a little more workable.
Checking the Facts builds on that same groundwork. In the middle of a flashback, the felt sense of danger is entirely real, but reality-testing, actively confirming that the threat is in the past and the current environment is safe, gives the rational brain something to hold onto while the alarm system settles.
Opposite Action addresses the behavioral side of the same problem. PTSD often pulls a person toward withdrawal, isolation, or avoidance, all understandable responses to feeling unsafe, but responses that tend to deepen the condition's grip over time. Deliberately acting against that pull, going for a walk when the urge is to stay frozen in place, reaching out to someone when the instinct is to disappear, can shift an emotional state that talking alone often can't reach. Between naming an emotion accurately and then choosing to act against what it's urging, someone has two concrete moves to make when panic, anger, or shame threatens to take over, rather than being left to wait out the feeling with no tools at all.
For a deep dive on Opposite Action and other Emotion Regulation skills, check out the Thriving With DBT podcast episode below where TheraHive co-founder Dr. Alicia Smart walks through the skills in real-time with a real TheraHive student.
Interpersonal Effectiveness: Rebuilding Trust and Connection
Trauma rarely stays contained to the person who experienced it; it tends to ripple outward into relationships. Trust becomes harder to extend, irritability can surface with people who did nothing to deserve it, and withdrawal often starts to feel safer than staying connected, even when connection is exactly what would help most. Interpersonal effectiveness is the DBT module built to address this directly, through a handful of practical communication skills.
DEAR MAN gives someone language for asking for support or declining a request without the interaction tipping into either passivity or aggression, both common reactions when trust has been damaged. Describing what's actually happening factually, expressing the feeling behind it, and asserting the ask directly turns a vague sense of "I need something to change" into a request someone can actually act on, which matters for a person who's used to either over-explaining or saying nothing at all.
GIVE works on the maintenance side of the same relationships: staying gentle in tone, acting genuinely interested in the other person's experience, and validating their perspective even without agreeing to every detail helps rebuild the kind of everyday connection that trauma tends to erode first.
FAST addresses a different piece of the same problem: holding a limit without turning it into a confession. PTSD tends to load ordinary limits, needing quiet time, skipping an event, not being able to talk about something yet, with far more guilt than the situation calls for. Being fair to both people in the exchange, skipping unnecessary apologies, and sticking to what's actually true, rather than a softer story that avoids conflict, gives someone a way to say plainly, "I'm having a hard day and need some quiet time," and mean it without over-explaining.
Practicing these skills in low-stakes moments can gradually rebuild a sense that connection doesn't have to be dangerous, and it's frequently the module that makes the most visible difference to the people around someone in recovery, even before the person themselves feels much internal change.
Research on DBT for PTSD
PTSD and Borderline Personality Disorder overlap more than most people realize; roughly half of people diagnosed with BPD also meet full criteria for PTSD. For a long time, that overlap put clinicians in a bind. Trauma-focused therapies like Prolonged Exposure or Cognitive Processing Therapy were often withheld from patients who were actively suicidal, self-injuring, or prone to severe dissociation, out of concern that trauma work would destabilize them further. Standard DBT, meanwhile, was built to manage exactly those crises, but wasn't designed to directly treat the trauma underneath them; roughly a third of people who complete standard DBT see their PTSD fully remit within a year, leaving trauma symptoms as an ongoing driver of instability even after behavioral control improves. The two specialized protocols covered below, DBT Prolonged Exposure (DBT PE) and DBT-PTSD, were built specifically to close that gap.
A randomized controlled trial testing standard DBT against standard DBT combined with the DBT PE protocol in suicidal, self-injuring women with BPD and PTSD found that adding the exposure protocol roughly doubled the rate of PTSD remission among people who completed treatment, compared to standard DBT alone. Completers who received DBT PE were also substantially less likely to attempt suicide or engage in self-injury during follow-up than those who received standard DBT without it, evidence that layering trauma exposure onto DBT didn't destabilize this group, it helped stabilize them further.
