Using Art to Undermine Epistemic Injustice in DBT Research ENGAGE! | c r e at i v e a rts 38 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E Authors ELIZABETH BAILY College of Education, Wayne State University MONICA W. TRACEY College of Education, Wayne State University keywords: Dialectical Behavior Therapy, Activity Theory, Art, Epistemic Injustice abstract Through participatory arts-based research, constructed within the theoretical basis of the activity system, participants engaged with dialectical behavior therapy (DBT) program content to develop a cohesive and meaningful project structure and aesthetic. The body of literature that explores DBT skills training produces epistemic injustice by elevating practitioner/researcher perceptions of individual progress over participants’ interpretations of their own collective experiences. Research that relies on practitioners to report on patient experiences creates a self-perpetuating cycle where individual practitioners do not have the tools to regard patients as credible, allowing the field to render patients unintelligible. DBT is a skills-based psychotherapeutic approach that prepares individuals to address problems in living that result from the development of mental disorders in environments that persistently signal that an individual is an unreliable informant of their own experience. Arts-based research can be employed to disrupt the harmful parallels between the development of the disorders DBT is intended to treat and the dominant paradigm of DBT research. This publication centers on the experiences of individuals completing DBT, interrupts cycles of harm, and uplifts social knowledge construction that emanates from DBT skills training communities. epistemic injustice Epistemic injustice is the practice of favoring one group’s voice over another in a way that replicates and proliferates social, economic, political, and structural injustice (Fricker, 2013). Two types of epistemic injustice are identified, testimonial and hermeneutical. Testimonial injustice occurs when a speaker’s voice is dismissed based on aspects of the speaker’s identity, causing them to be deemed uncredible. Hermeneutical injustice occurs when a group is excluded from activities like scholarship and journalism that shape the ideas that people use to make sense of their lives. When an individual’s experiences are vastly different from these ideas, the individual is dismissed as unintelligible because the listener lacks a framework to understand their experiences (Fricker, 2013). The opposite of epistemic injustice is epistemic justice. Epistemic justice requires virtuous hearing, where listeners become aware of the impact of power imbalances on how they evaluate communication and make compensation VO L . 1 , I S S U E 2VO L . 4 , I S S U E 1 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E ENGAGE! | c r e at i v e a rts 39 for those imbalances (Fricker, 2007). Virtuous hearing requires time and the development of a micro-climate in which listeners are able to move past prejudicial notions of credibility and intelligibility (Bourgault, 2020). dialectical behavioral therapy Dialectical behavior therapy (DBT) is a skills- based therapy that is recommended for individuals who experience severe problems in living that develop in an environment that persistently invalidates the individual’s interpretation of their own experience (Linehan, 2015). This persistent invalidation results in skill deficits in the domains of interpersonal interactions, self-regulation of emotions and behaviors, toleration of distress, and connecting with the present moment. In its standard format, DBT includes a group skills training component. Skills training groups participate in collaborative learning activities including role play, discussions, and cooperative problem solving (Linehan, 2015). epistemic injustice in dbt research Despite the active, collective, and communal nature of DBT group skills training, the body of literature that explores DBT skills training most often reports on individual measures of success that are selected, administered, interpreted, and reported by practitioners to the exclusion of participant voices. This has the effect of elevating the perspectives of practitioners over participants, developing a paradigm where practitioners are upheld as superior informants on program outcomes and participant experiences. The second edition of the DBT Skills Training Manual employs a summary of 30 randomized control trials (RCT) and seven non-randomized control trials (Linehan, 2015, p. 17-18, 20- 21). These trials report patient outcomes at the individual level using standardized measurements administered and interpreted by the treating practitioners to assert the effectiveness of DBT. This pattern extends to case study literature. In a meta-analysis of 48 published English language case studies that incorporated DBT skills training, practitioner perspectives were the most consistently reported metrics of change. 