Authors: Linda A. Oshin, Shireen L. Rizvi
Categories: Article, Dialectical behavior therapy, oppression, race/ethnicity, sexual and gender minority, discrimination
Source: Psychotherapy (Chicago, Ill.)
Doi: 10.1037/pst0000541
Authors: Linda A. Oshin, Shireen L. Rizvi
As the popularity of Dialectical Behavior Therapy (DBT) grows, so does its use with increasingly diverse groups of clients. In this article, we demonstrate that DBT in its standard form can incorporate the sequelae of oppression as a target of treatment by providing clients with skills to identify oppression and its impact while responding effectively. To support the use of DBT with individuals experiencing emotion/behavior dysregulation and oppression, we review how each of the primary strategies of DBT can be used within the context of oppression. Specifically, we discuss how dialectical philosophy, the acceptance/change dialectic, communication strategies, and case management strategies can be viewed through an oppression lens. A brief review of DBT research with historically oppressed populations and common pitfalls in treating oppressed individuals are presented. As research in examining and adapting DBT for minoritized groups continues to catch up to clinical need, guidance is presented here for researchers and clinicians interested in using this empirically supported treatment in communities that experience oppression.
With a broad evidence base, the use of Dialectical Behavior Therapy (DBT) has grown in recent years to be used with individuals from a diverse range of backgrounds and clinical presentations. It was initially developed for borderline personality disorder (BPD), a disorder that is characterized by chronic and severe emotional, behavioral, and cognitive dysregulation (Linehan, 1993). The use of DBT was quickly expanded to target other problems related to emotion dysregulation, including bulimia nervosa, substance use, and the sequelae of trauma (Miller, 2015). DBT for adolescents (DBT-A) is now one of the most empirically supported treatments for adolescents with suicide and self-harm behaviors (Glenn et al., 2019). There are many reasons for DBT’s widespread popularity (Swenson, 2000), one of which is its principle-based approach, which allows clinicians to idiographically tailor treatment to the client’s needs, presentation, and identities. The principle-based approach and vast evidence base for issues related to emotion dysregulation positions DBT to be tailored effectively for use with individuals from historically oppressed groups. To facilitate the use of DBT with an increasingly diverse client population, this article interprets the fundamentals of DBT through the lens of oppression by explaining how the primary “core” strategies of DBT can be used to address the sequelae of oppression (see Table 1 for a summary and examples). The article ends with some common pitfalls DBT clinicians may encounter as they treat individuals from oppressed groups. It is our hope that this article can serve as a resource to both researchers and clinicians who want to balance tailoring treatment to unique needs with maintaining treatment fidelity.
While it is difficult to behaviorally define a concept that is as nebulous and pervasive as oppression, doing so will help to shape the target of our discussion. We define oppression as any action that results in the control, disrespect, or disadvantage of an individual who has an identity that has been historically excluded from positions of power within a specific culture or place. This definition focuses on the effect of the action rather than the intent as intent is often unknown to the individual who is experiencing oppression. This definition also corresponds with Critical Race Theory, which assumes that society systemically disadvantages specific groups of people with the goal of maintaining institutions that are dominated by White individuals (Delgado & Stefancic, 2023). While clinicians tend to focus on individual and interpersonal issues, it is important that clinicians also understand systemic issues and their influence on individuals. Systemic oppression can be defined as oppression that is perpetrated by institutions, governments, and societies while interpersonal oppression is defined as oppression that is perpetrated by individuals. Examples of systemic oppression prison sentencing policies that result in increased prison sentences for Black and Latinx offenders compared to White offenders, laws banning parents from pursuing affirming medical care for their transgender children, etc. In comparison, examples of interpersonal oppression using racial slurs, consistently misnaming individuals who share similar identities with each other, declining to consider an individual with an oppressed identity for a position of power, etc. We highlight in this article how DBT is well-suited to address the negative effects of both interpersonal and systemic oppression among clients. These behaviorally specific definitions will allow for a targeted discussion of how each of the primary strategies in DBT can be used to address the sequelae of oppression.
When Linehan first developed DBT, she incorporated many elements into the treatment to address oppression, guided by feminist theory. For example, Linehan incorporated the concept of interrelatedness due to the fact that many from oppressed groups tend to have more relational views of the self (Linehan, 1993), while balancing the emphasis of individualism in Western mainstream society. As is the case with many who experience serious mental illness, Linehan recognized the systemic oppression that many individuals with BPD face. For example, Linehan was aware that individuals with BPD would struggle to maintain regular employment, interact with state welfare agencies, and experience complex or disrespectful interactions with medical or mental health providers. An important aspect of DBT is helping clients interact with institutions effectively, while balancing the reality that these institutions are powerful, difficult to navigate, and often biased against them.