DBT-PTSD, developed for complex trauma tied to childhood abuse, has its own trial history. The original randomized trial of a 12-week residential DBT-PTSD program in women with childhood sexual abuse-related PTSD, nearly half of whom also had BPD, found large reductions in clinician-rated PTSD severity compared to a waitlist control, with outcomes that didn't differ between participants who had comorbid BPD and those who didn't. That last point mattered: it suggested severe personality pathology wasn't a reason to delay trauma treatment, which is the assumption the protocol was built to challenge in the first place.
A larger question was whether DBT-PTSD could hold up against an established, gold-standard trauma therapy rather than just a waitlist. A multicenter trial comparing outpatient DBT-PTSD to Cognitive Processing Therapy across three German university clinics, in nearly 200 women with childhood abuse-related PTSD and significant BPD features, found that both treatments produced meaningful improvement, but DBT-PTSD came out ahead on several fronts: a larger pre-to-post effect size on the primary PTSD measure, a notably lower dropout rate, and higher rates of symptomatic remission, reliable improvement, and reliable recovery. A follow-up analysis conducted nine months after treatment ended found that DBT-PTSD's advantage over CPT held up over time rather than fading, across PTSD severity, general functioning, and BPD symptoms alike.
Zooming out, a systematic review and meta-analysis pooling 13 studies of PTSD-specific DBT interventions found moderate-to-large effects on PTSD symptom severity and depression when measured against control conditions, along with large pre-to-post improvements in dissociation, general BPD severity, and non-suicidal self-injury. That last set of findings points to something the individual trials also suggest: treating the trauma directly doesn't just move PTSD scores, it tends to ease the behavioral dyscontrol and self-injury that trauma symptoms often feed. The traditional DBT assumption was that stabilization has to come before trauma work; the pattern in this research runs at least partly in the other direction, with unresolved trauma acting as a standing trigger for the very crises DBT's Stage 1 is built to manage.
Real-world implementation is the harder test for any specialized protocol, and DBT PE has some evidence here too. A nonrandomized effectiveness trial run across four public mental health clinics found that patients who started the DBT PE protocol saw significantly greater reductions in PTSD severity than those who stayed on standard DBT alone, with reliable improvement in a majority of people who completed it versus roughly a third of those who didn't get the trauma-exposure component. Just as important, adding exposure work in these ordinary clinic settings wasn't associated with any rise in self-injury, suicidal ideation, or crisis service use, further evidence against the older concern that trauma processing is too destabilizing for this population. The same study flagged a practical barrier worth naming: clinician turnover, not patient risk, was the biggest reason eligible patients never started the protocol at all, a reminder that access issues here are more about workforce stability than about whether the treatment itself is safe.
Across this body of research, the throughline is fairly consistent: embedding trauma exposure inside DBT's existing distress-tolerance and emotion-regulation framework appears to let people engage with trauma memories they might otherwise avoid, dissociate from, or drop out of treatment to escape, without the destabilization that kept trauma-focused therapy out of reach for this population for so long.
None of this suggests trauma-focused DBT protocols should replace individualized clinical care, medication, or crisis-level psychiatric support when those are needed. It suggests that for PTSD complicated by BPD, self-injury, or severe dissociation, specialized DBT trauma protocols now have a real evidence base behind treating the trauma directly rather than deferring it indefinitely.
Finding the Right Support
PTSD doesn't respond to a single fixed protocol, and people tend to arrive at DBT skills from different starting points. Some come in needing distress tolerance first, because they're in the middle of frequent triggers and need something for tonight. Others are drawn to interpersonal effectiveness because trauma has quietly cost them relationships they want to repair. There isn't one correct entry point, and a structured, virtual group format tends to make it easier to stay consistent regardless of which module feels most urgent at the start.
If the skills covered on this page sound like tools that could help, TheraHive's online DBT skills groups walk through this same four-module structure with a trained facilitator and a small group of peers. This kind of psychoeducational program is meant to complement, not replace, individual therapy, trauma-focused treatment, or medical care a person may already have in place. Anyone currently in crisis, or working through the aftermath of trauma that feels unmanageable day to day, should have a licensed mental health professional as part of their care team alongside any skills-building work.