37 case studies incorporated practitioner notes on patient changes as they were perceived by the practitioner. 31 case studies included practitioner-selected psychometrics as indicators of change, 18 included behavioral metrics, and 4 included physiometrics – such as changes in patient weight. 22 case studies published practitioner interpretations of patients’ responses to practitioner-generated follow-up interview questions. Three notable exceptions to the pattern of privileging practitioner perspectives are Lustig and colleagues (2000), who referenced a piece of narrative fiction authored by the participant; Heckwolf and colleagues (2014), who described patient-generated visual artwork; and McNair and colleagues (2016), who assessed participant- generated repertory grids. Despite these few exceptions, this preference towards practitioner insights defines a body of literature that holds practitioners as more trustworthy and their perspectives as more valuable than patients’. This pattern is uniquely damaging because the disorders that DBT is designed to treat often develop in environments that reject the individual as a reliable informant of their own experience (Linehan, 2015). Research that relies on practitioners to report on patient experiences creates a self-perpetuating cycle where individual practitioners do not have the tools to regard patients as credible, allowing the field to render ENGAGE! | c r e at i v e a rts 40 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E patients unintelligible (Vosinkel et al., 2021). By situating the patient as the primary source of knowledge, the inquiry for this publication interrupts cycles of injustice by creating a channel for social knowledge that emanates from DBT skills training communities to flow into academic discourse and literature. foundation for participatory research The Activity System Social knowledge construction is an actively constructive process that occurs when groups of individuals generate, negotiate, and respond to unique configurations of shared understanding (Duffy & Cunningham, 1996). Activity theorists expand the role of context in social knowledge construction to describe learning as a shared social endeavor (Engeström, 1987; Leont’ev, 1978; Vygotsky, 1978b), which is mediated by tools and situated within a broader community of practice (Barab et al., 2004). Figure 1 illustrates the relationship between the interactive components of the activity system described by activity theory (Engeström, 1987, p. 14). The research undertaken for this inquiry applies activity theory to structure relevant aspects of a micro-climate that facilitates virtuous listening on the part of the researcher. In this activity system, DBT skills training group participants are organized around a shared objective of representing the impact of DBT skill use in a collaborative art piece. Participants (subjects) work as part of a DBT skills training group (community) organized around producing an artwork (object). This process is mediated by art supplies and the concepts shared through DBT skills training (tools and symbols). The DBT Skills Training Manual provides the rules within the social environment that are further defined by an emergent division of labor. Arts-Based Research Arts-based research (ABR) is a constructive process in which knowledge is created and physicalized through the collaborative construction of work and the roles that participants embody (Greenwood, 2019). By providing a medium for participants to intentionally self-construct and self-edit (Greenwood, 2019), ABR democratizes research participation and reporting (Bartlett, 2015; Boydell, 2011). ABR expands opportunities for participants and audiences to engage with research by presenting findings in mediums beyond academic discourse (Bartlett, 2015; Boydell, 2011; Nilssen & Klemp,2020). Participatory research demonstrates the promising potential to interrupt epistemic injustice (Boni & Walker, 2020). The research undertaken for this publication is structured in accordance with Mitchell and colleagues’ participatory visual research methodologies (PVRM, 2011). PVRM promotes community engagement in arts-based research by creating a structure of relationship-building between researcher and participants alongside interpretation that Figure 1. Activity System Schematic, developed by Engreström, 1987 p. 14 41 VO L . 