Studies using standard DBT have shown that it can be used effectively with historically oppressed populations. As Harned et al. (2022) note in their systematic review of minoritized groups in DBT trials, while more recent trials have become more diverse, earlier trials of DBT lacked ethnoracial diversity and failed to report relevant descriptives on gender diversity. Some of the more recent trials of DBT used DBT for new clinical populations in addition to increasing ethnoracial diversity, incorporating modifications to address the psychopathology but with no described modifications to address ethnoracial differences (e.g., Goodman et al., 2016; Rosenfeld et al., 2019). There has also been a great deal of ethnoracial diversity reported in DBT-A research. For example, McCauley et al (2018) conducted a randomized clinical trial of DBT-A in a sample that was 27% Latinx. Although they were not RCTs, studies by Berk et al. (2020) and Yeo et al (2020) found positive outcomes in studies of DBT-A with ethnoracially diverse samples. In terms of sexual orientation, studies comparing the efficacy of DBT between LGBQ and heterosexual individuals have shown that there is similar efficacy, although there may be some disparities (Oshin et al., 2024; Poon et al., 2022). Harned et al. (2022) also note in their review that DBT trials included more sexual minorities than the US population and inclusion of transgender and gender expansive groups could not be accurately assessed due to lack of reporting.
Despite the attention paid to issues of oppression in DBT theory and research, there are important areas for improvement. There remains a need for more research to determine whether rates of response to DBT are different among various minoritized groups, particularly Black, Latinx, and American Indian/Alaska Native youth and LGBTQ+ groups across the lifespan as they are high risk for suicide (Haas et al., 2010; Meza & Bath, 2021; Wexler et al., 2015). Such research would help to determine if DBT in its standard form is applicable for different marginalized groups and, if not, whether adaptations are needed.
Another relevant concern about DBT is accessibility. While there is no evidence that DBT is less accessible than other evidence-based treatments, DBT is a complex and time intensive treatment to deliver, which translates to it being expensive and difficult to cover using insurance (Koons et al., 2013). Comprehensive DBT involves individual therapy, group skills training, phone coaching, and consultation for clinicians. In addition to cost, individuals from oppressed populations may find it difficult to commit to a minimum of 3 hours a week of therapy plus homework and phone coaching between sessions. Individuals from oppressed groups may struggle to make these commitments along with other demands on their time and resources. Thus, while there are elements of DBT that are well-suited for use with individuals from oppressed groups, it is also important to acknowledge that there may be aspects of DBT that are not relevant or inclusive of these groups. As we wait for research to provide the field with information regarding the implementation of DBT with oppressed clients, below we discuss how standard DBT principles can be viewed through the lens of oppression.
In the course of developing a new therapeutic approach, Linehan became highly influenced by dialectical philosophy (Linehan & Wilks, 2015). She incorporated this philosophy directly into her treatment which requires that clinicians adopt a dialectical worldview and specifically engage in a set of dialectical strategies. The worldview suggests that tension and opposites are constant and inevitable. Dialectics attempts to balance these oppositional truths, seeking a synthesis of these truths that achieves a more holistic understanding of reality. One benefit of dialectical thinking is that it highlights that pathology is not solely caused by ineffective behavior or lack of skills within the individual – it is also caused by an environment that blocks effective behavior from occurring and/or reinforces ineffective behavior. These truths can exist at the same time. Dialectical thinking is essential to DBT and can be a helpful way to consider oppression, especially systemic oppression.
A dialectical way to think of systemic oppression is that it is always present, and we are all functioning within systemic oppression – with the result being that oppressed groups are kept in a subordinate position – and that individuals can behave in ways that can reduce, maintain, or exacerbate the effects of systemic oppression. Thus, by accepting both truths, a dialectical perspective of oppression can protect against helplessness. An individual can consider how their actions can maintain, exacerbate, or improve their response to oppression without denying the role of other individuals, systems, and institutions in their oppression.
While taking a dialectical perspective of oppression, it is important to attend to respectability politics. Respectability politics is the concept that oppressed groups are often encouraged to present in a way that will minimize oppression and maximize opportunities. In other words, individuals from oppressed groups often must present themselves according to mainstream standards in order to be treated with basic respect and to avoid discrimination (Dazey, 2021). For example, the parent of a Black child may encourage the child to straighten their hair to ensure they are treated well at school, or a non-binary person may decide to present their self within the gender binary at work because they want to be respected by their superiors. A dialectical way to think about respectability politics is that one can mindfully decide to present according to mainstream standards in order to get their needs met (i.e., be effective) while also understanding that doing so comes at some cost to them and their group. A dialectical perspective of oppression allows for balance between accepting the reality of systemic oppression and the impact of their individual choices within that system.
