What Are We Missing?

One of the things that has always drawn clinicians to Dialectical Behavior Therapy (DBT) is that it continually asks us to look more closely. What is influencing this behavior? What is happening in the environment? What are we reinforcing? What are we failing to validate?

After reading Integrating Diversity into DBT: Dialectical Principles and Clinical Applications and having the opportunity to sit down with its authors—Lizbeth Gaona, Lisa Bolden, and Katherine Anne Comtois—one question kept surfacing that every DBT clinician should ask themselves more often:

What are we missing?

Throughout the conversation, a theme kept returning—what I began thinking of as the “third side of the coin.” We may believe we understand the client. We may have conducted a thorough behavioral chain analysis and be following the treatment to fidelity. And there may still be another part of the client’s experience we have not considered: culture, race, identity, language, socioeconomic circumstances, power, marginalization, family, community, or simply a lived experience very different from our own.

The message of this book is not that we need to reinvent DBT. In fact, one of the biggest takeaways was the opposite: DBT already gives us many of the tools we need if we are willing to do some self-assessment to see what we may have been overlooking.

Cultural Humility Begins With Us

In full transparency, reading this book was uncomfortable at times—and that is meant as a compliment. There were moments of realizing, I haven’t considered that. There were others of wondering whether something believed to be validating may actually have been invalidating.

Cultural humility requires self-assessment by the clinician, and that fits naturally within DBT. We already practice mindfulness, strive for a nonjudgmental stance, cultivate beginner’s mind, and acknowledge our own fallibility.

Cultural humility does not require us to become experts on every culture or identity. It requires us to be willing to say: I may not fully understand this. What am I missing? Can you help me understand your experience? That is beginner’s mind.

The Third Side of the Coin

During the discussion of the DBT assumptions, Dr. Gaona offered an important extension of dialectical thinking: perhaps there are not simply two sides to the coin. There may be a third side—the part we have not considered.

We know the familiar DBT assumptions: clients are doing the best they can, and clients need to do better, try harder, and be more motivated to change. But there may be another question: Is something in the environment overpowering the client’s ability to do what we are asking?

A client may be trying incredibly hard while also experiencing poverty, discrimination, housing instability, systemic barriers, or significant power differentials. Considering those factors is not a departure from behavioral thinking. It is a more complete behavioral assessment.

When Validation Isn’t Actually Validating

The discussion of validation was perhaps the most personally impactful part of the conversation. We can believe we are validating because our words “sound” validating to us. But validation is contextual.

Dr. Bolden shared that even as a BIPOC clinician, clients had told her that she was not fully understanding or validating their experiences when systemic factors were being overlooked.

Consider a client who repeatedly interviews for jobs but is not hired. We might immediately move toward change: Did you practice your interview skills? What could you do differently? Let’s problem solve. Those interventions may eventually be appropriate.

But what if discrimination related to race, language, accent, disability, gender identity, or another characteristic affects the client’s opportunities? If we never consider that possibility, our attempt to help may inadvertently communicate: The problem is you.

Effective validation sometimes requires understanding not only the person’s emotional experience, but also the environment in which that experience is occurring.

We Don’t Need to Reinvent DBT

One of the most reassuring messages from the authors was that culturally responsive DBT does not require dismantling the treatment. DBT already asks us to understand people within context. We examine prompting events, vulnerabilities, contingencies, environments, and consequences. We conduct behavioral chain and solution analyses.

The challenge is to make sure culture and systemic or environmental factors are included when they are relevant. This extends to consultation team as well. Adding a cultural humility statement to a team agreement is not enough if we never incorporate that lens into case conceptualization. The authors suggest asking a simple but powerful question in consultation:

Is there a cultural piece missing here?

And importantly, the answer does not always have to be yes. Assuming culture explains everything can become just as problematic. Beginner’s mind means remaining curious rather than deciding in advance what the answer should be.

What Are We Missing?

Toward the end of the conversation, something became increasingly clear: cultural responsiveness is not separate from DBT. It is embedded within many of DBT’s foundational principles—dialectics, validation, mindfulness, environmental assessment, fallibility, and beginner’s mind.

We don’t have to know everything. However, we do have to remain willing to learn. We have to tolerate the discomfort of discovering our blind spots. We have to stay curious about experiences different from our own. And we have to remember that helping someone create a life worth living requires understanding what a life worth living means to them—not what we assume it should mean.

Integrating Diversity into DBT reminds us that sometimes there is another side we haven’t seen yet. Perhaps one of the most important questions we can bring into our individual sessions, skills groups, consultation teams, supervision, and our own self-reflection is simply:

What am I missing?

If you’re ready to deepen your DBT practice and explore how cultural humility can transform your clinical work, consider joining a consultation team or seeking supervision that prioritizes this lens. Your clients—and your practice—will be better for it.