Handbook of evidence-based mental health practice with sexual and gender minorities 1st edition john
Handbook of evidence-based mental health practice with sexual and gender minorities 1st Edition John E. Pachankis
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Advance Praise for Handbook of Evidence-Based Mental Health Practice with Sexual and Gender Minorities
“Pachankis and Safren have done the field a great service with the publication of this important and timely handbook. This volume is a must-read for researchers and practitioners who seek to develop and disseminate affirmative, evidence-based mental health treatments for sexual and gender minority populations.”
Mark
L. Hatzenbuehler, PhD, Associate Professor of Sociomedical Sciences and Sociology, Columbia University
“This up-to-date, comprehensive volume integrates findings from cutting edge empirical research with affirming and nuanced case examples and practical suggestions for culturally responsive clinical work, making it a must-read for all practitioners and educators in the mental health professions. The chapters in this important and timely volume include both population- specific and problemspecific approaches for the diverse and dynamic treatment needs of sexual and gender minority clients in the 21st century.”
Kimberly Balsam, PhD, Clinical Psychology Professor at Palo Alto University and Past President of the American Psychological Association’s Society for the Psychology of Sexual Orientation and Gender Diversity
Handbook of Evidence- Based
Mental Health Practice with Sexual and Gender Minorities
Handbook of Evidence- Based
Mental Health Practice with Sexual and Gender Minorities
EDITED BY
JOHN E. PACHANKIS, PHD AND
STEVEN A. SAFREN, PHD
Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries.
Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America.
All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above.
You must not circulate this work in any other form and you must impose this same condition on any acquirer.
Library of Congress Cataloging-in-Publication Data
Names: Pachankis, John E., editor. | Safren, Steven A., editor.
Title: Handbook of evidence-based mental health practice with sexual and gender minorities / edited by John E. Pachankis, Steven A. Safren.
Description: New York : Oxford University Press, 2019. | Includes bibliographical references and index.
Identifiers: LCCN 2019008911 (print) | LCCN 2019011120 (ebook) | ISBN 9780190669317 (UPDF) | ISBN 9780190669324 (EPUB) | ISBN 9780190669300 (paperback)
Subjects: LCSH: Gays—Mental health services. | Lesbians—Mental health services. | Sexual minorities—Mental health services. | BISAC: PSYCHOLOGY / Clinical Psychology. | SOCIAL SCIENCE / Gender Studies.
LC record available at https://lccn.loc.gov/2019008911
9 8 7 6 5 4 3 2 1
Printed by WebCom, Inc., Canada
CONTENTS
Foreword ix
Joanne Davila and Marvin R. Goldfried
About the Editors xi
Contributors xiii
SECTION I Background
1. Adapting Evidence-Based Practice for Sexual and Gender Minorities: The Current State and Future Promise of Scientific and Affirmative Treatment Approaches 3
John E. Pachankis and Steven A. Safren
SECTION II Evidence-Based Treatments for Specific Sexual and Gender Minority Populations
2. Cognitive–Behavioral Therapy for Sexual and Gender Minority Youth Mental Health 25
Shelley L. Craig, Ashley Austin, and Edward J. Alessi
3. Evidence-Based Approaches for Sexual Health and Substance Use Problems in Sexual and Gender Minority Youth 51
Christopher A. Pepping, W. Kim Halford, and Anthony Lyons
6. Sexual Minority Parent Families: Research and Implications for Parenting Interventions 115
Abbie E. Goldberg, Reihonna L. Frost, and Néstor Noyola
7. Affirmative Mental Health Practice with Bisexual Clients: Evidence-Based Strategies 149
Andrew Young Choi and Tania Israel
SECTION III Evidence-Based Treatments for Specific Mental Health Problems Among Sexual and Gender Minority Clients
8. Anxiety Disorders and Obsessive–Compulsive Disorder: Evidence-Based Considerations for Affirmative Services for Sexual Minority Clients 175
Natalie R. Holt, Allura L. Ralston, and Debra A. Hope
9. Evidence-Based Approaches for Treating Depression Among Sexual and Gender Minority Clients 200
Christopher R. Martell
10. Evidence-Based Alcohol and Substance Use Disorder Treatment with Sexual and Gender Minorities 222
Adam W. Carrico, Walter Gόmez, and Cathy J. Reback
11. Application of Evidence-Based Practices for Trauma-Related Disorders Among Sexual Minority Women 244
Debra Kaysen, Keren Lehavot, and Emily R. Dworkin
12. An Evidence-Based Approach to Conceptualizing Trauma Responses Among Transgender and Gender Nonconforming Adults 268
Jillian C. Shipherd, Sarah E. Valentine, and Julie Woulfe
13. Evidence-Based Practice for the Prevention and Treatment of Body Image Disturbance and Eating Pathology in Sexual Minority Men 291
Aaron J. Blashill, Tiffany A. Brown, and Patrycja Klimek
14. Sexual Health Interventions for HIV-Negative Sexual Minority Men 313
Trevor A. Hart, Julia R. G. Vernon, and Nathan Grant Smith
15. Evidence-Based Approaches to HIV-Positive Sexual Minority Men’s Sexual Health 339
Audrey Harkness and Steven A. Safren
SECTION IV Evidence-Based Treatments for Sexual and Gender Minorities Using Novel Modalities
16. Group-Based Cognitive–Behavioral Therapies with Sexual Minority Clients 361
Jeffrey M. Cohen and Michelle G. Newman
17. Acceptance, Vulnerability, and Compassion: Contextual Behavioral Approaches for Sexual and Gender Minority Clients 381
Matthew D. Skinta, Brandon Hoeflein, and Daniel Ryu
18. Dialectical Behavior Therapy for Borderline Personality Disorder and Suicidality Among Sexual and Gender Minority Individuals 408
David W. Pantalone, Colleen A. Sloan, and Adam Carmel
