Evidence Based Practice
Ashley Taylor
TheScientificPursuitofSexualandGenderMinorityMentalHealth-EBP.pdf
The Scientific Pursuit of Sexual and Gender Minority Mental Health Treatments: Toward Evidence-Based Affirmative Practice
John E. Pachankis Yale School of Public Health
The time has arrived for psychological science to translate the accumulating empirical research regarding sexual and gender minority (SGM) mental health into evidence-based affirmative treatments for this population. Far from the unscientific, homophobic theories of the early 20th century, several recent efforts in psychological science are starting to pave the way for evidence- based SGM-affirmative mental health treatments. These efforts include (a) identifying clear treatment targets for SGM, (b) conducting treatment studies that test the efficacy of therapy for SGM populations, (c) increased reporting of sexual orientation and gender diversity in existing randomized controlled trials conducted with the general population, and (d) reducing stigma itself, which has heretofore impeded the resources necessary to produce scientific evidence about SGM-affirmative treatments. This article reviews this progress and outlines future research directions needed to advance evidence-based practice for SGM, including determining whether and how existing evidence-based treatments need to be adapted to address SGM-specific con- cerns, why SGM-affirmative treatments work, and for whom and under what conditions SGM- affirmative treatments work best. A program of research is described that attempts to address these questions through randomized controlled trials with strong comparison conditions, psychotherapy process research of current SGM-affirmative practice, and tests of treatment moderators. To the extent that the mental health profession continues to pursue these solutions, it can ensure the continued flourishing of this population, whose visibility and vibrancy likely represent the surest route toward improving public acceptance and therefore its future mental health.
Keywords: lesbian, gay, bisexual, transgender (LGBT), mental health practice, LGBT- affirmative practice, evidence-based treatment, empirically supported treatment
Science, ideally agnostic to political forces, has in fact been used to both empower and imprison populations over
time (Foucault, 1977). The existential validity of sexual and gender minority (SGM) individuals has long been con- tested, in democracies and autocracies alike, given the threat that diverse sexual and gender identities have posed to conservative values. Using scientific authority as its tool, the mental health profession (e.g., psychiatry, psychology, social work, mental health counseling), in particular, has historically played a key role in both supporting and chal- lenging the social and moral validity of this population across the past century. In this article, I review the history of scientific evidence regarding SGM mental health, from the unscientific, homophobic theories of the early 20th century to the pioneering research that now paves the way for evidence-based SGM-affirmative practice. I highlight how recent scientific and professional efforts are removing his- toric barriers to build the necessary evidence base for SGM- affirmative treatments. Finally, the article suggests a pro- gram of future research to advance evidence-based practice for SGM individuals, spanning psychiatric epidemiology to psychotherapy process research.
Editor’s note. John E. Pachankis received the 2018 APA Award for Distinguished Early Career Contributions to Psychology in the Public Interest. This article is based on an invited presentation at the 126th Annual Convention of the American Psychological Association, held August 9 –12, 2018, San Francisco, California.
Author’s note. John E. Pachankis, Department of Social and Behav- ioral Sciences, Yale School of Public Health.
Completion of this article was supported by grants from the National Institute of Mental Health (R01 MH109413, R21 MH113860). The content is the sole responsibility of the author and does not represent the official views of the National Institutes of Health. I thank Mark Hatzenbuehler and Steven Safren for their helpful feedback on this article, Timothy Sullivan for his help with manuscript preparation, and Susan Cochran and Marvin Goldfried for sharing their insight on many of the ideas presented here.
Correspondence concerning this article should be addressed to John E. Pachankis, Department of Social and Behavioral Sciences, Yale School of Public Health, 60 College Street, Suite 316, New Haven, CT 06510. E-mail: [email protected]
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American Psychologist © 2018 American Psychological Association 2018, Vol. 73, No. 9, 1207–1219 0003-066X/18/$12.00 http://dx.doi.org/10.1037/amp0000357
1207
Deriving Scientific Evidence Amid Political Terrain
During the first half of the 20th century, most early psychoanalytic theorists in the United States promoted the view that homosexuality was pathological and in need of eradication (e.g., Bieber, 1962; Socarides, 1968). Although this stance directly contradicted Freud’s (1935) belief that homosexuality was not an illness, vice, or degradation, the American psychoanalytic community hewed closely to the antihomosexuality zeitgeist of the time. Indeed, the mental health profession’s explicit homophobia, operating under the guise of scientific authority, was used to promote emo- tionally, and sometimes physically, abusive treatments, such as aversive conditioning and other forms of conversion therapies (Drescher, Shidlo, & Schroeder, 2002). These theories and treatments were not scientific by any standard definition, as they relied on extravagant, unfalsifiable claims (e.g., of homosexuality as an intrapsychic compro- mise). But without access to the social, legal, or academic power to collect empirical data, SGM individuals were without a necessary voice to refute the profession’s wide- spread, unchecked homophobia.