Another core element of dialectical philosophy is that the client possesses everything within them to achieve a life worth living and it is the role of the clinician to assist the client in attaining this goal. This corresponds with the philosophical idea that the elements for growth are present in the current situation; “the acorn is the tree.” This concept places the clinician and client on an equal plane as they collaborate in building a more effective life for the client. This focus on equality is often particularly effective for clients with BPD, who can be sensitive to power differences. The emphasis on collaboration and working toward an egalitarian clinician-client relationship comes from the feminist therapy tradition, and has been shown to increase engagement among clients (Alegria et al., 2019; Rader & Gilbert, 2005). An example of this from DBT is the priority placed on identifying and working toward the client’s goals for a life worth living, communicating that only the client can know what would make their life worth living. Thus, dialectical philosophy can be a helpful lens through which one can understand oppression within the context of treatment.
Using dialectical philosophy and extant research on emotion dysregulation, Linehan created the Biosocial Model to explain the etiology of BPD and pervasive emotion dysregulation (Crowell et al., 2014; Linehan, 1993). This model states that two factors contribute to the development of chronic and pervasive emotion dysregulation – biologically-based emotional vulnerability and environmental invalidation of emotions. Biological vulnerability refers to the physiological correlates of emotional dysregulation, such as HPA axis dysregulation, genetic predisposition to traits (e.g., impulsivity), impairments in neurotransmitter function (e.g., serotonergic or dopaminergic systems), etc. (Crowell et al., 2009). Examples of how biological vulnerability may be experienced by a client a family history of mental illness, perinatal trauma or exposure to teratogens (e.g., fetal alcohol syndrome, early head trauma, etc.), or subjective experience of emotions as being overwhelmingly intense. It is also important to note that the chronic and pervasive stress caused by a lifetime of oppression can contribute to one’s biological distress response (Wadsworth, 2015). Clients may not often be able to pinpoint a cause of their biological vulnerability, but often find it validating to have a clinician acknowledge that the client subjectively experiences their emotions as intense and difficult to regulate. For clients who experience racial oppression, they may also find validation in the research that shows that there is an association between race-related stress/trauma and emotion dysregulation (Roach et al., 2023)
Environmental invalidation refers to a developmental context which is intolerant of emotional expression in some way. Examples of environmental invalidation a caregiver with a harsh communication style, family members with poorly managed mental illness, bullying or other forms of community violence, etc. Most experiences of oppression likely fit within the construct of environmental invalidation. Indeed, Pierson et al. (2022) posited that racism creates a pervasive invalidating environment that disadvantages ethnoracially minoritized clients. Considering oppression as a form of environmental invalidation centers the experience of the individual regardless of the intention of the perpetrator. For example, a caregiver who was not affirming of a transgender child’s identity is not attending to their child’s emotional experiences of gender dysphoria, or the only Black child in a school would have experienced many negative emotions that were likely not understood or attended to in their school.
The biosocial model identifies these two factors – biological vulnerability and environmental invalidation – and also describes how these factors transact with each other to contribute to chronic emotion dysregulation. Those with increased biological vulnerability might be more sensitive to environmental invalidation, or invalidation in one’s environment could increase their biological vulnerability. Thus, the biosocial model can be a tool with which the clinician can help the client understand how oppression may be one of the many factors that has influenced their target problems. For example, the transactional nature of the biosocial model might help certain clients understand why their distress due to the sequelae of oppression is greater than others who have experienced similar levels of oppression without similar reactions, such as a client who is Muslim experiences increases in suicide urges when encountering news about violence against Muslims (Figure 1). Perhaps this client’s predisposition to emotionality (e.g., genetic predisposition for impulsivity, increased HPA axis activity due to history of trauma, etc.) interacted with their invalidating environment (e.g., chronic experiences of Islamophobia, frequent threats of violence in one’s neighborhood) leading to a tendency to have more intense emotional reactions in response to oppression (e.g., intense hopelessness and suicide urges). The client may not have the skills to appropriately cope with their negative emotions due to the oppression. In this way, the biosocial model can help a client understand their reactions to oppression and can inform how a clinician can work with a client to develop more effective responses to oppression.