19. Relationship-Focused Therapy for Sexual and Gender Minority Individuals and Their Parents 430
Gary M. Diamond, Rotem Boruchovitz-Zamir, Inbal Gat, and Ofir Nir-Gottlieb
20. Transdiagnostic Approaches to Improve Sexual Minority Individuals’ Co-occurring Mental, Behavioral, and Sexual Health 457
Craig Rodriguez-Seijas, Charles L. Burton, and John E. Pachankis
Index 477
Within the past three decades, there has been a major change in societal acceptance of lesbian, gay, bisexual, and transgender (LGBT) individuals, and although there clearly continues to exist discrimination and aggression against sexual and gender minorities, the shift has been dramatic. Although a bit late in coming, the shift also exists within the mental health profession. Once labeled as a mental disorder, identifying as LGBT is no longer considered to be pathological. Furthermore, the stress and discrimination that LGBT individuals experience in their lives are now recognized as a key source of the mental health disparities that exist. Research clearly demonstrates that compared to their heterosexual counterparts, LGBT individuals show higher rates of psychopathology, greater impairment due to psychological problems, and, as a result, utilize services at a higher rate.
In the past, mental health professionals contributing to the literature on LGBT issues needed to do so at their own professional risk. Indeed, we know of one such researcher who was closeted in his personal and professional life and kept a separate curriculum vitae that included his research on gay issues. This clearly no longer needs to be the case, and we indeed now have a new generation of researchers—not all of whom identify as LGBT—who are openly dedicated to our improved understanding of sexual and gender minorities and the development of more effective therapy interventions.
Another change within the profession is the fact that past writings on LGBT issues were typically written for other professionals who had an interest in learning more about what it is to be a sexual or gender minority. Consequently, the literature on LGBT issues typically appeared in specific journals dedicated to that topic and was ignored within mainstream psychology. For example, textbooks on human development typically said nothing about the identity issues that sexual minorities had to deal with while growing up. Thus, although LGBT professionals were telling, mainstream psychology was not listening.
A vivid example of this is an experience we had some years ago when conducting a panel on LGBT issues, in which four participants gave presentations. What was striking about this presentation was that there were fewer members in the audience than there were panelists. This has clearly changed over the years. Panels
on LGBT issues are common and well-attended at mainstream conferences. Mainstream journals, including the premier journals in clinical psychology, regularly publish work of relevance to sexual and gender minority issues, and mental health professionals have recognized that there is much to be learned from studying sexual and gender minorities. For example, one prominent researcher studying partner abuse changed her feminist conceptualization of abuse after reading the literature on partner abuse in same-sex couples.
Given the long-standing history of paying little attention to LGBT issues, therapists have typically not received the kind of clinical training that prepared them for working with LGBT individuals. Fortunately, there is now a new generation of researchers and clinicians dedicated to learning more about how to work with sexual and gender minority clients. This is critically important. Despite the progress that has been made in the United States in terms of acceptance of LGBT individuals and their rights, LGBT individuals remain at high risk for discrimination, violence, and resulting mental health problems, and they are greatly in need of culturally sensitive and affirming interventions. This book was designed to serve as a guide for such intervention.
This volume contains the work of a new generation of clinical scientists who are dedicated to developing and providing the most effective treatments designed to address the unique needs of sexual and gender minority individuals. Importantly, it focuses on evidence-based practice, making use of all available research evidence and clinical observations to guide effective clinical intervention. Furthermore, the contributions do not assume that all LGBT individuals or issues should be treated the same. The term “LGBT” implies the commonalities that everyone included under that umbrella shares, but it would be a grave mistake, particularly from a clinical perspective, to not recognize within-group differences. As such, the chapters reflect the specific issues facing, for example, transgender individuals, LGBT youth, LGBT older adults, couples, parents, HIV-negative men, and HIV-positive men. Although the chapters deal with the most common clinical problems experienced by sexual and gender minority individuals, they also move the field well past the stage of how to work with LGBT clients in general to how to work with LGBT clients on the specific issues they have and symptoms they are experiencing. In addition, the book provides not just one option for clinicians with regard to type of treatment but, rather, a range of options that can allow providers to select what might be most appropriate for their specific client and for their own strengths in how they work clinically.
With the publication of this volume, gone are the days when therapists could say that they do not know how to work with sexual and gender minority issues or clients. This book can and should serve as a key resource in training the next generation of diversity-competent professionals who can effectively work with LGBT clients.