A full skills group is also a real commitment, and it's completely reasonable to want a lower-stakes way to find out whether DBT is a fit before signing up for a multi-week program. Our free Navigating DBT mini course is built for exactly that: a shorter, no-cost introduction to the same four modules covered on this page, with no obligation to continue further. However far you decide to take it from here, starting small still counts as starting.
Frequently Asked Questions
Is DBT or trauma-focused therapy like EMDR and prolonged exposure better for PTSD?
They're generally not answering the same question. EMDR, prolonged exposure, and cognitive processing therapy are trauma-focused treatments built to directly process the traumatic memory itself, and they carry the strongest evidence base for reducing PTSD specifically. DBT skills training works differently: it builds the capacity to tolerate distress and regulate emotion without necessarily processing the trauma memory at all.
A pilot randomized trial testing DBT combined with a prolonged exposure protocol against DBT alone in women with borderline personality disorder and PTSD found that adding the exposure component led to larger improvements in PTSD than DBT skills alone, which is a useful data point precisely because it shows skills and trauma processing doing different jobs rather than competing for the same one. That protocol was delivered as individual clinical treatment, not a psychoeducational group, but the underlying logic still applies: DBT skills tend to work best as groundwork alongside trauma-focused treatment, not as a replacement for it.
Can DBT help with PTSD if I'm not ready to talk about what happened?
Yes, and that's often exactly where it's most useful. Mindfulness skills like Observe and Describe give someone a way to notice a trigger response as it's happening without needing to narrate the event behind it, and distress tolerance skills are built specifically for getting through a flashback or a panic spike in the moment, not for processing what caused it. For someone who isn't ready for trauma-focused work yet, or who's on a waitlist for it, DBT skills training offers something to do with the hyperarousal and avoidance in the meantime, without requiring the trauma itself to be discussed.
How do online DBT skills groups work for PTSD?
An online DBT skills group typically meets on a regular weekly schedule with a small group of participants and a trained facilitator, moving through the same four modules covered on this page: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. Sessions are psychoeducational rather than trauma processing, so nobody is asked to describe their trauma history to the group. The focus stays on learning and practicing skills that apply to hypervigilance, avoidance, and emotional overwhelm, meant to complement any trauma-focused therapy or medical care a person already has in place.
How do I know if a DBT skills group is right for me if I have PTSD?
DBT skills groups tend to fit best when PTSD shows up as difficulty regulating emotion, chronic avoidance that's shrinking daily life, hypervigilance that makes relationships and work harder to manage, or trauma responses that haven't fully settled with medication or general talk therapy alone. If those patterns sound familiar, and structured skills practice feels more useful right now than processing the trauma itself, this is generally worth considering.
It isn't a diagnostic tool, and it isn't a substitute for trauma-focused treatment when that's what's needed. Someone in acute crisis, actively dissociating in a way that feels unsafe, or newly exposed to trauma should start with a full clinical evaluation first. For the ongoing patterns covered throughout this page, chronic hyperarousal, avoidance, and difficulty regulating emotion around triggers, DBT skills groups are built to address exactly that territory.
What happens in a DBT skills group session?
A typical session opens with a short mindfulness exercise, checks in on how the past week's skill practice went, teaches one new skill from that week's module with concrete examples tied to PTSD-related situations, and closes with a specific practice assignment for the coming week. Sessions are structured and group-based, not open-ended trauma discussion.
Participants are never asked to share trauma details they aren't comfortable disclosing, and the format stays consistent from week to week, which matters for PTSD specifically, since predictability itself can lower the alarm response that unpredictability tends to trigger. Over the course of a program, sessions move through all four modules in sequence: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness.
Is online DBT as effective as in-person for PTSD?
Early research comparing online and in-person DBT skills training suggests outcomes for skill acquisition and symptom reduction are broadly comparable, though the evidence base is still smaller than for in-person delivery overall. For PTSD, virtual delivery carries a specific advantage worth naming directly: it sidesteps some of the exposure-like friction of getting to an unfamiliar building or sitting in a waiting room with strangers, which can itself function as a trigger for someone whose avoidance is already doing a lot of work to keep them out of situations that feel unpredictable.
References
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