DBT seeks to balance the need for behavioral change with the need to accept reality; we describe in this section how this balance is particularly helpful in managing responses to oppression and indeed reflects commonly used coping strategies that are used in racially minoritized families. As explained by the Racial Encounter Coping Appraisal and Socialization Theory (RECAST; Anderson & Stevenson, 2019), responding to racial stress involves many processes, including mindfully appraising an encounter and its effect on the individual and choosing an appropriate reaction. Families often teach children to identify racism and coach children in appropriately responding in ways that do not increase threat or negative outcomes. In these circumstances, families are helping children to balance accepting that they have been impacted by oppression (identifying the encounter as racist, noticing how it is affecting them, noticing the effects on others), and engaging in change behavior to either change the situation or how they feel about it (problem-focused coping, reappraisal, etc.). Historically, many people of color, as well as people of other oppressed groups, have learned how to respond effectively to oppression by balancing change and acceptance. This dialectic allows individuals to be fully aware of the oppression they experience without succumbing to hopelessness. Thus, the change-acceptance dialectic echoes practices that are common to racial socialization, although families will vary to the degree in which they engage in them (Hughes et al., 2006).
Balancing acceptance and change is especially effective when responding to systemic oppression. It is common practice that families of color educate their children about the oppression that faces their group, how to identify and respond to it, how to maintain pride in their heritage despite opposing messages, and how to work toward a better future for their group (Anderson & Stevenson, 2019). This education typically includes balancing the negative emotions (rage, hopelessness, loneliness) that come with experiences of oppression with positive emotions regarding their group (hope, pride, belongingness). In fact, Kamody et al. (2020) suggested that acceptance-based skills from DBT might be helpful in managing distress due to minority stress for Black adolescents. Similarly, identity pride is fostered within the LGBTQ community and is an effective protective factor against negative mental health outcomes (Perrin et al., 2020). Thus, the balance of negative emotions elicited by oppression with positive emotions associated with one’s group might be especially useful for individuals learning how to manage living a meaningful life while experiencing oppression.
The acceptance/change dialectic enables individuals to behave effectively in the face of oppression. Effective behavior, behavior that is most likely to achieve the client’s short- and long-term goals, is an important focus of DBT. Balancing change and acceptance is crucial when one’s goal is effective behavior, as one needs to understand and accept their reality (such as understanding they are experiencing discrimination and experiencing painful emotions as a result) in order to choose a behavior that would effectively meet their goals (mindfully choosing a response to the discrimination that will not make things worse). For example, consider a client who is a Latina and has a co-worker who says offensive comments about undocumented immigrants and frequently treats the client with hostility. Interactions with this co-worker are often a prompting event for this client’s suicide ideation and also makes her feel angry and worried about her family members who are undocumented. The clinician could work with the client to understand how these interactions with the co-worker makes her feel, how other co-workers react to the comments, etc. The clinician could then engage in problem solving with the client, while modeling balancing acceptance. Perhaps the client feels hopeless because she knows that her superiors like this co-worker and because she has experienced this discrimination in other settings with negative outcomes. The clinician could coach the client in self-validation and acceptance skills and validate how infuriating it is that the client must deal with this discrimination at work. By accepting her reality, the client can mindfully choose an effective change behavior. She needs to make money and these interactions with her co-worker put her at risk for suicide. She plans to talk with her other Latinx co-workers about this co-worker’s comments, prepares a “Cope Ahead” plan for interactions with this co-worker (Linehan, 2014), and commits to continuing to work on her community college application or applying for jobs every morning before work. By accepting her reality, the client can balance her short-term (make money) and long-term goals (achieve a better career) while attending to her reaction to the present.
A dialectical strategy in DBT is for the clinician to adopt and model a dialectical worldview and thus, DBT clinicians can model how to consider oppression with a dialectical lens. This can be done by using acceptance strategies from DBT, with a heavy emphasis on validation. Indeed, theorists have suggested that the use of change-based strategies that are common to CBT (e.g., cognitive reappraisal) can be invalidating for oppressed clients (Kelly, 2019). Validation allows clinicians to help their clients more fully understand the effect of their experience of oppression (e.g., How did it make them feel? What memories did it elicit? What were they worried was going to happen?). Clinicians must also balance these acceptance strategies with change strategies to help the client find effective ways to move forward from their experience. A rewording of an assumption within DBT may be helpful when considering change strategies in the face of oppression You didn’t cause your problems and it is up to you to deal with them (Pierson et al., 2022). In our example above, it was not the client’s fault that she was being targeted at work, and she needed to figure out how to effectively manage the situation so she could earn money while reducing risk for suicide. Change behavior will look different depending on the situation and the client; perhaps the client would find reporting her co-worker to management or participating in rallies to raise awareness about the needs of undocumented immigrants to be effective change behaviors. Thus, a clinician can work with a client to model and promote a dialectical way of viewing their experience of oppression.