Joanne Davila, PhD
Marvin R. Goldfried, PhD Stony Brook University
ABOUT THE EDITORS
John E. Pachankis, PhD, is Associate Professor at the Yale School of Public Health and the Director of the Esteem Research Group in New York City. He received his PhD in clinical psychology in 2008 from the State University of New York at Stony Brook and completed his clinical psychology internship at Harvard Medical School/McLean Hospital. His research seeks to bring evidence-based mental health interventions to LGBTQ people in the United States and throughout the world. With National Institutes of Health funding, he examines the efficacy of LGBTQaffirmative interventions delivered via novel technologies (e.g., smartphones), in diverse settings (e.g., Eastern Europe and Appalachia), and with diverse segments of the LGBTQ community (e.g., rural youth, queer women). He has published widely (more than 90 publications) in the areas of stigma, LGBTQ mental health, and psychosocial mechanisms linking stigma to mental health. This work appears in journals such as Psychological Bulletin, Developmental Psychology, Journal of Consulting and Clinical Psychology, and Health Psychology. His research has had national and international scholarly, legal, and popular impact, having been referenced in national professional guidelines for LGBTQ mental health practice; cited in numerous amici curiae briefs before US state and federal courts, including the US Supreme Court; and featured in national and international media outlets.
Steven A. Safren, PhD, is Professor of Psychology at the University of Miami; Co-Director of the Miami Center for AIDS Research (CFAR) at the University of Miami, Behavioral/Social Sciences and Community Outreach Core; and an expert on working with sexual and gender minorities, as well as on health-related behavior change. He earned his PhD from the State University of New York at Albany and did his internship and postdoctoral fellowship at Massachusetts General Hospital (MGH)/Harvard Medical School. Before moving to the University of Miami in August 2015, he was the founding director of the current MGH Behavioral Medicine Service at Massachusetts General Hospital and of the Harvard University Behavioral and Social Science Core for the Harvard University CFAR. In addition, for more than 15 years, he led behavioral science research projects at the Fenway Institute at Fenway Health in Boston, one of the nation’s largest health centers for sexual and gender minorities. He has been
principal investigator (PI) or protocol chair of 15 National Institutes of Healthfunded grants and has authored more than 300 peer-reviewed publications in his professional areas of interest. In addition to studies in which he has served as PI, he has regularly served as co-PI or mentor on studies related to sexual and gender minority health, HIV prevention and treatment, work with other medical illnesses, and on cognitive–behavioral approaches to managing adult and adolescent attention-deficit/hyperactivity disorder (ADHD). He has co-authored books on cognitive–behavioral therapy (CBT) with LGBT individuals and integrating CBT with motivational interviewing, and he is editor of a book on behavioral medicine interventions across various illnesses. He has co-authored two sets of published treatment manuals on CBT for treating depression and adherence in chronic illness and on treating adult ADHD, respectively. He is currently the Publications Coordinator for ABCT and Associate Editor for the Journal of Consulting and Clinical Psychology. He has also served as Editor and Associate Editor for ABCT’s clinical journal, Cognitive and Behavioral Practice
Edward J. Alessi
Associate Professor School of Social Work
Rutgers University
New Brunswick, New Jersey
Ashley Austin
Associate Professor School of Social Work
Barry University
Miami Shores, Florida
Aaron J. Blashill
Assistant Professor
Department of Psychology
San Diego State University
San Diego, California
Rotem Boruchovitz-Zamir
PhD Candidate
Department of Psychology
Ben-Gurion University
Be’er-Sheva, Israel
Tiffany A. Brown
Postdoctoral Fellow
Department of Psychiatry
University of California, San Diego
San Diego, California
CONTRIBUTORS
Charles L. Burton
Associate Research Scientiest Department of Social and Behavioral Sciences
School of Public Health
Yale University
New Haven, Connecticut
Adam Carmel
Clinical Assistant Professor Department of Psychology University of Washington Seattle, Washington
Adam W. Carrico
Associate Professor Department of Public Health Sciences University of Miami Miami, Florida
Andrew Young Choi
Doctoral Candidate
Department of Counseling, Clinical, and School Psychology
Gevirtz Graduate School of Education
University of California, Santa Barbara
Santa Barbara, California
Jeffrey M. Cohen
Clinical Instructor of Psychology (in Psychiatry)
Department of Psychiatry
Columbia University Medical Center
New York, New York
Shelley L. Craig
Associate Professor
Factor-Inwentash Faculty of Social Work
University of Toronto Toronto, Ontario, Canada
Joanne Davila
Professor of Clinical Psychology Department of Psychology
Stony Brook University
Stony Brook, New York
Gary M. Diamond Professor
Department of Psychology
Ben-Gurion University
Be’er-Sheva, Israel
Emily R. Dworkin
Postdoctoral Fellow
Department of Psychiatry and Behavioral Sciences University of Washington Seattle, Washington
Brian A. Feinstein
Research Assistant Professor Institute for Sexual and Gender Minority Health and Wellbeing
Northwestern University Chicago, Illinois
Reihonna L. Frost
Doctoral Student Department of Psychology
Clark University
Worcester, Massachusetts
Inbal Gat
PhD Candidate
Department of Psychology
Ben-Gurion University
Be’er-Sheva, Israel
Abbie E. Goldberg
