Let’s Talk about CBT - Research Matters is a brand-new podcast from the BABCP, hosted by Steph Curnow, Managing Editor for the BABCP Journals Behavioural and Cognitive Psychotherapy and The Cognitive Behaviour Therapist.
In this episode, Steph talks to Dr Jake Camp a clinical psychologist and DBT therapist about their paper “Gender- and sexuality-minoritised adolescents in DBT: a reflexive thematic analysis of minority-specific treatment targets and experience” published in the Cognitive Behaviour Therapist.
This study aimed to understand the experiences of GSM young people in DBT and what difficulties and dilemmas associated with their gender and sexuality diversity were thought by them to be important to target in DBT. Jake talks about what this study found and highlights some really helpful recommendations for clinicians working with young LGBTQ+ people.
You can find Jake's ful paper here: https://bit.ly/45GhM1C
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Transcript:
Steph: Hello and welcome to Let’s Talk about CBT- Research Matters, the podcast that explores some of the latest research published in the BABCP journals with me Steph Curnow. Each episode, I'll be talking to a recently published author about their research, what was the motivation behind it and how they hope it will impact the world of CBT?
In this episode, I talked to Dr Jake Camp. Jake is a clinical psychologist and lead author of the paper “Gender and sexuality minoritised, adolescents in DBT, a reflexive thematic analysis of minority specific treatment targets and experience” which was published in the Cognitive Behaviour Therapist.
Steph: Hi, Jake, welcome to the podcast.
Jake: Hello, nice to be here.
Steph: Thank you so much for joining us. So just to start off the podcast, are you okay to tell me a bit about yourself and the service that you work for?
Jake: Yes, absolutely. So, so my name is Jake Camp. the pronouns I use are he/they. I'm a clinical psychologist, and DBT therapist. So my main area of work is at a national, DBT service for adolescents that's based at the renowned Maudsley Hospital. I also work academically, mostly with the department of psychology and the LGBTQ+ mental health research group. So that is at King's College, London. and I mostly work with young people who have experienced a ton of trauma, sadly, and have had a lot of difficulties that have led to, finding it very hard to sort of survive and thrive in the world. Often, young people end up being quite highly suicidal, sadly and my area of research that I'm particularly keen with, and of course what we're hopefully talking a bit about today, is mainly around how therapies work for minoritised groups and particularly LGBTQ+ groups as my sort of main area of research. So, it's great to have a chat about that.
Steph: So yeah, that leads us really nicely into talking about the paper because we are talking about one of the minority groups that you have been researching. So do you want to tell us a bit about who they are and what the paper is that we're talking about today?
Jake: Yeah. So, the paper that we are focusing on today is, one where I really wanted to spend some time privileging and I suppose, increasing the sort of voices of LGBTQ plus young people in DBT. For those who are not familiar with that acronym, although hopefully most people are, of course, that is usually people who identify with a minoritised or minority sexual identity, so that's like lesbian, gay, queer, etc and or a sort of minoritised or diverse gender identity, so that might be trans, non-binary, or so forth. So the paper really was to try and, you know, sort of give a platform to LGBTQ+ young people about their experiences of Dialectical Behaviour Therapy or DBT, because what we know from the literature is that, generally LGBTQ plus people experience quite a lot of barriers to accessing services.
There's also some evidence of poorer experiences of services and even some of the poorer outcomes, particularly in the sort of adult literature. So we know that there's a bit of a problem with how we meet the needs of LGBTQ plus group generally across our services, and we know that LGBTQ plus groups usually are significantly more likely to experience mental health difficulties and particularly engage in self-harm and suicidal behaviours, sadly, which we think is associated with, societal oppression, what we call minority stress. So those are stressors unique to their sort of minority characteristics or identity. So, we think it's super important, you know, to sort of do more work in this area. And of course, sadly, there's not actually that much, particularly in DBT about this, but, I would say there's also not much robust work, across that sort of fields as well. So, so this is the paper.
Steph: And I think one thing that really struck me when I was reading the paper, I've read a couple of iterations of it from when it was submitted to the published version, it's really about how much the lived experience of the young people you were researching in this was very important to, to the topic and to you. And so what motivated you really to look at this research area in particular and, and focus on this.
