Insights into LGBTQ+ Mental Health

There are several texts that I would recommend for persons interested in developing their expertise in working with LGBTQ+ clients. The list below is not exhaustive, but they are texts that I have found helpful.

Referrals for LGBTQ+ specialists are slightly more tricky. While many people might say they have expertise with LGBTQ+ issues, there isn’t necessarily an easy way to know the extent of their training. Still, many providers will highlight their comfort working with LGBTQ+ folks on their public-facing profiles (for example, on Psychology Today or Zencare). This might be the easiest way to find an affirming therapist. There is also the National Queer and Trans Therapists of Color Network which might be useful.

Helpful texts:

1. The Handbook of Evidence-Based Mental Health Practice with Sexual and Gender Minorities edited by John Pachankis and Steve Safren

2. Transdiagnostic LGBTQ-Affirmative Cognitive Behavioral Therapy: Therapist Guide (with accompanying client workbook) by John Pachankis, Audrey Harkness, Skyler Jackson and Steven Safren

3. Contextual Behavior Therapy for Sexual and Gender Minority Clients: A Practical Guide to Treatment by Matthew Skinta

4. Affirmative Counseling for Transgender and Gender Diverse Clients by Lore Dickey and Jae Puckett

5. The Queer Mental Health Workbook by Brendan Dunlop

The most important thing to appreciate when working with LGBTQ+ individuals is the sometimes insidious ways that stigma impacts LGBTQ+ individuals’ lives. I have not participated in specific training other than that provided by mentors in graduate school (several of whom are authors of the recommended books). However, we received some funding to develop a more comprehensive training program for our graduate students at the University of Michigan in LGBTQ+-affirming psychotherapy from the Society for a Science of Clinical Psychology. I hope we will be able to offer the training to mental health professionals more widely once we complete the development of the program.

A big part is the importance of validation. I have mainly worked with sexual minority men in my own work. While there are similarities in the ways that stigma compromises sexual and gender minority individuals’ health, there are certainly also important specifics. However, a general approach would be to validate and help LGBTQ+ individuals with whom you are working to process the emotions that come up in the face of stigma.

While it might be possible in some instances to act in ways to counteract experienced stigma, there are times when acting against stigma is not always possible for every client based on their circumstances. An important part is recognizing this fact as a therapist and normalizing for clients for whom it is appropriate that failure to combat stigma is not a blemish or personal failing on their part.

For more specific information when working with transgender and gender-diverse clients, check out Affirmative Counseling for Transgender and Gender Diverse Clients by Lore Dickey and Jae Puckett.

When we say that minority stress has a transdiagnostic effect, we mean that it is related to core underlying processes that span myriad psychiatric disorder diagnoses. Indeed, the research shows that minority stress processes are associated with multiple psychiatric disorders and with the underlying factors that relate disorders to one another.

There is a comprehensive intervention that was based on the Unified Protocol that has recently been published which specifically adopts a minority stress-focused lens in the transdiagnostic treatment of psychosocial problems among sexual minority individuals:

Transdiagnostic LGBTQ-Affirmative Cognitive Behavioral Therapy: Therapist Guide (with accompanying client workbook) by John Pachankis, Audrey Harkness, Skyler Jackson and Steven Safren

Like any diagnosis, Borderline Personality Disorder (BPD) can be helpful for some individuals. The diagnosis might provide someone with a way to understand the difficulties they have been experiencing. On the other hand, individuals with a BPD diagnosis face stigma from general society and healthcare providers.

Given the populations I tend to work with and study, I prefer to think about structural and social processes (such as stigma and discrimination) that help me understand an individual’s presenting concerns rather than the diagnosis for which they meet criteria exclusively. Even in cases where we think a BPD diagnosis is warranted, my colleagues (Brooke Rogers and Shayan Asadi) and I have pointed out the importance of framing the diagnosis in relation to stigma experiences that LGBTQ+ individuals face. In our article, referenced below, we discuss how the general conceptualization of a personality disorder might not align with ways of understanding LGBTQ+ mental health.

In this specific sense, BPD illustrates that a failure to understand the negative impact of stigma and environmental stress on LGBTQ+ individuals can result in assumptions that might not always be appropriate for the clients at hand. We might think of BPD or other forms of psychiatric malaise as resulting from some internal processes or a failure to develop a normal personality. However, if we understand the context in which LGBTQ+ individuals exist, it may be possible to view BPD and psychosocial difficulties as related to chronic and inescapable stigma.

More information is available at the following link:

https://doi.org/10.1037/per0000600

This is a question that we are still trying to figure out in my lab. One possible explanation is bias from healthcare providers to interpret behaviors exhibited by LGBTQ+ individuals through a Borderline Personality Disorder (BPD) lens. Another possibility is that the effects of stigma in LGBTQ+ individuals’ lives result in their exhibiting behaviors that correspond with the BPD diagnosis.

From some of the work that we have done, we see that BPD is often diagnosed comorbid with PTSD. Indeed, LGBTQ+ individuals are more likely to experience traumatic events than their cisgender heterosexual counterparts. Whether it is misdiagnosis, clinician bias, higher BPD due to LGBTQ-specific stigma, or a confluence of these and other factors I cannot say at this time. However, this is something we are actively working to disentangle.

I don’t think it is inappropriate for someone to ask a potential therapist about their theoretical orientation or what experiences/training they have in working with LGBTQ+ people and people from other marginalized backgrounds.

Finding the therapist that works for you does involve comparison shopping at times. However, feeling challenged by a therapist does not make it a bad therapist interaction. Indeed, psychotherapy is often uncomfortable and involves confronting difficult processes.

Avoidance is one of the most common things we see clinically and can manifest in many ways. When working with LGBTQ+ clients, it is important to recognize that there might be legitimate risks and dangers; avoidance is often functional and highly adaptive. As the therapist, there needs to be an acknowledgment and understanding of the function of avoidance in the face of stigma. It can be helpful to focus on creating flexibility about when, where, how and with whom a client might avoid.

When there is little social support or few avenues for affirmation, it is sometimes useful for the therapist and client to work creatively to carve out places where they can experience affirmation. This process involves becoming aware of resources within their community such as affirming religious institutions in the area and social spaces the client might be able to explore safely. In other words, working with LGBTQ+ clients often involves researching local, national and international resources if one is not already aware of or entrenched in the community.

For LGBTQ+ individuals, being sensitive and on the lookout for rejection can serve very adaptive functions. For example, many LGBTQ+ youths face rejection from their families of origin upon their LGBTQ+ identity being discovered/suspected. Types of rejection may include ridicule, bullying, physical violence, pressure or being submitted to conversion therapy, homelessness, losing financial and emotional support and so on. I think it is often helpful to: 

1. Consider how sensitivity to rejection serves an adaptive purpose

2. Name when this sensitivity to rejection comes up in adult life (I work exclusively with adults hence this frame of reference)

3. Help clients learn to understand how habitual exposure to potential rejection and concerns about the impacts of rejection might lead to learned behaviors that impact current functioning.

When actual rejection occurs, it is important to validate and normalize the painful experience. An expectation and perhaps overestimation of the impact of rejection may prevent clients from doing things they value. In these instances, increasing psychological flexibility can be helpful so that clients can slow down the thinking process and decide whether or not this is a situation in which potential rejection might be dangerous. If not, they might choose to act in ways that better align with their wants and needs with the knowledge that should rejection occur, they have the skills to process it.

There’s a great article from Brian Feinstein on rejection sensitivity for understanding sexual minority mental health, which I recommend to interested readers:

https://doi.org/10.1007/s10508-019-1428-3