4 , I S S U E 1 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E engages all stakeholders. PVRM recommends five characteristics of research design: a reassuring invitation to draw, choice of drawing tools, leisurely pace, shared analysis, and civic dissemination. collaborative investigation with the dbt skills training community Guiding Questions This inquiry applies the theoretical framework of activity theory (Leont’ev, 1978) while using best practices for arts-based research (Mitchell et al., 2011). The guiding questions focus on exploring the ways in which DBT skills training participants organize themselves around creating a collaborative art piece: Q1: How are tools and symbols used by participants to mediate shared expression of knowledge constructed in DBT skills training? Q2: How do participants negotiate shared expression of public knowledge constructed in DBT skills training? Q3: How does a division of labor emerge to organize participant actions around creating a shared expression of knowledge construction in DBT skills training? Q4: In what ways are the expectations provided by the DBT Skills Training Manual applied by participants in creating a shared expression of knowledge constructed in DBT skills training? Each guiding question is designed around a unique triad of activity system nodes that includes the subject node, the object node, and one additional node. These triads are: Q1 subject, object, tools; Q2 subject, object, rules; Q3 subject, object, division of labor; Q4 subject, object, community. While these questions are not explicitly answered by this publication, they serve as a basis for the approach to inquiry and interpretation of outcomes. Participants and Context The participants in this inquiry were active in an outpatient DBT skills training program that is offered through the counseling center at an urban research university in the midwestern region of the United States. This treatment program is offered at a sliding scale cost to students and community members. Two DBT skills training program participants agreed to be part of the research. The identities of the participants have been anonymized for confidentiality reasons. Approach to Collaborative Inquiry Participant introductions occurred virtually following a regularly scheduled skills training session. Individuals who expressed interest in participating were provided an informed consent form, and individuals who completed the form were sent an electronic survey that asked about art supplies that were familiar and of interest to them. This survey offered a “choice of drawing tools” (Mitchell et al., 2011), which were then purchased and provided to the participants at no cost. These supplies included a mounted canvas measuring three feet by four feet; acrylic paints, brushes, and pallets; and collaging materials including magazines, construction paper, and adhesive. Next, participants attended a virtual planning meeting that lasted approximately 30 minutes. This meeting provided a "reassuring invitation to draw" where participants were assured that "the focus is on the content of their drawing, and not on the quality of it as a drawing" (Mitchell et al., 2011 p. 23). Participants were shown the materials available and discussed their approach to the project. At the end of the first meeting, participants determined the need for a second discussion. The second virtual meeting lasted approximately 20 ENGAGE! | c r e at i v e a rts 42 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E minutes and allowed participants to set a leisurely pace (Mitchell et al., 2011) that fostered creative engagement with the project. Both meetings were audio-recorded to produce a conversation transcript which was reviewed using conversation analysis (Charmaz, 2014). After receiving the partially completed piece from Participant 1, Participant 2 experienced several life-interrupting events that derailed piece completion. As a result of these disruptions, the final stage of the project had not yet been reached at time of publication; the piece had not been completed, participants had not created a shared description of the final piece, and the piece had not been put on display. findings Participant quotations from the two planning meetings are employed in reporting the results of this collaborative project. Italicized words indicate descriptive choices employed by the participants throughout the meetings. By including participant quotations in their entirety, using participant utterances as the primary organizational structure, and by using descriptive