What can we learn from cultural adaptations of dialectical behavior therapy?

Challenges with mental health occur worldwide. However, the psychotherapies that treat these concerns have been mainly developed by and for people who are White and live in Western countries. Because of this, many efforts have been made adapt psychotherapy to the cultures of people of color and cross-cultural clients. These cultural adaptations are similar to tailoring a pair of jeans to be a functional fit for an individual. The function of and the material of the jeans remain largely the same, although various sections may be added, removed, or reshaped to better fit the individual. For cultural adaptations, in practice this usually looks like modifying the language and examples that are used in therapy. However, some individuals may be in contexts where jeans are not functional, and more significant substitutions are needed –  for cultural adaptations, this may involve the introduction of novel components or removal of irrelevant components.

Research studies are a tool to assess whether culturally adapted therapy are effective for addressing mental health concerns. There are several summaries of research on cultural adaptations of commonly used therapies, such as cognitive behavioral therapy. These summaries have been helpful in justifying the use of culturally adapted therapy (instead of nonadapted interventions), as well as offering clinicians practical information on how to adapt their interventions to people of color and cross-cultural clients. Until recently, no such summary existed for cultural adaptations of dialectical behavior therapy (DBT), a widely used treatment for emotion dysregulation. DBT is principle-based and behavioral, and involves the teaching of skills in four modules: mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. To summarize cultural adaptations of DBT, we conducted a systematic review of research studies that described any tailoring of DBT to better fit individuals within non-Western countries or people of color within Western countries. We found 18 articles that summarized cultural adaptations of DBT.

What were some of the cultural adaptations of DBT that were implemented?

  • Translation of DBT handouts to different languages and delivery of DBT in different languages (e.g., Portuguese, Mandarin, Spanish, Nepali)
  • Intentional therapist-client ethnic and language matching
  • Use of metaphors and allegories from clients’ cultural backgrounds (e.g., from the natural world for Native American clients given cultural beliefs surrounding unity with nature)
  • Additional content on addressing cultural stigma surrounding mental health
  • Discussion of Critical Race Theory and intergenerational trauma
  • Removal of the concept of “self-respect” given its lack of translation and cultural unfamiliarity in Nepal
  • Use of non-numeric and visual diary cards (used to track client target behaviors and emotions)
  • Addition of tribal practices for Native American clients (e.g., healing circles, sweat lodge ceremonies)
  • Delivery of treatment in non-traditional therapy settings to address transportation barriers

What were some of the challenges in making cultural adaptations of DBT?

  • Difficulty with written homework materials and numeric scales in certain cultures
  • Transportation and logistical barriers to accessing therapy
  • Clients’ beliefs that bodily expressions of emotions were not sufficiently addressed
  • Therapist-client identity differences and barriers in therapist understanding of certain client cultural practices
  • Language barriers in understanding nuances in emotion terminology when therapy was not delivered in the client’s native language
  • Incongruence of the goals of the interpersonal effectiveness module with client cultural context (e.g., a focus on the individual rather than the group)
  • Some interpersonal effectiveness skills may have put female clients at a safety risk in the context of a patriarchal society

Based on our findings, what are some recommendations for clinicians?

  • Train mental health professionals already integrated into racial, ethnic, or cultural communities
  • Include cultural experts in the design, implementation, and dissemination of interventions
  • Translate materials and consistently deliver DBT in the clients’ native language
  • Incorporate strategic therapist self-disclosure of cultural backgrounds
  • Address access barriers (e.g., transportation, flexible meeting times)
  • Tailor diary cards to client’s needs (e.g., creativity in non-numeric/visual diary cards, increased attention to somatic concerns in chain analyses)
  • In the pretreatment phase, develop a plan for addressing community stigma, as well as include historical and intergenerational trauma, acculturative stress, cultural differences, and discrimination and racism in discussing the biosocial theory
  • Use culturally relevant contingencies to reinforce homework completion
  • Increase attention to interpersonal context and interdependent relationships when teaching interpersonal effectiveness skills

Clearly, we can learn a lot from the cultural adaptations of DBT that have been implemented to date. However, given only 18 studies have been completed so far, there is insufficient evidence to conclude that culturally adapted DBT is more efficacious than nonadapted DBT. We also question whether these are true cultural adaptations of DBT that are required, or just DBT as applied by culturally competent clinicians. We conclude that future work is needed in both training DBT clinicians to be culturally competent and culturally adapting elements of DBT.

Target Article

Haft, S. L., O’Grady, S. M., Shaller, E. A. L., & Liu, N. H. (2022). Cultural adaptations of dialectical behavior therapy: A systematic review. Journal of Consulting and Clinical Psychology. Advance online publication. https://doi.org/10.1037/ccp0000730

Discussion Questions

  • Do principle-based treatments (such as DBT) really require cultural adaptations, or should the focus be on simply training culturally competent clinicians?
  • Why might the interpersonal effectiveness module of DBT (which focuses on effective behaviors in relationships) require the most cultural tailoring?
  • How can training in DBT become more accessible to clinicians who work with people of color and cross-cultural clients?
  • What might be missing here and needed to make DBT more effective for people of color and cross-cultural client-therapist dyads?

About the Authors

Stephanie L. Haft MA is a PhD candidate in Clinical Science at the University of California Berkeley. She is a training DBT therapist and conducts research on acculturation, discrimination, and mental health in immigrant youth and adults. Stephanie can be contacted at stephanie.haft@berkeley.edu. Twitter: @stephanie_haft

Sinclaire M. O’Grady MA is a PhD student in Clinical Science at the University of California Berkeley. She is a training DBT therapist and conducts research on developmental pathways to self-harmful behaviors. She can be contacted at sinclaire_ogrady@berkeley.edu. Twitter: @sinclaireogrady