Associate Professor
Department of Psychology
Clark University
Marvin R. Goldfried Professor of Clinical Psychology
Department of Psychology
Stony Brook University
Stony Brook, New York
Walter Gόmez
Doctoral Student
School of Social Welfare University of California, Berkeley Berkeley, California
W. Kim Halford
Professor of Clinical Psychology School of Psychology University of Queensland Brisbane, Australia
Audrey Harkness
Postdoctoral Fellow
Department of Psychology University of Miami Miami, Florida
Trevor A. Hart Professor Department of Psychology
Ryerson University Toronto, Ontario, Canada
Brandon Hoeflein
PhD Candidate
Department of Psychology
Pacific Graduate School of Psychology
Palo Alto University Palo Alto, California
Natalie R. Holt
Doctoral Student Department of Psychology University of Nebraska–Lincoln Lincoln, Nebraska
Debra A. Hope Professor
Department of Psychology University of Nebraska–Lincoln Lincoln, Nebraska
Tania Israel Professor
Department of Counseling, Clinical, and School Psychology
Gevirtz Graduate School of Education
University of California, Santa Barbara
Santa Barbara, California
Debra Kaysen Professor
Department of Psychiatry & Behavioral Sciences School of Medicine University of Washington Seattle, Washington
Patrycja Klimek Doctoral Student Department of Psychology
San Diego State University/University of California, San Diego Joint Doctoral Program in Clinical Psychology
San Diego, California
Keren Lehavot Investigator
Denver–Seattle Center of Innovation for Veteran-Centered and Value-Driven Care
Health Services Research & Development
VA Puget Sound Health Care System
Seattle, Washington
Anthony Lyons
Associate Professor
Australian Research Centre in Sex, Health, and Society
La Trobe University
Melbourne, Australia
Christopher R. Martell
Director and Lecturer
Psychological Services Center Department of Psychological and Brain Sciences
University of Massachusetts
Michael E. Newcomb
Assistant Professor Institute for Sexual and Gender Minority Health and Wellbeing
Northwestern University Chicago, Illinois
Michelle G. Newman Professor of Psychology and Psychiatry Department of Psychology The Pennsylvania State University University Park, Pennsylvania
Ofir Nir-Gottlieb PhD Candidate Department of Psychology
Ben-Gurion University Be’er-Sheva, Israel
Néstor Noyola Doctoral Student Department of Psychology Clark University Worcester, Massachusetts
David W. Pantalone Associate Professor Department of Psychology University of Massachusetts Boston, Massachusetts
Christopher A. Pepping Lecturer in Clinical Psychology Department of Psychology & Counselling School of Psychology & Public Health La Trobe University Melbourne, Australia
Allura L. Ralston Doctoral Student Department of Psychology University of Nebraska–Lincoln Lincoln, Nebraska
Cathy J. Reback
Core Director
Center for HIV Identification, Prevention and Treatment Services
Craig Rodriguez-Seijas
Doctoral Candidate
Department of Psychology
Stony Brook University
Stony Brook, New York
Daniel Ryu
PsyD Candidate
Department of Psychiatry
PGSP-Stanford Psy.D. Consortium
Palo Alto University
Palo Alto, California
Jillian C. Shipherd
Director
Lesbian, Gay, Bisexual, and Transgender (LGBT) Health Program
Veterans Health Administration
Washington, DC
Clinical Research Psychologist
National Center for PTSD
VA Boston Healthcare System
Boston, Massachusetts
Matthew D. Skinta
Clinical Faculty
Department of Psychology
Pacific Graduate School of Psychology
Palo Alto University
Palo Alto, California
Colleen A. Sloan Assistant Professor Department of Psychiatry
Boston University School of Medicine
Boston, Massachusetts
Nathan Grant Smith
Associate Professor
Department of Psychological, Health, and Learning Sciences College of Education University of Houston Houston, Texas
Sarah E. Valentine Assistant Professor of Psychiatry
Department of Psychiatry Boston University School of Medicine Boston, Massachusetts
Julia R. G. Vernon Graduate Student Department of Psychology Ryerson University Toronto, Ontario, Canada
Julie Woulfe
Attending Psychologist
Department of Psychiatry and Behavioral Sciences Montefiore Medical Center
The University Hospital for Albert Einstein College of Medicine Bronx, New York
Adapting Evidence- Based Practice for Sexual and Gender Minorities
The Current State and Future Promise of Scientific and Affirmative Treatment Approaches
JOHN E. PACHANKIS AND STEVEN A. SAFREN
Today represents the first time in history that a critical mass of empirical evidence exists regarding suitable treatment goals and delivery methods for sexual and gender minority (SGM)-affirmative mental health practice. Taking advantage of this unprecedented situation, this handbook compiles the strongest examples of evidence-based SGM-affirmative practice to guide clinicians and researchers in considering ways in which SGM individuals’ unique presenting concerns might be affirmatively addressed using evidence-based techniques. As an introduction to this handbook, this chapter first reviews the historical application of science to SGM mental health, current barriers toward evidence-based mental health treatments for SGM, and the recent progress to overcome these barriers as showcased throughout this handbook. The chapter reviews pressing questions and potential solutions regarding evidence-based SGM-affirmative practice, including why existing evidence-based treatments need to be adapted to address SGM-specific concerns, how existing evidence-based treatments can be adapted to address these concerns, and how clinical wisdom of expert mental health providers can serve to guide the adaptation of existing evidence-based treatments to facilitate their ability to affirm SGM as they improve SGM mental health.