Jake: Yeah. Yeah, good question. I think, it really stems, obviously, from early on, and I touch on this a little in the paper, I identify as LGBTQ+ so generally just describe myself as a queer/nonbinary psychologist and I think, you know, growing up in a societal context where we had the sort of echoes of what I now know was sort of Thatcherism, Section 28, which precluded, the sort of conversations around what was termed homosexuality in schools, which ultimately meant that, you know, things like bullying with content around this, things like talking about modelling good experience of this, showing you that you could be a queer young person and be okay and thrive, were just completely absent from my childhood, mixed in with, I think, you know, we certainly were coming out of the AIDS epidemic when I was growing up and a number of other social, cultural things, I think just meant that, you know, growing up as a queer kid really wasn't comfortable and from a very early age, starting to feel different from people and starting to feel that societal oppression was very heavy.
Mixed in with, a number of other sort of areas of difficulty and trauma in my sort of familial environment. I think I was I've always been very keen to try and use my privilege to help people, help my kin almost, help people, help those queer kids, you know, to sort of grow up and thrive, because I really didn't feel like I had that.
And so that sort of informed how I've ended up going down the route of LGBTQ mental health as my sort of main area of research. And, I think, of course, part of that is they're my tools, they're my tools for activism in some ways, is that, the area that I can use and the privilege I have is that I can focus my research energy into this and hopefully try and make the system better.
So, they're the sort of overarching aims. The reason I ended up in this sort of project area specifically is firstly, because, I work in DBT and very passionate and keen about supporting people who have quite complex trauma that other sort of traditional services don't always quite meet their needs, you know, so the sort of the running theme for it, and I think DBT does that really nicely and when I started working in the National DBT Clinic, I was very surprised to quickly see that in this group of very highly suicidal young people, that about 60 to 70 percent of them were LGBTQ+ which of course is an outrageous over representation, compared to what should be if there was no health inequality there. And that sparked my interest because I thought, I need to work out what's going on here. And I need to try and make sure we're meeting their needs and make sure that other services are meeting their needs too, because I think what that potentially speaks to is that their needs are not being met sufficiently earlier in the treatment pathway before they end up needing DBT.
And of course, DBT, you know, is really made for people where they're highly suicidal, high severity of difficulty usually been going on a long time. So this paper sort of squarely came out of that. I thought, where do I start? Well, I want to start, you know, with the young people and their voices, and I want to know what's working for them, what isn't working for them, and actually what is important about their experience as a minoritised individual that we need to be thinking about in therapies, in particular, of course, DBT. So that was the sort of inspiration for it, and it's part of a wider program of work, of course, to try and complement some of those questions that I had. But here it was squarely about, what do the young people think? what would they advise us to do, which I think is super important.
Steph: Yeah, absolutely. And that really comes across in the paper, I think. Like I say, it's really nice when you can read papers that you know have been written with real thought and real compassion as well, that definitely comes across in the paper. Before we getting into talk about the paper itself, would you mind explaining a little bit about DBT for maybe listeners who don't know what it is, or maybe don't know that much about it?
Jake: Yeah, of course, yeah. So DBT stands for Dialectical Behaviour Therapy. so, we usually describe it as a sort of third wave CBT approach. for those who are not familiar with that terminology, third wave, I usually think of as meaning standard sort of second wave CBT, which is the usual CBT you see out there for, you know, specific disorders, often like panic, social phobia or so forth plus some other elements of something, mostly mindfulness, of course, and that's usually the biggest, sort of inclusion of other principles or techniques in third wave CBT and models, but also usually a lot of other stuff to borrowed from other areas of work or, or schools of thought as well.
So DBT is a very good example of that, it builds in mindfulness, it builds in a number of other principles to try and support its target population. DBT mainly aims to work with people where emotion dysregulation or difficulties managing emotions is sort of the key underlying difficulty to, so, you know, generally we think it works quite well as a nice transdiagnostic intervention because that's the key treatment target rather than key symptoms necessarily, albeit, of course, Borderline Personality Disorder was the original symptom structure or sort of ideology that they were sort of made to target. Most of the people that I work with tend to have emotion dysregulation and engage in self-harm and suicidal behaviours or other behaviours that are judged, by society as being dangerous and maladaptive. We work with people in quite an intensive way in DBT so, it isn't just individual sessions.
