Table 6. Recommendations for DBT Therapists Supporting GSM Young People.

General considerations	• Consider the potential for pathologising normative behaviours, particularly with the BPD diagnosis • Increase the use of validation strategies and the acceptance end of the dialectic • Accept that sexual and gender identity may change over time • Engage with work on your own identity, biases, and blind spots • Educate yourself on GSM-related issues • Do not over-rely on GSM people to educate you • Include minority stress and GSM identities in the biosocial model and formulation of difficulties • Consider the role and impact of traumatic invalidation • Consider safety with the client when inviting change in cis-heterosexist environments
Creating safety in DBT	• Be overtly accepting, supportive, open, and non-judgemental regarding GSM identities • Model and self-disclose diversity • Make parameters of confidentiality regarding sexual/gender identity clear • Ensure clients access therapy from a safe location where they cannot be overheard • Be clear about where related information will be recorded/disseminated, and who has access • Involve parents/carers in interventions to increase support/validation (in consultation with the client) • Create safety signals in the environment (e.g. pronouns in emails, pride symbols, etc.) • Promote social connection with similar and accepting others • Make effort to get pronouns and names correct, and be non-defensive if mistakes are made (refer to the fallibility and consistency agreement; Linehan, 1993)
Negotiating targets and focus in DBT	• Ask about sexual and gender identity and name and pronouns (conveying it is optional) • Invite optional space for sexual- and gender-identity-related difficulties/dilemmas • Collaboratively negotiate how to make space if this does not fit with traditional targeting • Consider how sexual- and gender-identity- and minority-stress-related cues, experiences, and context may fit in the hierarchy of treatment targets, diary-card monitoring, formulations (including the transactional biosocial model), and chain analyses • Apply and generalise skills to relevant dilemmas explicitly • Include relevant psychoeducation and complementary skills for GSM-associated targets (these may be from sources outside of DBT, where these do not exist within the DBT model)

Note Suggestions informed by participant feedback and previous research (Camp, 2023; Cohen et al., 2021; Skerven et al., 2019; Sloan et al., 2017; Tilley et al., 2022). Recommendations are not in any particular order.