This blog piece by guest blogger, Dr. John Pachankis, on behalf of Division 12’s Education and Training Committee, discusses recent efforts to establish evidence-based treatments for mental health and co-occurring psychosocial concerns (e.g., alcohol use, sexual compulsivity, sexual risk behavior) among lesbian, gay, and bisexual (LGB) clients. John Pachankis is an Associate Professor in the Department of Chronic Disease Epidemiology (Social and Behavioral Sciences Division) at the Yale School of Public Health. He is a clinical psychologist whose research seeks to uncover reasons that LGB individuals, on average, are more likely to experience poorer mental health than heterosexuals. He received his Ph.D. from SUNY-Stony Brook, completed his clinical internship at McLean Hospital / Harvard Medical School, and currently receives funding from the National Institute of Mental Health and the Fogarty International Center to develop and test the efficacy of mental, behavioral, and sexual health interventions for gay and bisexual men. He teaches a graduate seminar in Stigma and Health at Yale and supervises therapists working with LGB clients.
In an upcoming webinar, Dr. Pachankis will discuss a transdiagnostic treatment approach for alleviating co-occurring mental, behavioral, and sexual health issues among gay and bisexual men. His team developed this treatment in close consultation with members of the LGB community. The treatment demonstrated efficacy in a recent randomized controlled trial, making it one of the first evidence-based LGB-affirmative mental health treatments that specifically addresses unique issues in gay and bisexual men’s mental health.
A Transdiagnostic Treatment Approach for LGB Individuals’ Mental, Behavioral, and Sexual Health
In the past several years, psychologists have found that despite most LGB people being resilient and not experiencing mental health problems, LGB individuals on average are significantly more likely than heterosexuals to report experiencing certain mental health problems like depression and anxiety, that LGB individuals are more likely to utilize mental health services, and that most psychologists report seeing at least one LGB individual in their practices. Sexual orientation mental health disparities start relatively early in development and co-occur with several sexual and behavioral health risks, such as alcohol use and sex-risk behavior.
The American Psychological Association has issued guidelines for psychological practice with LGB individuals to draw attention to key issues affecting this population. My current research gathers empirical evidence for translating this guidance into empirically supported practice. Specifically, I recently conducted in-depth interviews with 21 expert mental health providers and 20 depressed and anxious gay and bisexual men, who provided suggestions for adapting standard practice to address LGB individuals’ unique treatment needs.
Several principles for adapting standard practice emerged from this research:
- Normalize the adverse impact of minority stress. Minority stress refers to the disproportionate stigma-based stress borne by LGB individuals compared to heterosexuals that compounds general life stress and exacerbates mental health risk. Because stigma often operates in unseen ways to compromise health, LGB individuals might not perceive this potential source of disproportionate stress. This principle encourages helping LGB individuals attribute certain personal distress to stigmatizing social structures instead of personal failings.
- Facilitate emotion awareness, regulation, and acceptance. Given evidence that minority stress taxes LGB individuals’ emotion regulation resources and thereby confers risk for psychopathology, helping LGB individuals learn strategies for mindful awareness of minority stress reactions can facilitate positive mental health.
- Reduce avoidance. Chronic stress exposure can lead to maladaptive forms of cognitive, affective, and behavioral avoidance. Helping LGB individuals confront painful minority stress memories, emotions, or interpersonal encounters in safe contexts can potentially weaken the ongoing influence of those events on poor mental health.
- Empower assertive communication. Minority stress can teach LGB individuals that they are underserving of the same rights and opportunities afforded heterosexuals. Previous exposure to stigma can lead LGB individuals to self-silence, even in situations in which it would be most adaptive to openly express one’s needs, opinions, wants, and desires. This principle seeks to empower LGB individuals to assert themselves in situations in which it is safe and healthy to do so.
- Restructure minority stress cognitions. Early and ongoing minority stress can teach LGB people that their wants, needs, and emotions are invalid. Minority stress can also lead LGB people to internalize rejection or chronically and anxiously expect it. Cognitive therapy exercises can be modified to reduce the ongoing impact of minority stress-driven cognitive biases.
- Validate sexual minority individuals’ unique strengths. This principle helps LGB individuals appreciate their unique personal strengths and experiences, such as navigating the coming out process, for example, and to draw on those strengths as sources of pride and optimism. This principle also helps LGB individuals connect with the remarkable resilience shown by LGBT communities currently and across history.
- Build supportive relationships. Given the importance of social support for buffering against minority stress, this principle helps LGB individuals build supportive families, relationships, and communities, and strengthen existing connections.
- Affirm healthy, rewarding expressions of sexuality. Most LGB people become aware of their sexuality in isolation during adolescents when they may not have the supportive resources necessary for navigating same-sex sexual feelings. Further, sexual minority sexuality is not often addressed in mainstream sources of sex education, such as from parents and schools. Therefore, this principle seeks to affirm healthy, rewarding aspects of sexuality among LGB individuals as a way to promote mental, sexual, and behavioral health in this population.
We recently conducted a randomized controlled trial in which we incorporated these principles into standard cognitive behavioral practice and compared this adapted treatment to a waitlist control. This preliminary efficacy trial demonstrated reductions in depression, alcohol use, sexual compulsivity, and condomless anal sex among 63 young gay and bisexual men. We conducted this first test occurred with men given that, for gay and bisexual men, mental health problems co-occur with health-risk behaviors such as sexual compulsivity, alcohol use, body image concerns, and condomless anal sex to form a synergistic epidemic of health threats in particular need of attention. Future tests of this LGB-affirmative minority stress intervention ought to test its efficacy for reducing psychosocial problems faced by women, older LGB adults, and LGB individuals seeking treatment in different settings, such as community clinics and student counseling centers.
Interested in attending January 28th Webinar on this topic with Dr. Pachankis? Click HERE.
Further Reading
American Psychological Association (2012). Guidelines for psychological practice with
lesbian, gay, and bisexual clients. American Psychologist, 67, 10-42.
Cochran, S. D. (2001). Emerging issues in research on lesbians’ and gay men’s mental health: Does sexual orientation really matter?. American Psychologist, 56(11), 931-947.
Eubanks‐Carter, C., Burckell, L. A., & Goldfried, M. R. (2005). Enhancing therapeutic effectiveness with lesbian, gay, and bisexual clients. Clinical Psychology: Science and Practice, 12(1), 1-18.
Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707-730.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological Bulletin, 129(5), 674-697.
Pachankis, J. E. (2014). Uncovering clinical principles and techniques to address minority stress, mental health, and related health risks among gay and bisexual men. Clinical Psychology: Science and Practice, 21(4), 313-330.