In the middle of the 20th century, however, psychologists first used empirical approaches to help shift the field toward more affirmative practices. For instance, in the 1950s and 1960s, when the official psychiatric nosology classified homosexuality as a mental illness, visionary researchers (Hooker, 1957, 1958; Siegelman, 1972) gathered scientific evidence to substantiate observations that the psychological profiles of gay men and lesbian women were similar in important respects to those of heterosexuals. Similarly, dur- ing later decades, when same-sex relationships were crimi- nalized in many jurisdictions and not treated as equal to heterosexual relationships, psychological researchers again established that same-sex relationships were highly similar to heterosexual relationships in terms of relational goals and quality (Bell & Weinberg, 1978; Peplau & Cochran, 1981). Then, as now, these findings have been used to advance the equitable treatment of SGM, not only within the mental health profession, but in society at large. Here, the goal of equality is not just to remove symptoms of mental health disorders disproportionately experienced by SGM, but to promote the social, emotional, and physical well-being, life satisfaction, and open self-expression that follows.
The AIDS epidemic during the 1980s and 1990s in the United States brought even more significant empirical at- tention to the health of sexual minorities, specifically gay, bisexual, and other sexual minority men, who were, and remain, at greater risk of HIV infection than heterosexuals in much of the world (Centers for Disease Control and Prevention, 2010). During this time, an increasingly robust body of research suggested that the stressful effects of stigma and discrimination toward this population mani-
fested in greater psychiatric morbidity. Thus, one paradox- ical benefit of the AIDS crisis was a body of evidence highlighting the co-occurring epidemic of mental health problems in this population, which in fact had existed long before the AIDS epidemic. Specifically, this research showed that sexual minority men experienced elevations in stress-sensitive mental health disorders, such as depression, anxiety disorders, and substance use disorders, that not only co-occurred with HIV-related morbidity and risk but also stood on their own to disproportionately burden this popu- lation compared with heterosexuals (D’Augelli, 1989; Gar- nets, Herek, & Levy, 1990; McKirnan & Peterson, 1988; Meyer, 1995). The AIDS era in the United States also launched the first psychosocial interventions for sexual mi- norities tested in randomized controlled trials, with these studies focusing on HIV-related risk reduction and stress management among gay and bisexual men (e.g., Antoni et al., 2000; Lutgendorf et al., 1998).
Although this research demonstrated that sexual minori- ties were disproportionately affected by stress-related men- tal health conditions, it was often hampered by method- ological shortcomings that limited its persuasiveness. Specifically, most early studies on sexual minority men- tal health relied on nonrepresentative samples of sexual minorities who were disproportionately open about their sexual orientation, educated, White, and recruited from les- bian, gay, bisexual, and transgender (LGBT)-focused ven- ues. It was not until the late 1990s and early 2000s that population-based samples of sexual minority men and women overcame this limitation (Cochran & Mays, 2000a; Gilman et al., 2001; Stall et al., 2003). Population-based sampling, which represents all SGM individuals in a popu- lation regardless of demographic factors, has repeatedly shown that sexual minorities experience at least a twice greater likelihood of major depressive disorder, anxiety disorders, and substance use disorders compared with het- erosexuals (e.g., King et al., 2008). The greater comorbidity in mental health conditions among sexual minorities com- pared with heterosexuals also potentially indicates that such mental health problems manifest with more severe impair- ment, treatment resistance, and course (e.g., Cochran, Mays, & Sullivan, 2003). Notably, even to the present day, very few population-based studies have permitted examining mental health disparities and determinants by gender iden- tity (White Hughto, Reisner, & Pachankis, 2015).