Across its history, the mental health profession has used science to both harm and help the mental health of SGM (Drescher, Shidlo, & Schroeder, 2002; Haldeman, 1994). Throughout the first half of the 20th century, the mental health profession used its scientific authority to perpetuate societal stigma toward SGM individuals. Specifically, during this time, the profession peddled oppressive diagnoses and psychologically and physically harmful treatments to ensure that homosexuality remained the illness that society assumed it was. Science, in this case, was used to subjugate an already vulnerable population. Following years of advocacy, in 1973, the profession made the landmark decision that homosexuality was no longer a mental illness and gradually shifted toward a more affirmative treatment approach that empowered, rather than further imprisoned, this vulnerable population (Krajeski, 1996). Although today’s affirmative treatments no doubt represent a surer route to mental health than the unethical and harmful conversion therapies of the past (and today), scientific guidance for how such treatments should be developed and delivered has lagged. As described in the following section, several barriers have historically impeded scientific progress toward SGM-affirmative practice, which are currently being challenged to pave a more promising path forward.
BARRIERS AND PROGRESS TOWARD EVIDENCE- BASED SGM- AFFIRMATIVE PRACTICE
Despite clear professional, ethical, and scientific justifications for bringing a greater evidence base to SGM-affirmative practice, several barriers have impeded this goal (Pachankis, in press). Here, four such barriers are reviewed: (1) a lack of clear treatment targets; (2) a lack of treatment studies specific to SGM mental health; (3) failure to report SGM status in existing treatment studies; and (4) stigma itself, which perpetuates the lack of necessary resources to ultimately overcome the aforementioned barriers.
Lack of Clear Treatment Mechanisms
Only in the past two decades has the mental health field possessed accurate knowledge regarding the disparity in the prevalence of mental health problems that exists between sexual minority and heterosexual populations (Cochran & Mays, 2000a, 2000b; Gilman et al., 2001; King et al., 2008; Sandfort, de Graaf, Bijl, & Schnabel, 2001). Population-based data regarding gender minorities have only recently begun to emerge (Bränström & Pachankis, 2018). As this knowledge has emerged, researchers have used methodologically rigorous approaches to show that the root of this substantial disparity lies in SGM disproportionate exposure to stigma-related stress. Specifically, using population-based studies (Mays
& Cochran, 2001), interviewer-based assessments (Meyer, Schwartz, & Frost, 2008), experimental designs (Bosson, Haymovitz, & Pinel, 2004), and measures of exposure to structural stigma (e.g., discriminatory policy environments; Hatzenbuehler, Keyes, & Hasin, 2009), accumulating research has shown that stigma exposure explains SGM individuals’ consistently elevated prevalence of stress-sensitive mental health problems (e.g., depression, anxiety, and substance use disorder).
Although this research points to the elimination of stigma as the surest route to reducing mental health disparities affecting SGM, stigma, through its persistent mechanisms and lasting effects, is not easy to change (Hatzenbuehler, Phelan, & Link, 2013). Furthermore, although the advocacy of mental health professionals can certainly play an important role in reducing stigma (Drescher, 2012, 2015), such advocacy does not always represent the most immediately relevant goal in clinical contexts. Without knowing the modifiable psychosocial mechanisms through which stigma compromises SGM mental health, until recently the field has been without clear, evidence-based treatment mechanisms for SGM clients who present for mental health services. Therefore, identifying the psychological mechanisms through which stigma operates to impair mental health has become a paramount goal for clinical researchers attempting to bring a greater evidence base to SGM mental health treatment.
Consistent with clinical recommendations spanning several decades (Hetrick & Martin, 1987; Malyon, 1982; Perez, DeBord, & Bieschke, 2000; Savin-Williams & Rodriguez, 1993), an emerging body of research has sought to determine the psychological pathways that are driven by stigma; that cause mental health problems; and that, because they are psychological in nature, can be modified with psychological treatments (Hatzenbuehler, 2009; Meyer, 2003). These pathways include psychological processes that are both specific to SGM, such as internalized homophobia (Newcomb & Mustanski, 2010), rejection sensitivity (Pachankis, Goldfried, & Ramrattan, 2008), and sexual identity concealment (Pachankis, 2007), and also universal risk factors for psychopathology that are elevated among SGM compared to heterosexuals, including social isolation (Safren & Heimberg, 1999), emotion dysregulation (Hatzenbuehler, McLaughlin, & Nolen-Hoeksema, 2008), and behavioral unassertiveness (Pachankis et al., 2008). Because these pathways are cognitive, affective, and behavioral, they lend themselves to being addressed through existing cognitive–behavioral (Fairburn et al., 2009; Farchione et al., 2012), emotion-focused (Elliott, Watson, Goldman, & Greenberg, 2004), and other evidence-based approaches (Diamond et al., 2010). Many chapters contained in this handbook illustrate the adaptation of these existing treatment approaches to address the minority stress treatment mechanisms reviewed here.
