Exploring adolescents’ experiences of talking about race, ethnicity and culture during dialectical behaviour therapy (DBT): a qualitative study using thematic analysis

Abstract

Although anti-racist adaptations to dialectical behaviour therapy (DBT) are emerging, little qualitative research exists exploring adolescents’ perspectives on therapists’ approach, cultural competency and humility regarding ethnicity, race and culture (ERC) within DBT. This study explored diverse adolescents’ experiences of talking about ERC during all aspects of DBT treatment. Ten adolescents from diverse ERC backgrounds who attended DBT at a National and Specialist Child and Adolescent Mental Health Service (UK) completed semi-structured individual interviews that were transcribed verbatim and analysed using reflexive thematic analysis, adopting a critical realist approach. Five over-arching themes were developed from the data. Theme 1 captures the power for explicit ERC-related conversations to facilitate change, as they are frequently overlooked in therapy. Theme 2 discusses factors that facilitate or inhibit ERC-related discussions. Theme 3 captures the difficult ‘double bind’ that adolescents find themselves in: not wanting to be a spokesperson for ERC issues whilst hoping for their therapist to facilitate/model ERC-related discussions. Theme 4 explores how adolescents navigated their identity in relation to ERC, their wider systemic context, and experiences of ERC-related trauma. Theme 5 explored therapeutic alliance, and how therapists might encourage DBT skills use with greater ERC sensitivity, emphasising validation. Using a bottom-up approach, we show a clear mandate from diverse adolescents for (White) clinicians to proactively create the space and safety required for ERC-related discussions. We emphasise the importance of anti-racist praxis including cultural humility, multi-cultural competencies, and validation of ERC-related difficult experiences within a wider systemic context. Key learning aims (1) A recent publication by Pierson et al. (2022) has raised the importance for White DBT therapists to adopt an anti-racist position and actively reflect on how a lack of anti-racist stance can form therapist treatment-interfering behaviours. (2) The current study explores the views of adolescents from diverse ethnic, racial and cultural (ERC) backgrounds on how ERC issues are being brought into DBT. (3) Adopting a bottom-up approach, we identify key themes from adolescents’ perspectives on the barriers and facilitators to talking about ERC in the therapy room, why such discussions are important in supporting adolescents to navigate their own identity in therapy, and recommendations for clinicians to consider on ways of increasing and enhancing such conversations in the clinical setting.