If you're getting full comprehensive DBT, which is the most widely evidenced version, you usually should be getting weekly individual therapy sessions to build motivation, support with your problem solving and a number of other things, weekly skills groups, try and teach you skills to sort of manage life and emotions. You should get your therapist phone number where there's a between session phone coaching. So it's like a tips hotline. So you get to call your therapist and navigate your life. I know, right. And it's pretty good. I feel like, you know, I need a therapist hotline sometimes just to, um, and there should be a therapist consult which is a sort of weekly meeting where it's almost like therapy for the therapist. Therapists support each other to stay in frame, to do a good job for their clients and not to burn out. Because of course, the risk is working with high complexity and suicide, which is very scary of course, is that there's risk of therapist burnout.
So DBT delivers it through those modes and it has all these principles such as problem solving, validation, zen and mindfulness, skills, which is probably the biggest, known part of DBT is the skills aspect, behaviourism, cognitive restructuring, a number of principles that we pull on to help our clients, you know, sort of build that life worth living. So pretty complex model. But, you know, it's a pretty good model for working with people where they wouldn't naturally fit maybe that sort of lower severity frame if that makes sense, usually where emotional dysregulation is particularly tricky.
Steph: And how long would you expect a young person to be in your service then? Cause it sounds it's much more intensive than like you say, like a traditional second wave CBT.
Jake: Yeah, good, good question. It's interesting actually. Um, and this, so we have debated lots since DBT has been integrated into the NICE guidelines, for young people. So for adult DBT most of the time, it's about a year and DBT is meant to not be the end goal. So DBT is like the first stage, which sometimes people call stabilization. And then the next stages are meant to be going on to do things like trauma reprocessing, working through other difficulties, building your life, making everyday decisions so they get a year usually. In our, adolescent program, our treatment length has differed over time based on a number of different factors.
Currently, we are a seven-month program with opportunity to extend to nine. The actual evidence base for DBT for adolescents though, usually positions itself as three to six months. And the NICE guidelines only quotes the three months, which is interesting because they miss all of the other lovely RCTs and pieces of evidence out there, like uncontrolled studies or controlled studies that actually usually mostly use the six month model. And that's, I think, because DBT for adolescents was always positioned a little bit more as early intervention. So get in there before the difficulties really emerge. Whereas, often what we see in our clinic is people have had these difficulties for a pretty long time. And they're usually in that sort of slightly artificial threshold, between adolescence and adulthood, you know, so in that sort of 16, 17, 18 range as well. So usually a lot of difficulties
Steph: Yeah, well, that was a really good explainer. Thank you. Okay, so shall we get into the paper itself then? So, am I right in thinking that your participants for this study were already in your service receiving DBT, and they were recruited because they identified as Gender and sexuality minority.
Jake: yes, that's correct. So, I think part of the inclusion criteria that I had was to make sure that they had finished at least the first six months of our skills group. And that's because by that point, you've covered pretty much every piece of skills content. So, my rationale behind that was thinking, you know, I want you to have enough experience of the program to be able to talk about it. But otherwise it was just that they were in the program, that they identified as LGBTQ+ or gender and sexuality minoritised. And yeah, and that they were willing, of course, because that's, that's very important.
Steph: first rule of participation is are you willing?
Jake: Absolutely,
Steph: Okay. So you conducted some interviews with the ones that were willing to participate. What kind of things were you asking them and what did you find?
Jake: Yep. So, I, I sat down with, 14, young people who were in our program. they were really wonderful interviews, actually. Like, I felt very privileged. privileged to have the young people share their wisdom and their experience with me. I came out of nearly every interview thinking, wow, like, you know, this is such a wonderful thing to be able to do.
And what was really lovely is that they were saying similar to me at the end. There was like, no one's ever asked this, like no one's ever sat down and sort of spoke to me about this stuff. So they were really grateful as well. So I felt very reinforced in behavioural terminology, for doing this project and I'm very motivated, to do more, with it.