Lack of Treatment Studies Specific to SGM Mental Health
One paradoxical outcome of the HIV/AIDS crisis of the 1980s and 1990s was greater research attention to the health of SGM communities. This research
illustrated not only that sexual minority men and transgender women are at vastly disproportionate risk of HIV infection compared to heterosexual and cisgender individuals but also that their greater risk for HIV co-occurs with other health disparities to synergistically exacerbate this risk (Stall et al., 2003). In particular, this research showed that mental health problems represent a prominent concern in the lives of many, if not most, SGM populations, that both co-occur with HIV risk, and also stand on their own to compromise SGM health (D’Augelli, 1989; Garnets, Herek, & Levy, 1990; McKirnan & Peterson, 1988; Meyer, 1995).
This era of research also ushered in the first randomized controlled trials of psychosocial treatments applied to SGM. This first set of treatment studies focused on stress coping and HIV risk reduction among gay and bisexual men (Antoni et al., 2000; Lutgendorf et al., 1998). Still to this day, nearly every randomized controlled trial conducted with SGM has been limited to the context of HIV prevention and care among sexual minority men (Mustanski et al., 2017; Parsons, Lelutiu-Weinberger, Botsko, & Golub, 2014; Safren et al., 2009). Although such studies provide invaluable evidence-based guidance to practicing clinicians regarding the sexual health needs of SGM populations, they typically address mental health only as one of several determinants of HIV-related behavioral health (e.g., medication adherence, condom usage) and have been limited to sexual minority men.
Despite the historic lack of randomized controlled trial data for SGM, several notable attempts have nonetheless been made to incorporate professional recommendations for SGM- affirmative practice into evidence- based practice (American Psychological Association, 2017). In general, these attempts have been in the form of either (1) clinical suggestions for applying observational research regarding SGM mental health in practice (Brown, 1988; Davies, 1996; Martell, Safren, & Prince, 2003; Ritter & Terndrup, 2002) or (2) clinical case studies incorporating SGM- affirmative principles into existing evidencebased approaches (Glassgold, 2009; Kaysen, Lostutter, & Goines, 2005; Safren & Rogers, 2001; Walsh & Hope, 2010). This first source of SGM- affirmative treatment guidance draws upon research regarding common developmental experiences of SGM individuals to increase therapists’ awareness of these experiences and help SGM clients adapt to the stressors typical of each stage. This guidance also draws upon consumer report studies of treatmentseeking SGM to guide therapists toward gaining SGM-specific knowledge and avoiding heterocentric assumptions about their SGM clients, which SGM clients consistently specify as critical therapeutic requirements (Burckell & Goldfried, 2006).
Several existing SGM-specific case studies have described the application of cognitive–behavioral treatments to SGM clients. That so many case studies of SGM-affirmative evidence-based practice describe the application of cognitive–behavioral therapy is not surprising given the natural fit between minority stress conceptualizations of SGM mental health and the stress-coping orientation of
cognitive–behavioral interventions (Balsam, Martell, & Safren, 2006). These case studies report helping SGM clients challenge negative attitudes about themselves and SGM peers, weigh the objective risks and benefits of sexual orientation disclosure, identify a supportive niche within the SGM community, and understand current symptomatology against a backdrop of societal homophobia. The chapters in this handbook draw upon, and extend, the best of both of these traditions to suggest strategies for merging this clinical wisdom into current evidence-based mental health practice.
Failure to Report SGM Status in Existing Treatment Studies
Although nearly every randomized controlled trial conducted with the general population includes SGM individuals by virtue of the random and diffuse distribution of SGM individuals in the general population, hardly any randomized controlled trials report the SGM status of their samples and none has stratified results by SGM status (Heck, Mirabito, LeMaire, Livingston, & Flentje, 2017). Thus, despite having the potential to relatively easily provide much-needed information regarding the efficacy of existing evidence-based practices for SGM individuals, this opportunity is currently lost. This pervasive tendency has left unanswered the question of whether SGM individuals experience comparable benefit to heterosexuals from existing evidence-based practice.
Nonetheless, a few recent studies, mostly conducted in naturalistic treatment settings, have examined whether SGM respond similarly or differently to treatment, with mixed results. For instance, in a hospital-based sample, SGM patients were found to experience equal treatment outcomes compared to heterosexual patients after participating in a general cognitive and dialectical behavioral treatment program, although subgroup analyses found that bisexual patients reported more thoughts related to self-injury and suicide and worse perceptions of care compared to other patients (Beard et al., 2017). In a large sample of students who sought therapy at college counseling centers throughout the United States, sexual minorities presented with greater depressive and anxious symptoms compared to heterosexuals but did not exhibit different treatment outcomes (Lefevor, Janis, & Park, 2017). In one of the few randomized controlled trials to examine treatment efficacy according to sexual orientation, homeless sexual minority adolescents experienced greater reductions in internalizing symptoms and drug use compared to homeless heterosexual adolescents after receiving a cognitive–behavioral substance use treatment (Grafsky, Letcher, Slesnick, & Serovich, 2011). Overall, these studies do not paint a definitive picture regarding the efficacy of existing treatments for SGM or answer the question of whether SGM-specific adaptations to existing evidence-based practice might be required. Notably, no studies have examined diverse gender identities as moderators or treatment efficacy.