choices made by participants, this work uplifts participant experiences as the primary source of knowledge in this inquiry. Program, Project, and Constraints: The idea of balance “And just the idea of balance. Because balance was something that definitely came to me really fast, just in terms of how we’re associating it to the skills and everything that we talk about” (Participant 1, meeting 1). Participants constructed knowledge when they discussed structures for the project alongside logistical constraints, a process that determined the structure of the piece. Participants considered two possibilities for structure. They explored the possibility of having the first participant create a rough version of the piece that covered the entire canvas and then having the second participant overlay their work onto the existing piece. The second possibility the participants explored was to split the canvas into a half-half structure with a side-to-side horizontal orientation of the canvas, and each participant would create their portion of the piece on half of the canvas. Participants found the half-half structure was more clearly defined while the overlay structure was less clear, and participants recognized there would be more negotiation involved in the overlay approach. As participants engaged with their proposed half-half structure, they explored the ways in which DBT engages with duality. The participants reflected on the idea of existing along dialectics – the idea that two apparently opposing things can be true simultaneously – which is foundational to DBT. Participants also discussed balance and the ways in which messages surrounding balance are threaded throughout DBT skills training. “Emotions that you’re dealing with can be put in as far as how distress tolerance and emotion regulation help balance these emotions. But the emotions can be present via color or words” (Participant 2, meeting 1). Aesthetic Choices: Brightness and darkness “That brightness and darkness. And its correlation to how we identify with these things, especially with our own feelings and emotions” (Participant 1, meeting 1). The consideration of the dualities explored by DBT supported the participants’ decision to engage with the half-half structure. This decision led to further discussion on aesthetic choices. Participants agreed that Participant 1 would make aesthetic choices 43 VO L . 4 , I S S U E 1 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E that could be easily continued by Participant 2, referring to a color spectrum that could be terminated in a line that would fade into a solid color allowing the participants to merge from color to color providing a unified look to the piece. Participants also discussed the ways in which emotion regulation and distress tolerance allowed them to manage emotions characterized by brightness and darkness, and ways the artwork could externally express this internal experience. As the project developed, participants began to discuss more concrete options for the visual and aesthetic representation of the temporal aspect of DBT skills training. They considered the ways that skills practice may translate into a mindset over a span of time. “I was thinking about things going from in focus to out of focus or vice versa. Words are kind of smudgy and it’s become more bold” (Participant 1, meeting 2). Communication of Knowledge Constructed: A glimpse of artistically what it means “People who might not even know what DBT is could at least get a glimpse of artistically what it means” (Participant 2, meeting 2). Participants constructed connections between the content of their program, the ideas that underly their program, and the impact of DBT skills on their lives outside of the program. The participants then considered the ways in which these different aspects can be expressed visually. This process included considerations of project content that segued into discussing metaphoric options for visual expression. As the structure, content, and aesthetic choices became more concrete for the participants, they began to consider their intended audience’s perceptions of the piece. Participants began to view their piece as a negotiation of meaning between themselves alongside their audience as they worked to navigate the tension of trying to visually translate the impact of a large program on a finite canvas in a way that would provide a meaningful experience to the audience. “What has stood out to me and what parts of each module stick out to me. And it’s kind of a challenge to do that. To put that in display” (Participant 2, meeting 2). implications Epistemic justice requires virtuous