So, so yeah, so I was asking them questions about how they found DBT. So as a person who identifies as LGBTQ plus, how did you find it, and where were, where were our blind spots or where we needed to, make things better and where were areas that we did well. I also asked them, what experiences related to their LGBTQ plus identity were important for us as therapists to know and to potentially work on or integrate into the therapy somehow and this was to try and get an idea of potential minority specific treatment targets or, areas of conversation. I hesitate with targets because, of course, it suggests a certain amount of potential. possible pathology, which, you know, I really want to stay away from, of course, but areas that, as a therapist, I need to be clued into and I need to be potentially supporting my client with if I can.
So that's why I asked them. What we found was, well they shared so much wisdom as well. The analysis was really tricky because of course what you have to do in qualitative analysis is where you distill meaning into these themes and, I battled lots with losing lovely nuanced bits of information in the sort of collective overarching theme and, my supervisors and my co-authors were very wonderful at supporting me with thinking about how to still do it justice and of course you can't include everything.
But anyway, the sort of main areas were; there were sort of themes that were about potential targets in DBT. So these were, one area that was particularly spoken about was, difficulties with identity. So what a lot of the young people spoke about was being quite confused about gender and sexual identity Understandably, of course, for their developmental stage, but also, more so possibly because of the difficulties that they had had, and actually struggling with building up self-acceptance. It was interesting because the young people said, gender actually was a lot harder. Of course, given the socio-political context around that right now, compared to sexual orientation, which they felt was, somewhat easier in comparison, albeit still tricky. And what a lot of them said to me was like, this was an area that needed a lot more space if we could have done in DBT. The other area around targets that was mentioned was, like, the impact of others, so a big area that was spoken about was what we call, like, cis heterosexism, which is, like, a sort of umbrella term that describes societal oppression related to gender and sexual orientation or minority status.
And they said that this was from the spectrum of overt versions, so that might be, like, explicit homophobia, transphobia, biphobia, and all the way through to those more subtle, insidious versions which we sometimes call more microaggressions, where maybe a therapist didn't mean to, make an aggression and at the same time did sort of thing.
So they said these were important for therapists to know and help me to cope with and played a big role in why I found things difficult. The flip side to the impact of others was a lot of young people said one of the biggest protective things for them was community connectedness. So finding a way to connect with people either who were accepting, or were similar to them so that they could see similarity and they could find connection with others. So they felt like DBT nurtured that quite well, especially in the skills group aspects, because we of course bring young people together, even though they would love to not most of the time- but most of the time by the end of the group, they actually tend to really get a lot out of it and get a lot out of being around other people who share some degree of similar experience as well.
So, so yeah, and, and the ultimate thing we're pointing out that like identity and the impact of other stuff was to say, this is the areas where DBT therapists particularly here, but therapists generally probably need to be a bit aware of what that might look like for young people and to try and help them navigate some of those key dilemmas, because of course, you know, these young people in particular were saying, these are things we're going through, these are things that would probably be helpful to support with more, if you can. And of course, I'll speak a little bit to that a bit in the future, because it can be a tricky dilemma with fitting everything into your therapy, especially when you've already got a lot of higher order targets that, you know, you need to focus on first.
The second area of findings were about, well, how did they find it, what worked and what didn't and this was split into two main themes. So the first was difficulties or wherever it worked about negotiating, focusing on LGBTQ plus stuff or associated dilemmas in DBT. And the other one was about creating safety.
So the first one, the negotiating focus, what young people said was, what was a bit tricky in DBTs, because it has a really high threshold for including difficulties in the therapy, because of course we work with highly suicidal clients, our first and foremost priority is keeping our clients alive. So life threatening behaviours are always going to be priority, first and foremost. And then even then, when you get past that and you get more towards the other things that are causing them problems, it often has a really high threshold for being included in DBT because of course the sort of principle is like, is it severe enough that you need DBT rather than an alternative sort of intervention? And that can be tricky because the young people are saying I wanted to focus on it, it was there. But I couldn't get to it because there was so much other stuff in the way. even though their wisdom was actually if you could have helped me a little bit with some of that stuff more, it might have made the other problems better.
