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Cross-Cultural Considerations

Empirical evidence suggesting that DBT is efficacious as an outpatient treatment in urban settings is abundant (Lynch et al., 2006). However, one cannot assume that those results will generalize if the treatment is applied outside this context. Both cultural and systemic adaptations to the therapy may be required when the model is applied to populations beyond BPD. It is dear that new dialectics will emerge between the therapy and the population of choice. To progress from a state of static tension, both the therapy and the culture must adapt by reciprocally influencing each other. Because the model was designed in the United States and in response to one particular treatment population, care must be taken to consider needed adaptations in the therapy, the counselors, and the therapeutic system.

When determining the efficacy of the treatment, the treatment providers are of obvious importance. Dialectical behavior therapy is a complex treatment that requires the counselor to master a number of strategies and skills in addition to standard cognitive-behavioral therapy techniques. It requires, therefore, much intensive and extensive training and supervision.

The area of training counselors leads to several questions for future empirical research. First, how adherent to the treatment protocol must a counselor be to obtain the same results as the original outcome study or at a minimum show improvement in the client's symptoms? Second, what counselor qualifications or characteristics will predict how quickly a counselor will become adherent? Clinical experience would suggest that a counselor with a variety of qualifications can become DBT counselors, although those with a behavioral background require less time. It seems likely that specific qualifications will not prove as predictive as specific counselor characteristics, such as being nondefensive or being able to think conceptually and quickly. The various tasks and modalities of the model may also require a variety of counselor skills and characteristics. Thus, different members of a team could fulfill different roles according to their own strengths.

Another area for consideration is the duration and frequency of treatment. In the original model, clients attended concurrent individual counseling and group skills training for 1 year. However, as practitioners have attempted to use this approach with other populations, this extended time frame has been prohibitive in some settings and more time has been needed in other settings. Counselors must not overlook how adjusting the time frame of treatment will affect the efficacy while also considering how the intensity of treatment will affect the client. Current adjustments include a 16-week regimen for suicidal adolescents and a 2-year program for chronically mentally ill persons who have been in the mental health system for 10 to 15 years (Van Nuys, 2007).

The impact of culture on the treatment must also be considered in relation to the strategies used in DBT. For example, DBT places emphasis on balancing irreverence with reciprocal communication. Any change in setting, treatment providers, or population may adjust what is considered irreverent or reciprocal. Some counselors may be resistant to such strategies as potentially negative to the therapeutic relationship.

Because the DBT model uses a workbook with handouts for clients, an obvious example of a need for cultural modifications is the language of the training manual. The handouts may need to be adapted not only to the culture in which it is being used but also in response to specific populations such as adolescents.

Finally, as the DBT model was originated for the treatment of BPD, consideration for the stigma of this diagnosis cannot be overlooked. Some clinicians in the United States are hesitant to use the diagnosis of BPD out of concern for the potential negative impact of labeling. Cultures outside the United States may also hesitate to diagnose clients with BPD. As a model, DBT addresses these concerns and uses diagnostic labeling in a way that minimizes the negative and maximizes the positive impact. Within a behavioral approach to diagnosis, the therapist or counselor teaches clients about the diagnosis, allowing an opportunity to communicate to the clients that they are not alone in dealing with these issues. Informing clients that the treatment may help solve the problem communicates hope. Aligned with the concepts of DBT, acceptance balances change.

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