hearing (Fricker, 2013), and virtuous hearing requires a micro-ecosystem and time (Bourgault, 2020). This publication presents a discussion of the arts- based activity system as a micro-ecosystem that can contribute to epistemic justice in DBT skills training research, with further exploration of the role of time in future research. The micro-ecosystem empowered participants to determine their own expression priorities – a structure that stands in stark contrast to researcher/practitioner-driven case studies and trials. By minimizing researcher/practitioner voices, this research created space for DBT skills training participants to serve as active agents of knowledge construction and experts in their own experience. Within this space, participants demonstrated profound insight and creativity as they planned and executed their shared project. While practitioners have deep knowledge of the therapeutic and training processes, only participants can truly be experts on the impact that skills have on them. Participant voices can – and should – provide insights that guide the future of DBT skills training research. While the findings revealed in this study are likely already present in ENGAGE! | c r e at i v e a rts 44 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E practice for many DBT practitioners, they are left unexamined in literature, preventing these lessons from being broadcast across the wider community of DBT skills trainers and therapists. The data collected for this study demonstrate the types of insights and knowledge that can be gained when participants’ voices are centered. The data not collected for this study contain equally valuable implications for working alongside vulnerated communities. Individuals completing DBT skills training are part of a community that experiences an increased likelihood of encountering life- interrupting events. To collaboratively create knowledge surrounding their experiences, that community’s relationship to – and experience of – time must drive project timelines and pacing. Centering participant voices requires intentional effort to elevate the participants’ experience with time over the researcher’s preferences for expediency, or any sponsoring institution’s time- bound requirements for results. Researchers/ practitioners should work with participants to create and communicate fluid expectations for completion that fit the changing circumstances of participants’ lives. While practitioners have deep knowledge of the thera- peutic and training processes, only participants can truly be experts on the impact that skills have on them. 45 VO L . 4 , I S S U E 1 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E References References marked with an asterisk indicate studies included in the me- ta-analysis. * Banks, B. P., & Gibbons, M. M. (2016). Dialectical behavior therapy techniques for counseling incar- cerated female adolescents: A case illustration. Journal of Addictions & Offender Counseling, 37(1), 49–62. https://doi.org/10.1002/jaoc.12015 Barab, S. A., Evans, M. A., & Baek, E.- O. (2004). Activity theory as a lens for characterizing the participatory unit. In D. H. Jonassen (Ed.), Hand- book of research on educational communications and technology (pp. 199–214). Lawrence Erlbaum Associ- ates Publishers. * Barrett, J. J., Tolle, K. A., & Sals- man, N. L. (2017a). Dialectical behavior therapy skills training for persistent complex bereavement disorder. Clinical Case Studies, 16(5), 388–400. https://doi. org/10.1177/1534650117699700 Bartlett, R. (2015). Visualising dementia activism: Using the arts to communicate research findings. Qualitative Research, 15(6), 755–768. https://doi. org/10.1177/1468794114567493 Boni, A., & Walker, M. (2020). Poten- tial of participatory action research processes to overcome epistemic injustice in non-ideal university set- tings. In M. Walker & A. Boni (eds.), Participatory research, capabilities and epistemic justice: A transfor- mative agenda for higher education. Palgrave Macmillan. https://doi. org/10.1007/978-3-030-56197-0_10 Bourgault, S. (2020). Epistemic injustice, face-to-face encounters, and caring institutions. International Journal of Care and Caring 4(1), 91- 107. https://doi.org/10.1332/239788 219X15682725266696 Boydell, K. (2011). Using performa- tive art to communicate research: Dancing experiences of psychosis. Canadian Theatre Review, 146, 12-17. https://doi.org/10.3138/ctr.146.12 * Braden, A., Ferrell, E., Redondo, R., & Watford, T. (2020). Dialectical behavior therapy skills and behavior- al weight loss for emotional eating and obesity: A case study. Journal of Contemporary Psychotherapy, 