Stigma as a Barrier to Evidence-Based Mental Health Practice with SGM
No doubt, stigma itself represents a fundamental obstacle to building a greater evidence base for SGM-affirmative mental health treatment (Pachankis, in press). Because stigma keeps marginalized groups away from the necessary power, resources, and social conditions necessary for creating more equitable social conditions (Bränström, Hatzenbuehler, Pachankis, & Link, 2016), it is not surprising that stigma would also interfere with the necessary conditions for generating accurate knowledge about mental health treatments for SGM. For instance, although SGM have been a visible and vibrant segment of the US population for decades and although a critical body of research has suggested that SGM experience substantial mental health disparities, among the largest in all of psychiatric epidemiology, and that these disparities are due to stigma-related stress, hardly any SGM-affirmative mental health treatment approaches have ever been tested for efficacy with SGM individuals (Chaudoir, Wang, & Pachankis, 2017).
Outside of HIV/AIDS-related research, which itself initially required dramatic acts of protest to receive adequate attention and funding resources (Epstein, 1996), SGM health has simply not received resources commensurate with the size of the problem. In fact, three-fourths of the National Institutes of Health’s portfolio for SGM health research is allocated to HIV/AIDS research, typically among gay and bisexual men, despite the fact that mental health problems, especially suicide, have likely surpassed HIV/AIDS as the leading cause of premature mortality among SGM (Hottes, Ferlatte, & Gesink, 2015). Although HIV/AIDS research pertaining to SGM certainly merits funding resources given the disproportionate impact of HIV/AIDS on gay and bisexual men and transgender women in the United States and in many world regions, to rely on this research for knowledge about SGM mental health likely overestimates risk and overlooks the distinct concerns of sexual minority women and gender diverse individuals.
Another way that stigma interferes with accurate evidence regarding SGM mental health is through diminished academic power. Until recently, with a few courageous exceptions, it was nearly impossible to stake an academic career on studying SGM mental health given the reality of professional homophobia. Therefore, despite the fact that SGM seek mental health services at significantly higher rates than the general population (Cochran, Björkenstam, & Mays, 2017), mental health training programs often lacked sufficient coverage of SGM-relevant topics, thereby perpetuating a lack of SGM-specific treatment knowledge across successive generations of mental health trainees. Today represents the first time in history that mental health trainees can seek training in SGM-specific training with the goal of making SGM mental health a core focus of their careers. The following chapters of this handbook, in fact, suggest ambitious programs of SGM treatment research that could easily require many entire careers to pursue. Fortunately, the field now possesses a critical mass of scholars with just such goals.
DO EXISTING EVIDENCE- BASED TREATMENTS NEED TO BE ADAPTED TO ADDRESS SGM- SPECIFIC CONCERNS?
The mental health professions aspire to deliver both SGM-affirmative treatments and evidence-based treatments as a matter of ethical and professional practice (American Psychological Association, 2012; APA Presidential Task Force on Evidence-Based Practice, 2006). These aspirations suggest that evidence-based practice should be delivered to SGM in a way that is SGM affirmative and that SGM-affirmative practice should be tested for empirical support. In terms of progress toward these goals, although existing research and clinical recommendations strongly encourage clinicians to employ an SGM-affirmative stance when delivering all treatments, including evidence-based treatments, only one SGMaffirmative mental health treatment has been tested for efficacy in a randomized controlled trial (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015).
A distinct but equally pressing question is whether existing evidence-based mental health treatments need to be adapted that is, changed from their current form—to address the specific concerns that SGM might bring to treatment (Johnson, 2012). Here, we review evidence for and against this possible need. On the one hand, emerging empirical findings and practical considerations suggest that SGM-specific adaptations to existing practice might not be required. First, SGM mental health disparities have been found to be driven by universal psychosocial risk factors (Hatzenbuehler, 2009), suggesting that existing evidence-based treatments that address these risk factors should be helpful for SGM clients without adaptation. In fact, as reviewed previously, the few studies that have examined differential efficacy of existing mental health treatments according to sexual orientation have found that, with the exception of hospital-based treatment for bisexuals, sexual minorities seem to benefit just as much, if not more than, heterosexuals from existing practice (Beard et al., 2017; Grafsky et al., 2011; Lefevor et al., 2017). Furthermore, rather than SGM experiencing barriers to engagement in existing treatments, population-based research suggests that sexual minorities are actually more likely to engage in existing treatments, even after accounting for their greater burden of mental health problems (Cochran et al., 2017). One might additionally argue that whether novel SGM-specific adaptations of evidence-based treatments are needed should be weighed against the prodigious outlay of resources required to develop and test new interventions. Indeed, if every population subgroup were to require its own treatment approach, the field would be in the untenable position of having to create thousands of distinct treatments (Kazdin, 2000). Therefore, novel adaptations to evidence-based practice might only be required when a given population experiences unique mechanisms underlying their mental health disparities or when that population does not benefit from existing practice (National Institute of Mental Health, 2010). Whether SGM mental health needs rise to this threshold remains to be determined.