So some of our recommendations are very much around how therapists find some of these what we call controlling variables or like key, almost like hot links in the chain that lead up to these difficulties or, or difficult behaviours, which might be to do with minority stress, right? Might be that it's often their own thoughts around, you know, their gender or their sexual orientation or, or people's behaviour towards them that lead to say self-harm or alcohol use or so forth. That actually, if you can find those and work with those, that's a way around the trickiness with getting it on our, our treatment hierarchy or what we're going to work on. so yeah, so that was one difficulty. The other thing that they said is they actually thought that a lot of the DBT stuff was really generalisable. They were like, it's great, you know, the skills themselves are not like pigeonholed into this idea that they wouldn't work for queer people or LGBTQ young people. But what they said is that sometimes, Well, a lot of the time, therapists didn't help them generalise it in that way, so they, they, a lot of the young people said to me in the interviews, like, Now you're talking about it, I know I could use X skill for, you know, when people are transphobic towards me, or when people do, do X behaviour, but no one ever told me, so I never sort of made that link. And, there’s a really big, you know, the whole function of phone coaching, for example, but also just, generally an emphasis on generalisation in DBT and making sure we're helping people generalise and not assuming that they naturally would generalise the skills to all relevant contexts.
So, that was another really important point that was pulled out that therapist generalise and help your clients like scaffold their ability to generalise where you can. Another area was they were saying you know, actually, sometimes the skills needed a little bit of extra something to help with LGBTQ specific areas. So, you know, if I'm navigating trying to come out or, I'm navigating trying to challenge someone on, say, transphobia or something, it's probably going to have to have an extra couple of steps or layers in it that are going to be really important for that skill to be applicable. So one of the biggest examples of that was the consideration around safety and how you build safety into skills practice.
Because of course, yes, it might be great for me to say, yeah, sure. Be assertive, go assert your needs. But if you've got a risk of say, being harmed physically or killed at worst, like you, You probably want to weigh that up, before you do that. And that's super important to do.
So some of the stuff just needs a little bit of like extra thought or augmentation in order to make sure people are safe. So that was the main stuff. Final bit, which was creating safety, super important. A lot of the young people said it was a lovely safe space. So that very much warmed my heart to know that they found it, DBT, a relatively safe space, and the way they described that, as I said, it felt very open, non-judgmental, very accepting, which is the spirit of, there's a lot of Zen philosophy that's built within DBT, and of course, therefore, the spirit of stuff is genuinely and radically accepting people for who they are and that sort of wonderful, innate wisdom that they have, so that came through which was nice and that's extra needed. So again, another tip for therapists is you know, as Queer people we experience a lot of messages about change in our lives. So we're told from a very early age that there's something not quite right with us or unacceptable, and that therefore we need to change ourselves, you know, in very subtle and explicit ways as well as people explicitly saying you should be straight or you should be cisgender or, or so forth in, in much less nice ways than I just said it. So therefore, it's really important for people working with LGBTQ people to lean much more on their acceptance and validation side of skills, because you really want to, you need to sort of outdo the balance of all the change based messages that we have in society, in order to make us feel a bit more safe.
So this came through a little bit in that feedback. Other stuff with creating safety was just things like making sure confidentiality is clear, like who, where are you going to record this information about my sexual orientation and gender, and where is it going to end up? making sure that you display safety signals, so some of those are like environmental safety signals, like pride symbols, diverse examples in content, some of it might be policy based safety signals to make sure there's like, like policies in place for those where that becomes, visible to, or is necessary. Making sure that you model diversity within your team, of course, ideally, and disclose if you feel comfortable doing so, although actually, we, we think that that's super important. If you're asking your young person to disclose, it's possibly quite important that you're willing to do, you know, what you're asking of, although I know that that doesn't fit for, for all models. yeah. And just sort of making sure that we're cautious around sort of inclusive language, like on forms in person as well. So get rid of that other section, you know, in, in your social demographic forms, because it's very othering. It's really problematic. It should be preferred to self-describe with the option to self-describe or ideally you just have all of the categories, making sure you do ask about sexual orientation, gender identity in forms and in therapy, because of course context, identity, it's all very important to the work and the lens of which we see the world. And if I go somewhere and on the form I see they're asking me about gender and sexual orientation, usually it's a good sign, like, hmm, they're being thoughtful about me and, people like me. Even better if it doesn't just say male, female, other, Because I'm like, uh, you know, I don't quite fit any of that, which, makes me immediately feel slightly not welcome there. So, hence the, you know, subtle and subtle things like that, that are quite small changes, can make a big difference, and the young people really commented on, they loved pronouns being announced and disclosed by clinicians and put in emails, they loved the sociodemographic form, being very inclusive, they loved rainbow lanyards, you know, all of those things that just help people feel a bit more safe in the environment.