50(3), 177-186. https://doi.org/10.1007/ s10879-020-09451-x * Burckell, L. A., & McMain, S. (2011). Contrasting clients in dialectical behavior therapy for borderline per- sonality disorder: “Marie” and “Dean,” two cases with different alliance trajectories & outcomes. Pragmatic Case Studies in Psychotherapy, 7(2), 246–267. https://doi.org/10.14713/ pcsp.v7i2.1090 * Cannon, J. L., & Umstead, L. K. (2018). Applying dialectical behavior therapy to self-harm in college-age men: A case study. Journal of College Counseling, 21(1), 87–96. https://doi. org/10.1002/jocc.12089 * Chan, C. C., Bach, P. A., & Bedwell, J. S. (2015). An integrative approach using third-generation cognitive-be- havioral therapies for avoidant personality disorder. Clinical Case Studies, 14(6), 466–481. https://doi. org/10.1177/1534650115575788 Charmaz, K. (2014). Constructing grounded theory. SAGE. * Cheng, P.H., & Merrick, E. (2017). Cultural adaptation of dialectical behavior therapy for a Chinese in- ternational student with eating dis- order and depression. Clinical Case Studies, 16(1), 42–57. https://doi. org/10.1177/1534650116668269 *Chu, B. C., Rizvi, S. L., Zendegui, E. A., & Bonavitacola, L. (2015). Dia- lectical behavior therapy for school refusal: Treatment development and incorporation of web-based coaching. Cognitive and Behavioral Practice, 22(3), 317–330. https://doi. org/10.1016/j.cbpra.2014.08.002 * Crossland, T., Hewitt, O., & Walden, S. (2017). Outcomes and experiences of an adapted dialectic behaviour therapy skills training group for people with intellectual disabilities. British Journal of Learning Disabil- ities, 45(3), 208–216. https://doi. org/10.1111/bld.12194 *Dimeff, L. A., & Linehan, M. M. (2008). Dialectical behavior therapy for substance abusers. Addiction Sci- ence & Clinical Practice, 4(2), 39-47. *Dimeff, L., Rizvi, S. L., Brown, M., & Linehan, M. M. (2000). Dialectical behavior therapy for substance abuse: A pilot application to meth- amphetamine-dependent women with borderline personality disorder. Cognitive and Behavioral Prac- tice, 7(4), 457–468. https://doi. org/10.1016/S1077-7229(00)80057- 7 Duffy, T. M., & Cunningham, D. J. (1996). Constructivism: implications for the design and delivery of instruc- tion. In D. H. Jonassen & Association for Educational Communications and Technology (Ed), Handbook of re- search for educational communica- tions and technology. (pp. 171-201). Macmillan. Engeström, Y. (1987). Learning by expanding: An activity-theoretical approach to developmental research. Orienta-Konutit. *Erb, S., Farmer, A., & Mehlenbeck, R. (2013). A condensed dialectical be- havior therapy skills group for binge eating disorder: Overcoming winter challenges. Journal of Cognitive Psy- chotherapy, 27(4), 338–358. https:// doi.org/10.1891/0889-8391.27.4.338 *Fassbinder, E., Schweiger, U., Marti- us, D., Brand-de Wilde, O., & Arntz, A. (2016). Emotion regulation in sche- ma therapy and dialectical behavior therapy. Frontiers in Psychology, 7, 1373. https://doi.org/10.3389/ fpsyg.2016.01373 *Finney, N., & Tadros, E. (2019). Inte- gration of structural family therapy and dialectical behavior therapy with high-conflict couples. The Family Journal, 27(1), 31–36. https://doi. org/10.1177/1066480718803344 *Florez, I. A., & Bethay, J. S. (2017). Using adapted dialectical behav- ioral therapy to treat challenging behaviors, emotional dysregulation, and generalized anxiety disorder in an individual with mild intellec- tual disability. Clinical Case Stud- ies, 16(3), 200–215. https://doi. org/10.1177/1534650116687073 Fricker, M. (2007). Epistemic injustice: Power and the ethics of knowing. Oxford University Press. DOI:10.1093/acprof:o- so/9780198237907.001.0001 Fricker, M. (2013). Epistemic justice as a condition of political freedom? Synthese 190(7), 1317-1332. https:// doi.org/10.1007/s11229-012-0227-3 Granato, H. F., Wilks, C. R., Miga, E. M., Korslund, K. E., & Linehan, M. M. (2015). The use of dialectical behav- ior therapy and prolonged exposure to treat comorbid dissociation and self-harm: The case of a client with borderline personality disorder and posttraumatic stress disorder: Integrating DBT and PE. Journal of Clinical Psychology, 71(8), 805–815. https://doi.org/10.1002/jclp.22207 Greenwood, J. (2019). Arts-based research. In J. Greenwood, Oxford research encyclopedia of edu- cation. Oxford University Press. https://doi.org/10.1093/acre- fore/9780190264093.013.29 Gunawardena, C. N., Lowe, C. M. A., & Anderson, T. (1998). Transcript analysis of computer-mediated conferences as a tool for testing constructivist and social-construc- tivist learning theories [conference session]. Distance