In addition to establishing the significant mental health disparities affecting sexual minorities, this latest generation of research has rigorously demonstrated that these mental health disparities are largely accounted for by sexual mi- norities’ disproportionate exposure to stigma-related stress compared with heterosexuals. For instance, this finding has been confirmed using population-based sampling (e.g., Mays & Cochran, 2001), interviewer-based assessments of minority stress experiences (e.g., Meyer, Schwartz, & Frost,
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2008), and measures of exposure to structural stigma (e.g., social policies that deny protections based on sexual orien- tation status; Hatzenbuehler, Keyes, & Hasin, 2009a). This most recent stage of research has found that stigma operates through diverse processes, such as the stress of victimiza- tion, identity concealment, and anxious expectations of re- jection, to compromise mental health (Meyer, 2003). These mechanisms often emerge in adolescence (D’Augelli, Her- shberger, & Pilkington, 1998; Russell, Everett, Rosario, & Birkett, 2014) and can compound general life stress to exert deep psychological effects across the life course (e.g., Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, 2013; Pachankis, 2007; Pachankis & Hatzenbuehler, 2013; Pachankis, Sullivan, Feinstein, & Newcomb, 2018). Al- though research on the mental health of people with diverse gender identities and transgender experience has accumu- lated more slowly, existing research suggests that this pop- ulation is at least equally burdened with poor mental health for many of the same stigma-related reasons affecting sex- ual minorities (White Hughto et al., 2015).
As this brief historical review shows, the mental health profession has shifted from unscientific theories influenced by social mores to more empirically sound observations about the distribution and determinants of SGM mental health. This research has laid the empirical foundation for the recent progress in evidence-based SGM-affirmative practice described in the following section.
Progress Toward Evidence-Based SGM- Affirmative Practice
SGM-affirmative mental health practice recognizes that SGM individuals possess distinct, and diverse, life experi- ences not experienced by heterosexual or cisgender individ- uals that can influence mental health. Across numerous clinical accounts, case studies, and clinician surveys (e.g., Fassinger, 2000; Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991; Pachankis & Goldfried, 2004; Ritter & Terndrup, 2002), SGM-affirmative practice is typically characterized by several principles, including helping SGM individuals develop insight into the ways in which stigma generates excess stress to compromise mental health; de- sensitizing SGM individuals to certain negative feelings, such as shame and guilt, and countering negative cognitive styles, such as hopelessness and low self-worth, that can emerge from stigma-related stress; promoting resilience, pride, and community building as an antidote to stigma- related stress; and therapists providing SGM-specific re- sources and acting as informed advocates against societal injustice. These SGM-affirmative principles can character- ize therapy of any theoretical orientation free of heterocen- trism and homophobia.
Currently, professional guidelines for SGM-affirmative practice derive from clinical experience and the application
of theory and research regarding SGM mental health to clinical practice, but not from direct tests of the efficacy or implementation of SGM-affirmative practice. Several inter- national professional organizations, such as the American Psychological Association (APA) and the psychological societies of Australia, the United Kingdom, and South Af- rica, among others, have adopted guidelines for SGM- affirmative practice (American Psychological Association, 2017). The APA has also published guidelines for affirma- tive practice with transgender and gender nonconforming individuals to address the mental health consequences of stigma-related stressors specific to this population given mental health professionals’ general lack of familiarity with transgender-affirmative care (APA, 2015). Yet without di- rect empirical examinations of the efficacy and implemen- tation of SGM-affirmative practice, the field has lacked concrete guidance for translating SGM-affirmative profes- sional guidelines into evidence-based practice.
Despite historical barriers, several recent developments suggest that the field is now well-positioned to move for- ward with evidence-based SGM-affirmative practice. As reviewed in detail below, this progress includes (a) identi- fying clear SGM-affirmative treatment targets, (b) conduct- ing treatment studies of the efficacy of SGM-affirmative practice, (c) asesssing SGM status in randomized controlled trials conducted with the general population, and (d) reduc- ing stigma itself, which has impeded the necessary re- sources required to produce treatment-related evidence. I discuss this recent progress in the following section.
Identifying Clear SGM-Affirmative Treatment Targets
Despite clear and consistent evidence that SGM popula- tions represent one of the highest risk groups for mental health problems, and that stigma-related stressors contribute to psychopathology among SGM, the mechanisms through which stigma-related stress compromises the mental health of this population have remained unclear until recently. Without knowing these mechanisms, the field lacked clear treatment targets. Recent methodologically diverse studies, however, have identified probable mechanisms shown to underlie the association between stigma-related stress expo- sure and stress-sensitive mental health outcomes—mecha- nisms that can be addressed by evidence-based treatments.
Some of these processes, like emotion regulation deficits, rumination, social isolation, and depressogenic cognitive biases, are universal risk factors for internalizing psycho- pathology but are elevated among SGM individuals com- pared with heterosexuals (Hatzenbuehler, 2009). Elevations in these universal mechanisms among SGM individuals have been found to emerge early in development (Hatzen- buehler, McLaughlin, & Nolen-Hoeksema, 2008) and to explain sexual orientation disparities in mental health prob-
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1209EVIDENCE-BASED AFFIRMATIVE PRACTICE
lems across the life span (Hatzenbuehler, 2009). Processes like rumination and social isolation are known precursors of internalizing psychopathology in the general population (Kawachi & Berkman, 2001; Nolen-Hoeksema, 2000), have been shown to causally mediate the association between stigma experiences and psychological distress among sexual minorities (Hatzenbuehler, Nolen-Hoeksema, & Dovidio, 2009b), and represent modifiable targets of existing evidence-based treatments, such as emotion-focused and cognitive– behavioral therapies (Elliott, Watson, Goldman, & Greenberg, 2004; Farchione et al., 2012).