Steph: Was it important to the young people that their therapist, wasn't just a straight cisgender person or did that not matter to them so much as long as they were accepting of who they were?
Jake: Yeah, this is a good question because, of course you see in ethnicity and race minoritised groups that, that, that ethnicity or race based matching actually has a really positive effect. in other research around LGBTQ+ stuff, the sort of idea currently suggests that actually you don't need to match based on gender or sexual orientation, as long as you are overtly and relatively overtly, accepting. albeit, there may be benefits, of course, for people feeling a bit safer, maybe, if they see someone who's overtly queer or quirky or, you know, something that just communicates that they're likely, thoughtful and accepting in this area.
The young people I interviewed didn't massively comment on this because what they spoke more about was it was just super important that their therapist was really overtly accepting. Because they did say that, One of the biggest barriers to safety was thoughts about and expectations that they generally would just be rejected or judged negatively as a queer person by their therapist or their team once they did know.
And of course, nearly all of them said, but when I did come out, it was received so well that, it was great. but that worry was there and, you know, and I can testify to that as a queer person, that worry is always there for me. There's like a sort of standard, cognitive, automated process that's in any new interaction with a person is immediately like, they are more likely to reject than not, you know, sort of thing, which of course, thankfully, many behavioural experiments and exposure to us later, mostly doesn't come true nowadays. But yeah, so that was very present for the young people.
Steph: And one thing that we touched on right at the beginning when we started talking about the paper was, being able to listen to the young people and, you felt very privileged to hear their thoughts and their experiences. And, one thing that really came across to me was you put little excerpts of the transcripts in throughout the paper to, highlight certain points, for example, when they've been feeling not accepted with regards to their identity and things like that, just a comment really that I wanted to make was how articulate a lot of them came across and actually, it must have been really lovely to hear some, I mean, heartbreaking sometimes, but also really lovely. I work with a lot of adult clients, and some of them can't so articulately explain, I feel othered because this happened to me or my therapist misgendered me or assumed I was straight. And that made me feel like this because, and that really came across, I think, in just the small excerpts of just how articulately could be and, really in tune, I think, with their feelings and their experiences.
Jake: Yeah, no, they did, you know, an absolutely wonderful job. And some of them did comment on, they felt like they had, really learned a way to describe their experience a lot through the work in DBT, because of course, a lot of our mindfulness practice is about how to observe and describe experience. It was very hard, at a similar point to like, you know, all the information fitting into themes, to cut the quotes, because some of the quotes were so beautiful in how they described, you know, of course that's a judgement, but like, how they described their experience, I just wanted to keep them all.
It went through a really, like, challenging process to cut them down to what was necessary, of course, for the reader, to see what was the sort of best quote to, to articulate that particular theme. But they did an absolutely wonderful job. I sometimes, and this is, of course, an assumption, not based in empirical evidence, but, you know, my assumption is that the generation, Gen Z, as they're often called now, that sort of generation that I was interviewing tend to be a lot more, well versed in areas of sort of equality, diversity, and inclusion in such a lovely way, that I think they're a lot more thoughtful about it, because I, for example, I never come across the word, like, heterosexism or internalized homophobia or any of that stuff until I started research. But yet, some of them were saying to me, without me even mentioning those terms, like yeah, that's heterosexist, or like, you know, that's so, you know, it's interesting, they've definitely picked up a lot more on some of that language.
Steph: So I think you've probably answered a lot of this, but what do you think the implications of your study are for the world of CBT? What impact do you want it to have made?
Jake: I've obviously been peppering some of the recommendations throughout, so, not to overly duplicate those, but certainly to say that, like, Yeah, absolutely. I, I think there is a bit of a problem with how we meet the needs of LGBTQ+ people in services, or at least how safe it feels to just access services.
