Dialectical Behavioral Therapy (DBT) for LGBTQ+
Introduction
Suicide rates in the U.S. increased by 36% in 2022 compared to in 2000, making suicide the second leading cause of death that year among individuals aged 10–14 and 25–34 (Centers for Disease Control and Prevention, 2024). While suicidality affects a large portion of the population, certain groups are disproportionately affected. Health disparities exacerbate these percentages. According to the CDC’s 2024 suicide report, people who identify as LGBTQ+ (Lesbian, Gay, Bisexual, Transgender, Queer) experience a higher prevalence of suicidal ideation and self-harming behaviors. Indeed, LGBTQ+ individuals are at increased risk for psychiatric morbidity (e.g., suicidality; King et al., 2008) due to minority stress. One approach to addressing these health disparities is Dialectical Behavior Therapy (DBT). DBT incorporates the concept of an invalidating environment, a space that LGBTQ+ individuals recurrently endure. The objective of this paper, therefore, is to contextualize DBT for LGBTQ+ individuals, examine the empirical support for its use, and outline future directions for research. The present paper also presents the ongoing scholarly discourse on whether DBT should be specifically adapted for this population and evaluates the empirical evidence supporting these adaptations.
Contextualizing DBT for LGBTQ+
DBT is an evidence-based intervention grounded in a biosocial theory, which proposes that emotion dysregulation develops from the interaction of biological emotional sensitivity and invalidating environments (Linehan, 1993). Its four core skill modules—Core Mindfulness (CM), Distress Tolerance (DT), Emotion Regulation (ER), and Interpersonal Effectiveness (IE)—balance acceptance and change. DBT’s emphasis on the invalidating environment is reminiscent of the experiences of LGBTQ+ individuals, as many experience invalidating environments that affect their mental well-being.
LGBTQ+ individuals experience health disparities due to their minority status. The Minority Stress Model provides a framework for understanding how social stressors uniquely affect LGBTQ+ individuals. The model distinguishes between distal stressors, such as external, objective events like prejudice, discrimination, and violence—and proximal stressors, which are internal processes shaped by an individual’s perception and appraisal of their environment. These proximal stressors include expectations of rejection, the concealment of one’s sexual orientation, and the internalization of societal stigma (Meyer, 2003). For example: A transgender individual experiences discrimination on the street because of the way they dress. This is an example of a distal stressor. This same individual has an internal fear of rejection; therefore, they conceal their personal identity and avoid public social interaction with family members. This is an example of a proximal stressor.
From the previous examples, it can be seen how the Minority Stress Model highlights external societal and internal attitudes, as well as the concealment of one’s identity. Specifically, this model highlights how social attitudes gain psychological significance through cognitive appraisals, becoming internalized and affecting mental health of, in this context, LGBTQ+ individuals. The repercussions of the previous examples highlight that in an invalidating environment, concealment of one's identity and isolation, to avoid discrimination, creates significant internal stress that can negatively magnify the mental and physical well-being of LGBTQ+ individuals. In fact, heightened suicide risk has been linked to minority stress in LGBTQ+ individuals (Dickey and Budge, 2020), along with a higher prevalence of mental disorders compared to heterosexual counterparts (Meyer, 2003).
DBT, with its biosocial theory, connects to the minority stress model through their shared focus on the interaction between internal experiences and external invalidation. When it comes to contextualizing this treatment to LGBTQ+ individuals, it is important to note that DBT treats individuals with suicidality or psychiatric morbidity. Subsequently, because LGBTQ+ individuals are at higher risk for psychiatric morbidity due to minority stress, DBT might be an ideal treatment for this population; specifically, DBT’s inclusion of the invalidating environment as a part of the context helps treat this population. This inclusion, then, raises a question addressed in the DBT literature: What features of DBT are adapted for LGBTQ+ individuals?
The literature debates whether adaptations of DBT for LGBTQ+ populations are necessary. Indeed, some studies have empirically tested the effect of standard DBT for this population. Nevertheless, when made, adaptations include tailoring validation strategies and enhancing the ER skills module of DBT to manage minority stress effectively; or in some cases, the incorporation of—on top of standard DBT skills—specific skills modules to address external stressors such as stigma. For LGBTQ+ individuals, applying DBT skills to address invalidating environments offers a practical coping strategy for mitigating the effects of minority stress. While some studies have demonstrated the benefits of adapted DBT approaches for LGBTQ+ individuals, others indicate that non-adapted DBT can still result in significant positive outcomes.
Existing Empirical Support
Non-Adapted DBT for LGBTQ+. Oshin et al. (2023) found that six months of comprehensive, standard DBT improved self-reported symptoms of borderline personality disorder (BPD), depression, emotion dysregulation, functional impairment, and coping among LGBQ (Lesbian, Gay, Bisexual, Queer) participants with BPD. However, while these improvements were significant, they also reported that LGBQ participants experienced smaller reductions in depressive symptoms, functional impairment, emotion dysregulation, and dysfunctional coping when compared to heterosexual participants. These findings align with Beard et al. (2017), who reported that DBT is generally effective for LGBTQ+ individuals, but small reductions were also noted when comparing results to a heterosexual group.