A primary feature of DBT is balancing irreverent and reciprocal styles of communication (Linehan, 1993). Reciprocal communication is defined by responsiveness, self-disclosure, warmth, and genuineness. This style of communication is likely familiar to clinicians. Irreverent communication is designed to throw a client off balance and “jump the track” in a session; it can take the form of humor, incongruity, and/or confrontation. Balancing these styles of communication enables a clinician to shake up the flow of the session, keep the client’s attention, and move purposefully toward goals. We next describe how these communication strategies can be used to effectively discuss experiences of oppression.
While reciprocal communication might come more naturally to many clinicians, the extent that this style is used in DBT might be more novel. One function of this style is to reduce the power differential between clinician and client through strategies like self-disclosure and genuineness. This might be particularly helpful for oppressed clients, who are used to being in a subordinate position. Of course, these strategies should be used thoughtfully and with awareness of the needs of the client. An example of a reciprocal communication in response to a client describing their experience of oppression would “Wow, I know you’ve faced this all of your life and I’m still horrified and sad that you have to encounter this on a regular basis,” or “It makes me so angry to hear about you being disrespected like that.” Clinicians may find self-disclosure useful when working with oppressed clients, especially in disclosing their own identities and discussing their similarities or differences with the client’s identities. As is always the case with self-disclosure, clinicians should focus on the benefit to the client when using this strategy. When disclosing similarities with clients, it is particularly important that clinicians avoid over-identifying with a client. Even if a clinician and client share an oppressed identity, the client’s experience of oppression might be different than the clinician’s. Assuming that similarities in identities is equivalent to similarities in experiences may lead to invalidation of the client.
If there is a difference in identities, it is advised that the clinician address the elephant in the room by initiating a conversation about it. Oppressed clients are likely already thinking of this difference in identities and may feel more comfortable if they know the clinician is considering it as well (Cardemil & Battle, 2003). Thus, by bringing up the differences and providing time to discuss how differences in identity could impact treatment, clinicians could be engaging in “level 3 validation” or stating what has not been said out loud (Linehan, 1997). Clinicians might feel uncomfortable bringing up differences in identity, which is understandable as one does not typically discuss identity openly in conversation! We encourage clinicians to practice discussing identity in team consultation and to commit to engaging in exposure if they notice anxiety about the conversation. There are ample opportunities to engage in these conversations, especially early in treatment. One way to open this conversation might be, “I wonder how you feel about working with someone from a different race/gender/sexuality/religion/etc.? I ask because I want to make sure that your time working with me is as helpful as possible to you.”
Many clinicians are nervous about using irreverent communication for fear that it will come across as sarcastic or mean, and that the relationship would be permanently damaged. This anxiety is often more a problem for the clinician than the client – in our experiences, clients value and appreciate these moments of humor and “realness” from the clinician. Additionally, since DBT emphasizes that the therapeutic relationship is a real relationship between equals, the stance is that any damage could be repaired. In fact, irreverent communication might make a client feel more welcome, especially if they are from a group that has not traditionally sought and experienced therapy. Using humor or incorporating cultural references that are meaningful to the client may be received well. Irreverent communication may also help to break through an avoidant response to oppression, “I’m sure this has never happened to a transgender person before. I’m shocked!”
Irreverent communication can be helpful in addressing oppression within sessions by providing an opportunity for clinicians to address topics that are not typically discussed in normal conversation. To use another DBT saying, we can be irreverent in “plunging in where angels fear to tread.” Clinicians can use their irreverent communication strategies to be direct in discussing issues related to oppression without mincing words. This provides an opportunity for the clinician to create an environment where the client can feel open discussing their experience. An example of using irreverent communication to discuss oppression would be a White woman clinician directly and without caution, saying to an Arab-American “Clearly, I do not have experience with being targeted by Islamophobia! You are the expert in that. And yet, I still strongly believe I have the skillset to help teach you how to deal with it when it happens to you.” Of course, a lack of self-awareness can lead to irreverent communication more likely to lead to a rupture. Clinicians must be aware of their position of power, their privileges, and be mindful of the impact of their actions on the client. In cases where rupture does occur, it is important for clinicians to consider their contributions to the rupture – is it possible that there is a lack of awareness from the clinician? Ruptures can be discussed with the consultation team to establish how it can be repaired and if there is need for exploration or education on behalf of the clinician or team.