At the same time that these universal processes have been found to be elevated among sexual minorities, recent re- search has identified processes specific to sexual minorities that are strongly associated with stigma exposure and inter- nalizing mental health problems, and that statistically me- diate the association between stigma exposure and poor mental health (e.g., Pachankis, 2015). Given that they serve as mediators of the association between stigma and poor mental health, they are also candidate treatment targets. For instance, in one of the largest samples of sexual minority men and women, collected across 28 countries, sexual mi- norities were significantly more likely to conceal their sex- ual orientation in highly homophobic countries, which, in turn, predicted their lower life satisfaction in those coun- tries, suggesting that the psychosocial experience of sexual orientation concealment might represent a stigma mecha- nism capable of being addressed in mental health treatment (Pachankis & Bränström, 2018a). Other studies have simi- larly identified processes like anxious expectations of rejec- tion and internalized stigma as mediators of the association between stigma exposure and mental health problems (e.g., Pachankis et al., 2015). Research has extended these find- ings to outcomes such as body image disturbance (Hamilton & Mahalik, 2009), relationship satisfaction (Newcomb et al., 2017), and HIV risk behavior (Pachankis, Hatzen- buehler, Hickson, et al., 2015). Given that they are distinct to sexual, and potentially gender, minority populations, processes like SGM identity concealment, rejection hyper- vigilance, and internalized stigma likely demand distinct adaptations to standard evidence-based practice in order to be effectively and sensitively addressed.
Conducting Studies on SGM-Affirmative Treatments
The lack of empirical evidence of distinct, treatment- amendable mechanisms affecting SGM individuals has im- peded the case for developing and testing SGM-specific treatments (National Institute of Mental Health, 2010). In fact, a recent systematic review of SGM mental health interventions (Chaudoir, Wang, & Pachankis, 2017) re- vealed only one such treatment to have been tested for efficacy in a randomized controlled trial. This particular
study, of a stigma-related stress coping intervention for young gay and bisexual men (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015), utilized a waitlist de- sign, not a particularly strong test of efficacy. Several other studies have utilized within-subject designs to examine whether SGM-specific treatments (i.e., those that address the SGM-treatment targets reviewed above) successfully reduce stress-related outcomes, such as depression and sui- cidal ideation, before and after treatment (e.g., Craig, Aus- tin, & McInroy, 2014; Diamond et al., 2012; Lucassen, Merry, Hatcher, & Frampton, 2015; Ross, Doctor, Dimito, Kuehl, & Armstrong, 2007). Without a control group, though, such studies cannot establish the causal impact of the examined intervention. Nonetheless, they offer a plat- form for stronger future tests, including randomized con- trolled trials with strong comparison groups.
In the relative absence of treatment studies, several clin- ical scholars have reported the results of case studies dem- onstrating the successful application of empirically sup- ported treatments to SGM clients (Glassgold, 2009; Kaysen, Lostutter, & Goines, 2005; Safren & Rogers, 2001; Walsh & Hope, 2010). Notably, these studies all described SGM-specific adaptations to cognitive– behavioral therapies (CBTs). Such applications are logical given that CBT (a) locates present maladaptive behaviors in the context of their developmental function and current environmental contin- gencies, such as conceptualizing stress-sensitive mental health problems as learned responses for coping with stigma; (b) empowers clients to cope with adverse envi- ronmental circumstances, such as stigma-related stress, by promoting coping self-efficacy; and (c) encourages the re- placement of maladaptive cognitive, affective, and behav- ioral stress responses, such as those emerging from stigma exposure (Balsam, Martell, & Safren, 2006). These case studies report helping sexual minority clients in the follow- ing ways: reworking negative attitudes about themselves and SGM peers that had been internalized across early development; facing fears related to sexual orientation dis- closure; reframing self-as-victim narratives into empowered coping narratives; forming relationships with SGM commu- nity members as a form of behavioral activation to build resilience and pride; and understanding current symptom- atology in the context of societal homophobia while pro- moting an active stance against homophobia.