On the other hand, the case for creating novel, SGM-specific adaptations of evidence-based treatments can be considered on ethical grounds (Pachankis, in press). SGM individuals seek mental health services at higher rates than do heterosexuals, in some cases even after accounting for their greater burden of mental health problems (Cochran et al., 2017). Creating novel adaptations of evidence-based treatments for such frequent consumers of mental health services would be an important reparation for the field’s historic perpetuation of psychologically, and sometimes physically, harmful treatments. Indeed, for much of its early history in the United States, the mental health profession, rather than seeking a scientific base for empowering SGM, proffered unscientific, homophobic treatments that further harmed this already vulnerable population (Pachankis, in press). Indeed, only 10 US states and the District of Columbia currently ban sexual orientation conversion therapy, and Vice President Mike Pence is an avowed supporter of the practice (Stack, 2016). Throughout the world, only two countries have legal sanctions against conversion therapy, and outright abuse abounds at the hands of the mental health profession (International Lesbian, Gay, Bisexual, Trans, and Intersex Association, 2017). In China, for instance, which has one of the world’s largest populations of SGM given its overall population size, one study found that 36% of mental health professionals support conversion therapy and 14% report practicing it (Beijing LGBT Center, 2014). Therefore, ethical reasons might compel the field to create novel adaptations of evidencebased treatments for SGM. It is simply morally inexcusable that Western societies have been more successful at disseminating abusive conversion therapies than evidence-based alternatives for SGM people.
The case for creating novel SGM-specific evidence-based treatments can also be considered on professional grounds. Several professional mental health associations throughout the world have adopted SGM-affirmative practice guidelines to promote appropriate treatment of SGM populations (American Psychological Association, 2017). According to these guidelines, SGM-affirmative treatment requires that therapists treating SGM possess awareness of the unique stressors facing this population; avoid homophobia and heterocentric assumptions; and become familiar with SGM developmental experiences, families, communities, and relationship norms (American Psychological Association, 2012). Yet, the field currently lacks an evidence base for translating these principles into evidencebased practice. To the extent that novel adaptations of existing evidence-based practice could incorporate concrete clinical strategies for implementing these SGM-affirmative clinical recommendations, the field will facilitate the implementation of its professional mandate. Another professional reason for creating treatments that address SGM-specific concerns is that treatment studies are themselves experiments and can provide needed knowledge regarding the impact of stigma and its alleviation on SGM mental health.
Overall, although empirical findings and practical realities suggest that the field must carefully justify the creation of novel SGM-specific adaptations to existing evidence-based practice, for ethical and professional reasons, such adaptations should at least be explored more than they have been to date. Importantly, this
consideration does not speak to the need to deliver SGM-affirmative evidencebased care; as noted previously, such care represents an obvious practice requirement, as specified in professional guidelines. Instead, this discussion is intended to outline reasons that SGM might benefit from existing, non-adapted practice even as they might additionally benefit from SGM-specific adaptations to current practice. Regardless of whether or not the field decides that SGM-specific adaptations are justified, there is reason for optimism that the field’s trajectory away from unscientific, harmful approaches toward SGM-affirmative evidencebased practice will continue.
HOW SHOULD EXISTING EVIDENCE- BASED TREATMENTS BE ADAPTED TO ADDRESS SGM- SPECIFIC CONCERNS?
Assuming that future research and ethical and professional considerations determine that existing evidence-based practice as applied to SGM clients can be made more effective by addressing SGM-specific presenting concerns, a key question becomes how SGM-specific adaptations to these treatments should best be made. Two potential options for addressing SGM-specific concerns in evidencebased practice are creating altogether novel approaches for SGM individuals and adapting existing evidence-based practice to address SMG-specific presenting concerns. Notably, all of the approaches described in this handbook represent adaptations of existing evidence-based approaches that make them responsive to SGM-specific presenting concerns. That no treatments described herein represent brand new treatment approaches created specifically for SGM likely reflects the fact that existing evidence-based approaches are relatively seamlessly consistent with minority stress conceptualizations of SGM mental health, given that both minority stress theory and evidence-based practice focus on modifiable cognitive, affective, and behavioral stress pathways, as noted previously. Thus, assuming that brand new treatments are not required for SGM, the question becomes how to best adapt existing treatments for this population.
The cultural adaptation literature, which typically addresses how to adapt mental health treatments for racial and ethnic minorities (Bernal, JiménezChafey, & Domenech Rodríguez, 2009; Hall, 2001; Lau, 2006), has been relatively silent on how to adapt mental health treatments for SGM. Nonetheless, this literature suggests that cultural adaptations of evidence-based practice must strike a balance between preserving fidelity to the original intervention given that its efficacy rests in science and sensitively attending to unique presenting features of culturally diverse clients. This literature also suggests that adaptation attempts consider whether adaptations should focus on addressing barriers to engagement in existing evidence-based treatments or on how existing treatments can accommodate the unique context surrounding the presenting concerns of diverse populations (Lau, 2006). Given that no evidence suggests the existence of barriers to sexual minorities’ engagement in treatment and, in fact, that sexual