Case management is an important part of DBT in helping the client learn to navigate their environment and relationships. DBT emphasizes the case management strategy of Consultation to the Client, in which the clinician teaches the client to advocate for their own needs rather than intervening on their own behalf. For example, rather than having a case manager enroll the client in a food assistance program, the clinician may work with the client to identify factors that have interfered with them enrolling on their own and coach the client in using skills to accomplish the task, maybe even assigning the client to bring an application to session and completing it together. Individuals with oppressed identities who are struggling with psychopathology may struggle to engage in their own case management for a variety of reasons. DBT uses treatment as an active teaching opportunity to assist clients in overcoming barriers to living their life on their terms. DBT prioritizes teaching clients how to swim rather than giving them a floating device as this will have more sustained benefits.
While consultation to the client is the goal in DBT, there is also an understanding that there are circumstances when the clinician needs to intervene on behalf of the client because the environment is too powerful. This occurs when 1) the outcome is important and 2) the client does not have capacity or power to achieve the outcome. While environmental intervention is often thought about in relation to safety concerns (e.g., consulting with inpatient clinicians when the client has been hospitalized and can’t advocate for themselves), environmental intervention may also be necessary when the environment is too oppressive. Specifically, the clinician may need to use their power and privilege to intervene for the benefit of the client. For example, a clinician may call a school district on behalf of a transgender client to draw their attention to laws/policies that require staff to use requested name and pronouns of students rather than those associated with their legal records. It is important that clinicians attend to the influence of identity in power dynamics in their client’s environment.
Clients who are referred to DBT are frequently dealing with a vast array of problems – behavioral and emotional dysregulation, suicide and self-harm behaviors, therapy interfering behaviors, etc. – that need to be addressed with a certain amount of urgency. It is easy to focus on urgent issues and ignore issues related to identity, oppression, and their influence on the client’s presentation. Research has consistently demonstrated that ignoring identity-related issues can reduce the efficacy of the treatment and the engagement of the client. Multiple meta-analyses have shown that treatments that have been culturally adapted are more effective in comparison to using a standard version of the treatment (Benish et al., 2011; Griner & Smith, 2006; Hall et al., 2016). While there may not be a systematic adaptation of DBT for your client’s specific identity, important information can be gleaned from these adaptations that can be helpful in tailoring your client’s treatment to their needs. See Haft et al., (2022) for a review of systematic cultural adaptations to DBT and Cohen et al. (2021) for considerations in adapting DBT skills training for sexual and gender minorities. Additionally, one must balance the important information we receive from systematic adaptations with the need to conduct individualized assessment to avoid over-generalizing adaptation research to our client’s unique identities. Rather than seeing the assessment of a client’s identity and experiences with oppression as another task to accomplish during treatment, we invite clinicians to consider identity and oppression as important information regarding a client’s background and learning history, which informs each step of treatment and cannot be ignored without jeopardizing treatment effectiveness.
It is also important to note the other side of this clinicians could focus too much on a client’s oppressed identity and not attend sufficiently to other identities or lose focus of the client’s treatment targets. As DBT is a treatment that was developed for individuals with severe behavioral and emotional dysregulation, ignoring treatment targets could be incredibly detrimental to a client’s health. This is why it is helpful to have solid conceptualization that is based in the biosocial model and a culturally informed assessment of the client. The biosocial model can help organize the conceptualization with a focus on the emotion dysregulation that is the target of treatment.
It is likely that clinicians are well aware of the need to assess identity and address oppression in treatment, but do not feel comfortable doing so. Despite the required multicultural training that most clinicians have received and having personal values about the importance of diversity, many are uncomfortable with “broaching,” or having explicit discussions about how identity factors are impacting treatment (Day-Vines et al., 2018). This discomfort may be due to several reasons (other than not seeing it as important to therapy, see above). Clinicians may have inadequate training, not feel personally comfortable doing so, have fears about the sequelae of the conversation, forget to do it, etc.
Given the previously discussed point that identity factors are related to outcomes, we consider the absence of discussing or evaluating identity as a therapy interfering behavior on the part of the clinician. As such, a clinician should mindfully consider barriers to engaging in this behavior, perhaps conducting a Missing Links Analysis for the behavior or discussing it with their consultation team (Linehan, 2014). This will allow the clinician to consider solutions – perhaps they need to set up exposure practices for discussing identity with their clients, seek more specialized training, create a required intake form to ensure it is discussed, etc. Perhaps the clinician has few experiences interacting with individuals with the same identity as the client and need to consider why they have not interacted with this group (e.g., residential segregation) and how they can respectfully increase their awareness of this group (e.g., attending cultural events, consuming media about this group).