Learning ‘98, Madison WI, United States. *Gupta, A., Kashyap, A., & Sidana, A. (2019). Dialectical behavior therapy in emotion dysregulation—Report of two cases. Indian Journal of Psy- chological Medicine, 41(6), 578-581. https://doi.org/10.4103/ijpsym. ijpsym_352_19 *Hewitt, O., Atkinson‐Jones, K., Gregory, H., & Hollyman, J. (2019). What happens next? A 2‐year fol- ENGAGE! | c r e at i v e a rts 46 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E References cont.. low‐up study into the outcomes and experiences of an adapted dialectical behaviour therapy skills training group for people with intel- lectual disabilities. British Journal of Learning Disabilities, 47(2), 126–133. https://doi.org/10.1111/bld.12267 *Huss, D. B., & Baer, R. A. (2007). Acceptance and change: The in- tegration of mindfulness-based cognitive therapy into ongoing dialectical behavior therapy in a case of borderline personality dis- order with depression. Clinical Case Studies, 6(1), 17–33. https://doi. org/10.1177/1534650106290374 *Johnson, L. (2013). Adapting and combining constructivist grounded theory and discourse analysis: A practical guide for research. Interna- tional Journal of Multiple Research Approaches, 4120–4141. https://doi. org/10.5172/mra.2013.4120 *Johnson, P., & Thomson, M. (2016). Journeys into dialectical behaviour therapy (DBT): Capturing the staff and service-user experience. Journal of Intellectual Disabilities and Offending Behaviour, 7(2), 84–93. https://doi.org/10.1108/ JIDOB-09-2015-0027 *Katz, L. Y., & Cox, B. J. (2002). Dialectical behavior therapy for suicidal adolescent inpatients: A case study. Clinical Case Stud- ies, 1(1), 81–92. https://doi. org/10.1177/1534650102001001007 *Keuthen, N. J., & Sprich, S. E. (2012). Utilizing DBT skills to aug- ment traditional CBT for trichotillo- mania: An adult case study. Cogni- tive and Behavioral Practice, 19(2), 372–380. https://doi.org/10.1016/j. cbpra.2011.02.004 *Koerner, K., Dimeff, L. A., Swenson, C., & Rizvi, S. L. (2021). Adopt or adapt? Fidelity matters. In L. A. Di- meff, L. Shireen, & K. Koerner (eds.), Dialectical behavior therapy in clin- ical practice (2nd ed., pp. 21–36). Guilford Press. *Kohrt, B. K., Lincoln, T. M., & Brambila, A. D. (2017). Embedding DBT skills training within a trans- actional-ecological framework to reduce suicidality in a Navajo adolescent female. Clinical Case Studies, 16(1), 76–92. https://doi. org/10.1177/1534650116668271 *Koons, C. R. (2011). The role of the team in managing telephone consultation in dialectical behavior therapy: Three case examples. Cog- nitive and Behavioral Practice, 18(2), 168–177. https://doi.org/10.1016/j. cbpra.2009.10.008 Leont’ev, A.N. (1978). Activity, con- sciousness, and personality. Pren- tice-Hall. Linehan, M. M. (2015). DBT skills training manual. Guilford Press. *Low, G., Jones, D., Duggan, C., MacLeod, A., & Power, M. (2001). Dialectical behaviour therapy as a treatment for deliberate self-harm: Case studies from a high security psychiatric hospital population. Clinical Psychology & Psychother- apy, 8(4), 288–300. https://doi. org/10.1002/cpp.287 * Lustig, S., Smrz, A., Sladen, P., Sellers, T. D., & Hellman, S. (2000). It takes a village: Caring for a trauma- tized art student. Harvard Review of Psychiatry, 7(5), 290–298. https:// doi.org/10.3109/hrp.7.5.290 * Martin, C. G., Roos, L. E., Zalewski, M., & Cummins, N. (2017). A dialec- tical behavior therapy skills group case study on mothers with severe emotion dysregulation. Cognitive and Behavioral Practice, 24(4), 405–415. https://doi.org/10.1016/j. cbpra.2016.08.002 * McNair, L., Woodrow, C., & Hare, D. (2016). Using repertory grid tech- niques to measure change following dialectical behaviour therapy with adults with learning disabilities: Two case studies. British Journal of Learning Disabilities, 44(3), 247–256. https://doi.org/10.1111/ bld.12142 * Mercado, A., & Hinojosa, Y. (2017). Culturally adapted dialectical be- havior therapy in an underserved community mental health setting: A Latina adult case study. Practice Innovations, 2(2), 80–93. https:// doi.org/10.1037/pri0000045 Mitchell, C., Theron, L., Stuart, J., Smith, A., & Stuart. J. (2011). Drawings as research method. In L. Theron, A. Smith, & J. Stuart (Eds.) Picturing research: Drawing a visual methodology (pp. 19–36). SenseP- ublishers. *Nararro-Haro, M. V., Hoffman, H. G., Garcia-Palacios, A., Sampaio, M., Alhalabi, W., Hall, K., & Linehan, M. (2016). The use of virtual reality to facilitate mindfulness skills training in dialectical behavioral therapy for borderline personality disorder: A case study. Frontiers in Psychol- ogy, 7, Article 