Despite the current lack of strong efficacy studies, a robust scientific basis now exists from which to further develop and test the efficacy of treatments for SGM popu- lations. Indeed, recent suggestions have been put forth not only for adapting cognitive– behavioral treatments for SGM clients (Pachankis & Safren, in press) but also for adapting several additional forms of existing evidence-based practice for SGM, including dialectical behavior therapy (Pantalone, Sloan, & Carmel, in press), relationship education (Pepping, Lyons, Halford, Cronin, & Pachankis, 2017), parent train-
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ings (Goldberg, Frost, & Noyola, in press), mindfulness- and acceptance-based approaches (Skinta & Curtin, 2016), and attachment-based family therapy (Diamond et al., 2012). Recent endeavors also illustrate how the growing scientific evidence of stigma-related stressors affecting transgender populations can be addressed through evidence- based practice (Austin & Craig, 2015). Emerging evidence- based suggestions for treating transgender clients are par- ticularly noteworthy given the considerable lack of empirical attention paid to transgender individuals to date compared with sexual minorities.
Documenting SGM Status in Existing Treatment Research
In addition to the historic lack of both clear treatment targets and treatment studies for SGM individuals, another barrier to creating evidence-based practice for SGMs has been the lack of collecting and reporting sexual orientation and gender diversity in empirical tests of evidence-based practice in the general population. Without knowing whether general treatments are differentially efficacious across diverse sexual orientations and gender identities, it has been impossible to know whether such treatments re- quired adaptations for these diverse populations (National Institute of Mental Health, 2010). In a recent systematic review, less than 1% of published randomized controlled trials reported sexual orientation as a demographic factor, none reported the presence of nonbinary gender identities, and none examined treatment efficacy by sexual orientation or gender identity (Heck, Mirabito, LeMaire, Livingston, & Flentje, 2017).
A few notable recent attempts have been made to examine whether treatment outcomes differ by sexual orientation in naturalistic treatment settings. For instance, in a sample of patients who had received CBT or dialectical behavior therapy in a clinic, SGM patients reported equal treatment outcomes compared with other patients, although bisexual individuals reported more self-injurious and suicidal thoughts and worse perceptions of care after treatment com- pared with other patients (Beard et al., 2017). In a large, national convenience sample of students who had received psychotherapy at a college counseling center, sexual minor- ities presented with greater symptoms of depression and anxiety, but they did not exhibit differential rates of change compared with heterosexual students (Lefevor, Janis, & Park, 2017). In a secondary analysis of a randomized con- trolled trial comparing cognitive– behavioral substance use treatment with treatment as usual, sexual orientation mod- erated treatment efficacy such that sexual minority adoles- cents experienced greater reductions in internalizing symp- toms and drug use than heterosexual adolescents (Grafsky, Letcher, Slesnick, & Serovich, 2011). Taken together, al- though these studies have begun to examine whether SGM
clients fare similarly in treatment as heterosexuals, they are not definitive in painting an overall picture regarding whether sexual minorities might experience differential benefit from existing evidence-based treatments. No studies have examined diverse gender identities as treatment effect modifiers.
Reducing Stigma as a Barrier to SGM- Affirmative Treatment Research
Stigma itself perhaps represents the ultimate barrier to progress toward effective treatments for SGM individuals. As illustrated in this section, an essential feature of stigma is its ability to rob the stigmatized of the very knowledge, power, and resources needed to shift the inequities that keep them stigmatized (Bränström, Hatzenbuehler, Pachankis, & Link, 2016; Link & Phelan, 2001).
Accurate data regarding SGM mental health have been slow to accumulate because of the complications of assess- ing a relatively hidden population whose members disclose at their own risk. Unlike many other minority populations, SGM individuals are not a readily identifiable population. This fact requires researchers to explicitly ask SGM indi- viduals about their sexual and gender identities at the same time that it requires SGM individuals to trust researchers to adequately protect this sensitive information (Hooker, 1993; Pachankis, Cochran, & Mays, 2015). Arguably for most SGM individuals in the world today, disclosure to strangers is an unwise prospect; in fact, a recent analysis estimates that most SGM individuals in the world are closeted, po- tentially to avoid harm (Pachankis & Brãnström, 2018b). Consequently, concealment, driven by stigma, represents a formidable barrier to knowledge regarding SGM mental health and effective treatments.