There are many resources to assist clinicians in increasing broaching behavior. Day-Vines et al. (2018) describes a number activities that could be used in supervision contexts to increase broaching and Davis et al. (2018) provide many examples of developing a multicultural orientation. The Cultural Formulation Interview is a part of the DSM-5 and includes several items that clinicians could use to assess for the influence of a client’s identities and background on their clinical presentation and treatment (Lewis-Fernández et al., 2015). Bauer and colleagues (2022) developed a toolkit that helps clinicians incorporate cultural humility to their practice. These are just a few of the many resources that are available to clinicians who wish to expand their knowledge and experience with the clinical needs of individuals from oppressed identities. Clinicians who identify this as an area of growth should consider making it a priority for continuing education and problem solving. Clinicians can also bring their own therapy-interfering behavior to their consultation team for assistance. A consultation team can help brainstorm solutions, identify barriers, help a clinician with dragging out behavior, etc. It is also important to remember that most clinicians struggle with broaching the topic of identity or oppression in treatment. Thus, it is possible that the clinicians on the consultation team also struggle with this behavior. The team can make efforts to increase this behavior as a group, adding tasks related to this behavior to the agenda, pooling and sharing resources, etc.
Clinicians may not know how to identify or define oppression and its sequelae in general or especially in the context of treatment. Experiences of oppression are often vague and undefined, leaving clients feeling confused, disrespected, angry, sad, etc. Microaggressions or systemic oppression are often not explicit or overt experiences. Thus, clinicians and clients may not be sure if an experience is oppression. In this case, considering oppression as a form of environmental invalidation is helpful. It eliminates the need to consider the intentions of the perpetrator and centers the feelings of the client. This also helps the clinician to effectively assess and validate experiences that they may not have personally experienced. For example, a clinician who speaks English as a first language might say to a client who speaks English as a second “That shop worker talking down to you must have felt so demeaning. I can only imagine how frustrating it must be to have people think poorly of you just because of your accent.” In this case, the clinician does not know what it is like to be disrespected because of an accent, especially to have this happen repeatedly and worry about it happening, but by assessing the client’s experiences, the clinician could validate them and the client’s emotions about their experience. This also allows for the clinician to collaborate with the client to understand how this experience and its impact on the client should be handled in therapy.
Relatedly, clinicians might struggle to identify or feel comfortable addressing systemic oppression. This is understandable as DBT is an individual intervention (or family, if using DBT-A), and systemic oppression can be hard to identify due to its pervasiveness. While identifying systemic oppression is difficult, failing to identify and target systemic oppression can lead to invalidation of our clients. Focusing on an individual’s behavior without attending to the ways in which the environment contributes to that behavior would lead to an intervention that is ineffective (Sloan et al., 2023). We encourage clinicians to seek education about systemic oppression that their clients face and to look to the change-acceptance dialectic to guide discussions and interventions around systemic oppression. Systemic oppression cannot be solved in therapy, though you can work to understand how it affected the client and how to respond effectively to their own experiences. An example of this may be acknowledging with a client that they are struggling to find quality mental health services because they live an area that is historically oppressed and lacking in resources. The clinician can then help the client identify resources together, the clinician can call mental health resources or insurance companies on behalf of the client to advocate for them, or the clinician and client can work together to create a resource list for the client to share in their community as a Contribute activity from the Wise Mind ACCEPTS skill. As with every experience, clinicians should also consider how this experience fits in with the client’s goals and targets in treatment. It might be something to validate, or something to assess as part of a chain analysis as a vulnerability factor, prompting event, etc. (Rizvi & Ritschel, 2014).
Both clinicians and clients might fall into hopelessness when in the midst of oppression. Indeed, there is cause for hopelessness in the face of oppression, given the long history a client’s group has likely had with oppression, the magnitude of systemic oppression that faces them, and their own learning history with oppression experiences. Clinicians may also feel a sense of hopelessness regarding oppression, whether they are empathizing with their client’s experience, considering the extent of the work that needs to be done to make DBT or the mental health field more inclusive, etc. This hopelessness is valid and can make it difficult for clients and clinicians to engage in change behavior. Indeed, research has suggested that hopelessness may be an important mechanism through which race-related stress influences suicide ideation (Polanco-Roman & Miranda, 2013).