1573. https://doi. org/10.3389/fpsyg.2016.01573 *Neacsiu, A. D., Eberle, J. W., Kramer, R., Wiesmann, T., & Linehan, M. M. (2014). Dialectical behavior therapy skills for transdiagnostic emotion dysregulation: A pilot randomized controlled trial. Behaviour Research and Therapy, 59, 40-51. https://doi. org/10.1016/j.brat.2014.05.005 *Nee, C., & Farman, S. (2007). Dialectical behaviour therapy as a treatment for borderline per- sonality disorder in prisons: Three illustrative case studies. Journal of Forensic Psychiatry & Psychol- ogy, 18(2), 160–180. https://doi. org/10.1080/14789940601104792 Nilssen, V., & Klemp, T. (2020). Encouraging working and commu- nicating like mathematicians: An illustrative case on dialogic teaching. In M. B. Postholm & K. F. Vennebo (eds.), Applying Cultural Historical Activity Theory in Educational Set- tings Learning, development, and research, (pp. 73-90). Routledge. *Owens, M. D., Nason, E., & Yeater, E. (2018). Dialectical behavior therapy for multiple treatment targets: A case study of a male with comor- bid personality and substance use disorders. International Journal of Mental Health and Addiction, 16(2), 436–450. https://doi.org/10.1007/ s11469-017-9798-z *Pluhar, E., Jhe, G., Tsappis, M., Bick- ham, D., & Rich, M. (2020). Adapting dialectical behavior therapy for treating problematic interactive media use. Journal of Psychiatric Practice, 26(1), 63-70. https://doi. org/10.1037/e515212008-001 *Potter, A. E., Davidson, M. M., & Wesselmann, D. (2015). Utilizing dialectical behavior therapy and eye movement desensitization and reprocessing as phase-based trau- ma treatment: A case study series. International Journal of Medical and Biological Frontiers, 21(2), 189. *Rizvi, S. L. (2011). Treatment failure in dialectical behavior therapy. Cog- nitive and Behavioral Practice, 18(3), 403–412. https://doi.org/10.1016/j. cbpra.2010.05.003 *Rizvi, S. L., Yu, J., Geisser, S., & Finnegan, D. (2016). The use of “bug-in-the-eye” live supervision for training in dialectical behavior therapy: A case study. Clinical Case Studies, 15(3), 243–258. https://doi. org/10.1177/1534650116635272 *Safer, D. L., Couturier, J. L., & Lock, J. (2007). Dialectical behavior ther- apy modified for adolescent binge eating disorder: A case report. Cog- nitive and Behavioral Practice, 14(2), 157–167. https://doi.org/10.1016/j. cbpra.2006.06.001 *Safer, D. L., Telch, C. F., & Agras, W. S. (2001). Dialectical behavior thera- py adapted for bulimia: A case re- port. International Journal of Eating Disorders, 30(1), 101–106. https:// doi.org/10.1002/eat.1059 *Sakdalan, J. A., Shaw, J., & Collier, V. (2010). Staying in the here-and-now: A pilot study on the use of dialectical behaviour therapy group skills train- ing for forensic clients with intel- lectual disability: DBT with Forensic ID clients. Journal of Intellectual Disability Research, 54(6), 568–572. https://doi.org/10.1111/j.1365- 2788.2010.01274.x 47 VO L . 4 , I S S U E 1 B A I L E Y & T R A C E Y | U N D E R M I N I N G E P I S T E M I C I N J U S T I C E *Scheiderer, E., Carlile, J. A., Aosved, A. C., & Barlow, A. (2017). Concurrent dialectical behavior therapy and prolonged exposure reduces symp- toms and improves overall quality of life for a veteran with posttrau- matic stress disorder and borderline personality disorder. Clinical Case Studies, 16(3), 216–233. https://doi. org/10.1177/1534650116688557 *Telch, C. F. (1997). Skills training treatment for adaptive affect regu- lation in a woman with binge‐eating disorder. International Journal of Eating Disorders, 22(1), 77-81. https://doi.org/10.1002/(sici)1098- 108x(199707)22:1<77::aid- eat10>3.0.co;2-f *Thomson, M., & Johnson, P. (2017). Experiences of women with learning disabilities undergoing dialectical behaviour therapy in a secure ser- vice. British Journal of Learning Dis- abilities, 45(2), 106–113. https://doi. org/10.1111/bld.12180 Voswinkel, M. M., Rijkers, C., van Delden, J. J. M., & van Elburg, A. A. (2021). Externalizing your eating disorder: a qualitative interview study. Journal of Eating Disorders, 9(128), 1-12. DOI:10.1186/s40337- 021-00486-6 Vygotsky, L. (1978). Mind in society: The development of higher psycho- logical processes. Harvard University Press. *Welch, S. S., & Kim, J. (2012). DBT-enhanced cognitive behavioral therapy for adolescent trichotilloma- nia: An adolescent case study. Cog- nitive and Behavioral Practice, 19(3), 483–493. https://doi.org/10.1016/j. cbpra.2011.11.002 Wooffitt, R. (2001). Researching psychic practitioners: Conversation analysis. In M. Wetherell, S. Taylor, & S. J. Yates (Eds.) Discourse as data: A guide for analysis (pp. 49–92). SAGE Publications, Inc.