Historically, stigma has imposed barriers to SGM people attaining prominent positions from which to rectify inequi- ties. For instance, in the latter part of the 20th century, with a few courageous exceptions, very few academic research- ers could devote their careers to studying SGM mental health given the career jeopardy that faced those who pur- sued such research. Although today represents the first time in history that a critical mass of mental health researchers has received graduate training in SGM mental health and is largely capable of staking their careers in pursuit of this topic without risk, this progress is mostly limited to the United States and a few other Western countries. Although greater prominence of SGM researchers within academia will at least partially rectify the historic lack of power available to address SGM mental health, the amount of work to be done to address these substantial mental health disparities is formidable.
Stigma has also driven a historic lack of funding devoted to SGM health. Even HIV/AIDS, the most acute public health threat to affect SGMs, was itself slow to garner
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adequate funding and ultimately required the now-famous dramatic acts of protest to bring necessary attention to the dire crisis that struck this population (Epstein, 1996). And now, despite the fact that mental health conditions very well might represent a greater overall health burden to SGM individuals than HIV/AIDS (Hottes, Ferlatte, & Gesink, 2015), nearly three quarters of the National Institutes of Health (NIH) funding portfolio for SGM health has been restricted to understanding and preventing HIV/AIDS among sexual minorities (NIH, 2015). Funding devoted to understanding and treating SGM mental health remains inadequate. Propagating these structural barriers to acquir- ing adequate funding resources is inconsistent recognition of SGM as a disparity population in federal agencies (Mus- tanski, 2015). For example, the National Institute on Mi- nority Health and Health Disparities (NIMHD) only re- cently recognized SGM populations as a disparity group, which is required to provide research funding targeted at reducing the population health inequities that exist by SGM status (NIMHD, 2016). To date, therefore, most of the highest quality mental health treatment data for SGMs de- rive from studies explicitly focused on reducing HIV trans- mission among sexual minority men. In addition to under- representing women and gender diverse populations, this focus on HIV transmission potentially overestimates risk. Hopefully, progress toward more equitable recognition and funding will yield the necessary power to continue improv- ing the mental health of SGM, including sexual minority women and transgender individuals.
Future Scientific Directions in Evidence-Based SGM-Affirmative Practice
As the field has started laying a foundation for evidence- based practice for SGM clients, several existing knowledge gaps suggest exciting avenues for future study. A primary future question involves determining whether and how ex- isting evidence-based treatments need to be adapted to address SGM-specific concerns. Other important future di- rections for bringing a greater evidence base to SGM- affirmative practice include determining why SGM- affirmative treatments work, and for whom, and in what contexts they work best. These future directions span epi- demiological surveys to fine-grained examinations of in- session psychotherapy processes (see Table 1).
Do Existing Evidence-Based Treatments Need To Be Adapted to Address SGM-Specific Concerns?
Given limited resources available to develop and test distinct evidence-based psychotherapies and the fact that universal psychosocial risks at least partially underlie the mental health of all populations, one might reasonably ask, “Why do SGMs need their own evidence-based treat-
ments?” Indeed, if every distinct population required its own evidence-based treatment, the field would be required to support, and providers would be required to learn to deliver, thousands of treatments—an untenable situation (Kazdin, 2000). Further, as growing awareness of intersec- tional realities highlights the unique experience of finer population subgroups (Pachankis, Hatzenbuehler, et al., 2018), this challenge multiplies. Therefore, a high threshold must be surpassed to justify the resource outlay required to support the development of distinct evidence-based psycho- therapies for any population subgroup. Whether or not SGM treatment needs surpass that threshold remains to be deter- mined.
On the one hand, substantial evidence from the cultural adaptation literature suggests that evidence-based treat- ments for distinct cultural groups (e.g., racial/ethnic minor- ities) yield better outcomes, including engagement, reten- tion, and satisfaction in therapy, when they are adapted to address the distinct social ecological contexts, presenting concerns, and symptom manifestations of those cultures compared with nonadapted versions of those treatments (e.g., Smith, Rodríguez, & Bernal, 2011). On the other hand, a small body of emerging research suggests that SGM individuals might derive comparable benefit as heterosexu- als from standard, nonadapted evidence-based treatments (e.g., Beard et al., 2017; Grafsky et al., 2011; Lefevor et al., 2017). Also, unlike racial/ethnic minority groups in the United States who underutilize mental health care services, discontinue prematurely, and receive poorer care compared with non-Hispanic Whites (Institute of Medicine, 2003), recent evidence suggests that SGM populations do not un- derutilize mental health care, even after taking into account SGM mental health disparities (Cochran, Björkenstam, & Mays, 2017), and that they do not perceive worse quality of care (Beard et al., 2017), compared with heterosexuals.