Hopelessness is a state that DBT clinicians encounter frequently, and hopelessness regarding oppression does not need to be treated differently. Clients and clinicians should mindfully attend to their hopelessness. Where is it coming from? What prompted it? What are they hopeless about? Clients and clinicians and work on validating their hopelessness regarding oppression. In fact, oppressed groups often have a history of finding ways to validate their hopelessness and negative affect regarding oppression. It might be helpful to ask a client how others in their group tends to manage these feelings. Are there readings, videos, etc., that validate their experiences of oppression and remind them that they belong to a group, rather than feeling isolated? A clinician might join the client in interacting with this validation if it is appropriate. Clinicians and clients can also engage in self-validation regarding their hopelessness, perhaps using mindfulness skills to observe and describe their hopelessness and being compassionate about these feelings.
DBT clinicians strive to balance this validation with change behavior. One might engage in Opposite Action by joining an activist group or attending a rally. One might engage in a pleasurable activity by spending time with a member of their group. In fact, there is a wealth of research that demonstrates that increasing affiliation with one’s oppressed group is an effective protective factor from the negative effects of discrimination (Branscombe et al., 1999; Brittian et al., 2015). It is possible that those who are struggling with the negative effects of oppression are isolated from their oppressed group, and a potential intervention would be to increase their contact with their group. Spending time with one’s group or thinking about the strengths that their identity brings to their life can be a helpful way to remember that there is more to their identity than the oppression that they face. There are several skills from DBT that can be helpful in managing hopelessness in response to oppression. Radical Acceptance may be a particularly powerful skill for those from oppressed groups. This would mean accepting that there is oppression, that it likely won’t end within one’s lifetime, and that their life will always include oppression. At the same time, radical acceptance allows one to stop fighting this reality and see that there can be beauty and freedom can co-exist with oppression. In fact, an adaptation of DBT skills training for disordered eating among Black girls showed that the participants found Radical Acceptance a particularly helpful skill.
As mentioned earlier, DBT is a comprehensive treatment that was developed within a specific context. There are many instances in which DBT has been adapted to fit different clinical presentation, setting, cultural, and population needs. Despite this important work, the increased interest in using DBT in diverse populations suggests that the clinical need for resources to tailor DBT to individuals from oppressed groups is outpacing the research. For example, despite increases in suicide among Black youth (Lindsey et al., 2019), there is very little specific research on the use of DBT-A with Black youth (Pierson et al., 2022). The question of adaptation is an important dilemma to consider when considering the use of DBT for individuals from oppressed groups. We invite readers to consider the issue of adaptation as a Any changes to DBT reduces fidelity to the model as an “off-label use” and, simultaneously, adaptation and tailoring may be necessary to accommodate client needs (Koerner et al., 2007). By acknowledging both truths, a provider can mindfully decide how to treat their client according to DBT principles while tailoring treatment to their client’s needs. Similarly for researchers, research has shown that adaptation for a particular population typically results in better outcomes (Hall et al., 2016), and yet there are insufficient resources for systemic adaptations for each population and thus we must accept that adaptations must occur reactively (Wiltsey Stirman et al., 2019).
We encourage clinicians and researchers to proceed with modifying DBT mindfully, weighing the potential benefits of an adaptation with potential deficits. For example, a frequent adaptation of DBT is to adjust the structure of the treatment to reduce burden on clients or clinicians (e.g., not offering phone coaching, eliminating or reducing the length of skills groups, etc.). This adaptation of structure should consider what treatment functions are lost (e.g., skills generalization, contact with other members of the DBT team, etc.). Additionally, clinicians may look to other DBT adaptations to find helpful resources to use with clients struggling with issues for which standard DBT does not address. For example, additional dialectical dilemmas were developed for Latinx families that incorporated acculturation issues (Germán et al., 2015) and consideration for mental health stigma was incorporated into DBT in Nepal (Ramaiya et al., 2018). These adaptations could likely be repurposed for other groups, with mindful consideration of pros and cons. Thus, adaptations may be necessary and we should approach them with intention and appropriate research and consultation. Clinicians may sometimes need to consider whether DBT is the ideal treatment for their client, if they find that they are making a number of adaptations. Perhaps the structure does not fit the client’s life, or the principles are not suited for the client’s presentation.
While a full description of all the ways one could use DBT with clients with oppressed identities would be too much information for one article, it is our aim to demonstrate how the core strategies and principles of DBT could be used to help a client effectively manage with the sequelae of oppression within the context of their treatment. Our goal for this paper is to provide clinicians with skills to use DBT with their oppressed clients, with the hope that someday the research in DBT will provide more specific and individualized resources for clinicians. We caution against overapplying these techniques; clients generally come to DBT because they want help with behavioral or emotional dysregulation, not necessarily for clinicians to treat their responses to oppression. These considerations will be helpful in guiding clinicians and researchers who are interested using DBT principles to treat clients who are experiencing oppression and work with them to have a life worth living.