Other studies suggest the lack of a link between sexual orientation and clinical treatment outcomes (Chang et al., 2023; Camp et al., 2024). For instance, Camp et al. (2024) found significant improvements across most clinical outcomes for LGBTQ+ individuals and their heterosexual counterparts. While no statistically significant differences in treatment completion were observed, emerging trends from this study suggest potential disparities in completion rates for LGBTQ+ subgroups. Furthering on the latter, Beard et al.’s study reported that bisexual participants showed higher levels of self-injurious and suicidal thoughts and worse perceptions of care at post-treatment compared to other sexual identities. Together, these studies show empirical support for the efficacy of standard DBT in the context of LGBTQ+ samples.
Adapted DBT for LGBTQ+. The question of when and how DBT adaptations are most effective for LGBTQ+ populations is worth discussing. Cohen et al. (2020) adapted the Emotion Regulation (ER) module of DBT Skills Training to address minority stress among LGB (Gay, Lesbian and Bisexual) veterans. This population often navigates invalidating environments marked by cisgender and heterosexual norms, contributing to heightened suicidality, depression, anxiety, and emotion dysregulation. Cohen et al.’s adaptation included acknowledging minority stress within the treatment framework and integrating “Affirmative DBT Skills Training” to address unique stressors faced by LGB adult veterans. Results demonstrated significant reductions in depression, emotion dysregulation, rejection sensitivity, internalized stigma, and concealment of sexual orientation.
Building on Cohen et al., Skerven et al. (2021) introduced the “Stigma Management (SM)” model within the four standard DBT skills training modules, creating “DBT-SM.” This adaptation emphasized understanding stigma and managing minority stress, particularly within the context of a Veteran Health Administration outpatient clinic. Skerven et al.’s study extended the scope of Cohen et al. (2020) by including transgender participants and found statistically significant reductions in minority stress-related distress, particularly among transgender and lesbian participants. These results highlight the positive effects of adapted DBT interventions in reducing the psychological burden associated with minority stress. Moreover, while in a different context than Cohen et al. and Skerven et al., Poon et al. (2022) also found positive results for LGBTQ+ individuals with a DBT adaptation for LGBQ adolescents. Specifically, Poon et al.’s treatment was DBT-A, which is an adaptation from standard DBT in terms of tailoring to adolescents in this case self-identifying as gay, lesbian, bisexual, or questioning. They found that both groups (LGBQ and heterosexual) demonstrated significant improvement in emotion regulation, depression, and borderline symptoms. The results from these studies suggest that adapting DBT for this population is also beneficial in reducing BPD symptoms.
Conclusions
Now more than ever, addressing health disparities is key to maximizing the efficacy of treatments—particularly for LGBTQ+ individuals. The empirical support for DBT in the context of LGBTQ+ population points to two main conclusions. First, what makes DBT a key treatment for this population is the fact that LGBTQ+ individuals face increased risks for suicidality due to minority stress, which DBT treats by the inclusion of the context of an invalidating environment experienced by LGBTQ+ individuals. Empirical support shows promising findings in the reduction of BPD symptoms and suicidal ideation among this population. Second, when DBT features, such as the ER training skills of the creation of new modules such as Cohen et al.’s creation of “Affirmative Skills,” are adapted with standard DBT, empirical support also indicates the reduction of BPD symptoms. Nevertheless, it should be noted that both Cohen et al. and Skerven et al. acknowledge the small sample size as a potential limitation. It should also be noted that Cohen et al.’s study did not include a control group in their experiment. Therefore, the findings of this study and the discussion of this paper should be seen as preliminary findings that open the door for future inquiry and DBT adaptation for LGBTQ+ individuals.
Future directions. Among all studies, a common limitation is the sample size. Nevertheless, while this is a common limitation in many other studies, it should also be acknowledged that even with a small sample size, the results are promising and stimulating. As such, this limitation of a sample size should be seen as a direction for future research in terms of replicating the results from studies testing the efficacy of DBT in LGBTQ+ individuals. While the studies in the present paper demonstrate positive results in reducing BPD symptoms for LGBTQ+, continuation and longitudinal studies could potentially be a future direction. For instance, Beard et al. reported that bisexual individuals had a slower effect in the treatment. Future research, then, could include a longitudinal study that investigates if these patterns are the same after more than 6 months, which was the DBT intervention in Beard et al. included. Another study could replicate Cohen et al.’s “Affirmative Skills” models used to adapt standard DBT and expand Cohen et al.’s LGB sample to include transgender individuals. Most of all, future directions should continue to replicate this treatment for LGBTQ+ to strengthen the already existing body of knowledge.
From this paper, though, what the reader can take away is a new perspective on DBT. DBT, while it is a vast evidence-based treatment for adults with BDP, can indeed be adapted and effective in treating other populations. Indeed, the fact that all the studies in this paper, and outside, are operationalizing sexual orientation to test the efficacy of DBT is a huge step in bridging the health disparities in society today by advancing the understanding of treatments such as DBT. As such, the question of when is a DBT adaptation necessary and in what context continues to have relevance in scholarly discourse. The paper addressed the latter question by examining both non-adapted and adapted versions of DBT. While standard DBT can be effective, further adapting interventions that are specific to unique stressors faced by LGBTQ+ individuals (such as Skerven et al. 's Stigma Managing module) have the potential to lead significant and meaningful reductions in BPD symptoms. Ultimately, as the field continues to explore and refine these adaptations, DBT holds significant promise for improving mental health outcomes for LGBTQ+ individuals.
References
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