Although these emerging findings do not conclusively answer the question of whether distinct evidence-based treatments are needed for SGM populations, they suggest the need to critically examine this question going forward. At the very least, future studies need to assess SGM status in both randomized controlled trials as well as naturalistic treatment settings to determine whether current treatments work comparably across populations or whether SGM peo- ple might experience disparities in treatment benefit, thereby necessitating treatment modifications to enhance efficacy. Further research is also needed to clarify whether SGM individuals experience barriers to treatment access or retention in care, which might necessitate SGM-affirmative adaptations to existing evidence-based treatments, even if such treatments show comparable efficacy across sexual orientations and gender identities. Future epidemiologic re- search is also needed to assess SGM mental health consum- ers’ satisfaction with existing treatments and potential pref- erence for SGM-adapted treatments, which might further
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justify developing distinct treatments. In fact, for some other minority populations, distinct cultural expectations, experiences, or needs of members of those populations have been shown to interfere with their engagement in those interventions, if not the efficacy of the intervention per se (e.g., Lau, 2006; Miranda et al., 2005; Sue, Fujino, Hu, Takeuchi, & Zane, 1991). Knowing whether and which features of existing treatments might interfere with treat- ment access, retention, and acceptability among SGMs can suggest whether and how those treatments might be adapted to best meet the needs of SGM individuals. Importantly, this research ought to consider the possibility that many impor- tant ingredients of existing evidence-based practice can be
effectively retained in treatment with SGM individuals and that even relatively modest or limited to changes to existing evidence-based practice might be able to better attract and retain SGM individuals in treatment if any barriers to treat- ment engagement and retention are discovered among this population.
How Should Existing Evidence-Based Interventions Be Adapted to Address SGM- Specific Concerns?
The question of whether existing evidence-based inter- ventions need to be adapted to address SGM-specific con-
Table 1 Future Directions in Evidence-Based Practice for Sexual and Gender Minority (SGM) Individuals
Research questions Possible solutions
Do existing evidence-based treatments need to be adapted to address SGM-specific concerns? Do SGM clients experience comparable benefit from existing evidence-
based treatments as heterosexuals? Routinely assess sexual orientation and diverse gender identities in
naturalistic treatment settings Do SGM-adapted evidence-based treatments work better than standard
evidence-based treatments and SGM-affirmative non-evidence-based treatments?
Conduct randomized controlled trials comparing SGM-adapted evidence-based treatments with evidence-based and non- evidence-based treatment as usual
Are SGM clients optimally satisfied with non-SGM-specific treatments? Do they have a preference for SGM-specific treatments?
Survey consumers of mental health services, ideally in population- based surveys
How do existing evidence-based treatments need to be adapted to address SGM-specific concerns?
Do SGM-specific treatments need to be created anew or are SGM adaptations of existing evidence-based treatments sufficient?
Determine whether theoretical frameworks of SGM mental health are compatible with theoretical frameworks of existing treatments
What strategies are currently effecting successful outcomes in community practice?
Conduct psychotherapy process research with practicing clinicians (e.g., qualitatively code effective treatment sessions to generate SGM-specific principles)
Why do SGM-affirmative treatments work?
Do SGM-affirmative treatments reduce minority stress and universal psychological mechanisms?
Measure and track trajectories of minority stressors and universal psychological processes across treatment
Do SGM-affirmative treatments facilitate SGM-affirming narratives and worldviews?
Perform linguistic/textual analysis of session transcripts to monitor shifts in narrative themes and worldviews (e.g., shame/pride)
Under what conditions do SGM-affirmative treatments work best?
Does the structural context (e.g., state policy environment) determine treatment outcome?
Examine structural stigma as a moderator of treatment outcomes in randomized controlled trials and naturalistic treatment settings
How can SGM-affirmative treatments be efficiently disseminated, especially in low-resource, high-stigma locales?
Examine the feasibility and efficacy of delivering SGM-specific treatments in low-resource, high-stigma locales (e.g., high-stigma developing countries, the U.S. South).
Can SGM-competence therapist training improve SGM treatment outcomes?
Conduct randomized controlled trials of therapist SGM-competence training linked to client outcomes
Does therapist–client match on SGM status affect treatment outcome? Examine therapist–client match as a moderator of treatment outcomes in randomized controlled trials and naturalistic treatment settings
For whom do SGM-affirmative treatments work best?
Do intersectional identities (e.g., racial minority status) influence SGM- specific treatment outcome?
Examine intersectional identities as moderators of treatment outcomes in randomized controlled trials and naturalistic treatment settings
Do SGM-affirmative treatments work best at certain ages or certain stages of SGM development?
Examine age and developmental stage as a moderator of treatment outcomes in randomized controlled trials and naturalistic treatment settings
Does baseline presence of SGM-specific stressors across individual, interpersonal, and structural levels influence treatment outcome?