So, from that standpoint and the fact that there's huge health inequalities, I think generally we should come from the default position as therapists as we probably need to do better for this group and we're still probably not fully meeting their needs I mean we may be but I would say it's better to come from that default point and therefore I suppose this paper is to like invite us to take a non-defensive fallible stance which is very much part of DBT sort of agreements and spirits is like, it's okay to be fallible. We're human, of course, we're going to make mistakes and, we need to learn from them and, still find our blind spots and so forth. So I think I would love it if, therapists would go away and, and reflect on, similar to anti racist principles, right, reflect on their blind spots, their privilege, think about, where they need to learn stuff, where they don't, educate themselves, and of course, yes, sure, you're, like I said in the paper, your clients are well placed to educate you, of course. And at the same time over relying on minoritised individuals to educate you about their oppression and minoritization is very exhausting, it's very burdensome. So unless you've got a lovely, willing, queer person in front of you who wants to give you, the lowdown of that is to try not to over rely on that, and it's to try to rely on finding your own sources, of information and checking those things out. So I think that's really important. I think therapists, I would say, to ensure that they use much more of those acceptance validation principles where possible, as I explained earlier, to try and undo those sorts of heavy change based narratives and ideas that, that sort of exist in society.
Accept that identity and especially these areas of identity are very fluid at times for some people, not for all, but not to invalidate that, therefore, you know, say someone. I don't know, identifies as bi now, maybe heterosexual or gay later, you know, vice versa, or any other iteration of that, that that means that any of those were not, valid or that at times that it's really, being okay with, with that change and that fluidity, still asking about it, still checking out, of course, being accepting of people because that's sort of the biggest problem is that it comes from lack of acceptance or sort of judgments of LGBTQ+ people. Trying to include context and minority stress in formulations and in interventions I think is a really important one as well because of course often our difficulties don't arise, in isolation of context and experience and, I think it's really important that we consider how, you know, say being LGBTQ+ how that's in some ways interacted with, the events or situations or experiences that have led up to the difficulties that I'm experiencing.
So just being mindful of that and, trying to, as I mentioned earlier, consider safety with clients. So, you know, whenever you're trying to do work around this stuff or generally, just making sure that there's not really rational, justifiable, safety concerns that, may come up and try not to invalidate that.
So I think that's some of the general stuff. I think that's definitely important stuff. Like I mentioned around creating safety. So get those safety signals out there. Like, you know, you want as much of that as possible. the overt stuff, model and disclosure, pride symbols, even just asking about it, like what I mentioned on forms or in assessments or so forth, you know, our safety signals asking is important because, of course, otherwise people just assume often, cisgender and heterosexuality. I think that that's fine if you're cishet, but that is not fine, you know, if you're LGBTQ+ of course, ask in a way that feels developmentally appropriate and, you know, feels, appropriately tentative that sort of communicates very clearly. You do not need to tell me if you'd rather not. But actually I'd love to know a bit about you, who you are, your context, you know, that's gender, sexual orientation, culture, race, religion, tell, give it all to me and know that there's some sort of explicit or implicit invite that if that stuff feels important, that's very welcome in this space.
Being overtly, nonjudgmental and part of the ways to of course, position yourself like that. Knowing that social connection and connectedness is really important for this population. So that might be a good area to focus, say your behavioural activation or, whatever other work that you're, you're doing with someone and make efforts to try and get pronouns, correct, and disclose them.
And if you get them wrong, non-defensive, fallible stance, and try your best in future. Of course. The thing is, is pronouns of course are, about gender and they are starting to become a bit more of a universal signal for I'm on board with and supportive of LGBTQ+ culture, that is a very easy augmentation to make in regards to disclosing your own in emails or at the start of meetings, and asking people for what they prefer to be used. And of course, if you're not used to using They/Them pronouns, or something similar, it's okay, practice. Like, language shifts and changes all the time. I tend to just prefer, from a sensitivity point of view, to remain relatively gender neutral about everything I'm talking about, until I know otherwise just because then there's less risk, of causing harm. So yeah, so, important. And obviously if people do want to bring this stuff to therapy, it's about trying to make sure that you show them what's possible and what isn't. And part of the principles that I often think about with this is like, what is your remit to treat.? And what are they, what do you have permission to be working with or treating in therapy? And actually, if your client isn't giving you permission to go near that stuff, that's okay, don't go. Like, you can invite it, you can ask for it, but you don't need to go there. Just because, say, you see them and you judge that maybe they are LGBTQ+ or assume that, you know, it doesn't have to be bigger than they want to make it, type thing. So being led by your client, of course. but inviting space because you are the person in power. So, you've got the sort of, you know, the more powerful privileged position in the therapy room. And therefore, you need to lead in some ways and show, you know, equalize the playing field a bit by showing that there's space for this stuff. But if you can and, and the person wants it and thinks it's important, absolutely collaboratively negotiate, build it into the therapy, whether that's just formulation, whether that's in some of the work you do, whether that's just in some side talk about people's lives and what goes on. It's just, acknowledging that for some it's important, for some it's not, and that's okay too of course.
And final tip I suppose is just say that of course none of this is in isolation of intersectionality with other areas of minoritised characteristics and therefore some of the beauty of that is really being able to have really lovely rich conversations about other areas of difference or identity and how these things intersect and, you know, how, how that person sort of makes sense of their world through that lens.
Steph: That's all really, really wise and insightful. So thank you so much for all of the thoughts and for sharing. Two last questions I have before I let you go and get back with your day. the first was, if you had to do this study all again, is there anything you'd change or anything you'd do differently?
Jake: Hmm, good question. I mean, what I would love to do is, this was very specific of course to the program I work in, which is a national program, so to some degree has a slightly more wide-reaching population, than maybe a local clinic but I would love for something that's a little more widespread in regard to DBT programs, etc. So, that would definitely be one thing. I think the other thing that probably needs to be done, and it has a little bit, there's some studies out there, is that I think gender and sexual orientation here made sense to keep together as an ideology, because the way the young people spoke about it made a, you know, they didn't speak about those two things in isolation really much. So they felt very intertwined in regards to experience and difficulty, and yet there's going to be very specific potential, needs and adaptations for sexual minorities that may be the same or different from gender minorities. So, you know, I would also have loved to have gone out there and got a nice group of gender minority young people who have been in DBT, get their views, and then same sexual minority.
And yeah, thankfully in my program I've researched the sort of next steps, some co production work to try and build a bit of an augmented, or sort of optimised, part of the treatment or component of the treatment, that can be easily built into the model and, I'm really hoping to get a bit more opportunity to sit down with lots of wonderful, young people who, you know, willing to give their time to sort of help build this and for us to use as therapists.
So, that's, that, that's what I'd love to do too, but that's what I'm planning to do next as well.
Steph: So that leads into my very final question then for you, which was, what can we expect from you next? I know that you've had a couple of papers in both of the journals, which are in progress so what can we expect to see from you?
Jake: Yeah so this was sort of the foundational program of research really to sort of build on so that includes, this paper, which was the centre of the voices of young people, one of the papers that's coming out soon is, disaggregating outcome data from DBT for different gender and sexual orientation based groups to check quality of outcomes that should be out there soon.
And a number of other projects that are side projects in other areas of equality and diversity. So, you know, we've just published one which is around people from race and ethnicity minoritised groups speaking about ethnicity, race and culture in DBT and how, to try and, support the work in building on anti-racist principles in DBT, and also stuff around autistic young people in DBT.
So there's a paper recently published on disaggregated outcomes, and then we've got another qualitative piece of work ongoing, which is trying to get the experience of autism, autistic young people in DBT to try and optimize that. So I think there's really nice learning from across those groups that can be pulled together.
So it's why I like to not keep it specific to LGBTQ groups. So that, that are the ongoing bits. The next step of the program of research is there's a small side project to think about implementing adapted DBT skills training for trans or gender diverse people that's outside of the NHS because of course, you know, the NHS is riddled with sadly systemic transphobia and so forth that means that it's not the most accessible system, to say the least for this population. So trying to get DBT into more safer community based organizations. So that's a lovely side project that's going on. And then I'm hoping to do some co production and piloting work for sort of augmented slightly adapted version of, of DBT principles and skills. We can easily pull into DBT and other models as well, hopefully, for specific dilemmas that have been brought up by the young people in this paper. So that's the next stage and hopefully will be out soon.
Steph: I’m really looking forward to seeing this research coming out Hopefully you can come on again and talk about some further research when it's published and the results from that. So, Jake, thank you so much.
Jake: Thank you.
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