Examine SGM-specific stressors as moderators of treatment outcomes in randomized controlled trials and naturalistic treatment settings
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cerns begs the additional question of how existing treat- ments should be adapted if research suggests incomparable benefit from existing treatments. Options include creating brand new treatments for SGM populations or infusing existing treatments with SGM-affirmative adaptations de- rived from empirical evidence. It is unlikely that SGM- specific treatments need to be created anew given the robust efficacy of existing evidence-based treatments, efficacious adaptations to those treatments for other distinct popula- tions, and the high compatibility between empirically sup- ported theories of SGM mental health and existing evidence-based practice (e.g., Hatzenbuehler, 2009; Meyer, 2003; Pachankis, 2007). Therefore, the most promising op- tion, if distinct treatments are found to be justified, would be to adapt existing evidence-based treatments to meet the distinct needs of SGM individuals.
When considering how existing treatments ought to be adapted, one obvious and promising solution would be to draw on the effective strategies currently being imple- mented in treatment settings. Practicing clinicians are al- ready addressing their SGM clients’ distinct concerns in their day-to-day practice; in fact, doing so is a professional mandate (American Psychological Association, 2012). This situation sets the stage for clinical researchers to employ psychotherapy process research methods to identify expert community clinicians, qualitatively code their treatment strategies, and then quantitatively determine which of their approaches facilitate positive treatment outcomes (Pachan- kis & Goldfried, 2007). This endeavor would yield not only adaptations for existing evidence-based treatments that could be compared in randomized controlled trials with nonadapted treatments but also clinically useful principles that can be implemented immediately in the community. In fact, clinicians might find SGM-affirmative principles more useful than treatment manuals (Westen, Novotny, & Thompson-Brenner, 2004). Such principles have the added benefit of preventing a situation in which dozens of, if not more, distinct treatments are developed and tested for nu- merous distinct presenting concerns among distinct sub- populations of SGM, placing an undue demand on already constrained treatment resources without appreciably ad- vancing clinical knowledge or science.
Why Do SGM-Affirmative Treatments Work?
Another pressing empirical question for improving the evidence base of SGM-affirmative practice asks why SGM- affirmative treatments work. Randomized controlled trials again provide one needed solution for answering this ques- tion, for instance, by examining whether theoretically in- formed treatment mediators (e.g., minority stress processes, universal psychological processes) temporally precede and statistically mediate clinical improvement from an SGM- affirmative treatment. Yet perhaps an equally promising
direction for determining why SGM-affirmative treatments work is, again, to take advantage of the expert SGM- affirmative treatment currently being delivered in the com- munity.
Psychotherapy process research conducted with practic- ing clinicians might explore, for instance, how minority stress narratives unfold over the course of treatment and which therapist responses are most conducive for promoting healthy, resilient narratives. Another process question is whether therapists who focus on stigma-related stress de- spite an SGM client’s beliefs that stigma is irrelevant to their presenting concerns effect poorer outcomes. Whether, how, and when therapists disclose their own SGM status, and react to their SGM clients’ disclosures, can also be linked to treatment outcomes, thereby providing clinicians with concrete guidance for how to handle this particular situation especially relevant to working with SGM clients. These process findings can inform potential SGM-specific adaptations for future randomized controlled trials.
For Whom and Under What Conditions Do SGM-Affirmative Treatments Work Best?
As important as knowing whether and why various treat- ments are efficacious for SGM individuals is knowing under what circumstances, and for whom, such treatments are most efficacious. Emerging research suggests potential moderators, such as the structural environment, race/ethnic- ity, minority stress processes, and developmental stage, as areas for future exploration.
Future research might find that the structural environment in which SGM-affirmative treatments are delivered repre- sents a moderator of treatment efficacy. In fact, meta- analytic evidence suggests that the race-related structural conditions (e.g., racial residential segregation of the com- munities in which treatments are delivered) hinder the effi- cacy of HIV-prevention interventions for racial minorities (Reid, Dovidio, Ballester, & Johnson, 2014). The SGM- related structural climate in which SGM-affirmative mental health treatments are delivered might similarly influence the efficacy of such treatments. This possibility would suggest that treatments might need to be tailored to address the structural context (e.g., by helping clients cope with the unfortunate demands of staying closeted in high-stigma locales) and that treatment providers working in high- stigma locales, who may not readily find guidance for delivering SGM-affirmative treatments, might need profes- sional support for doing so. High-stigma contexts, in which brick-and-mortar SGM-affirmative clinical venues might be absent or unsafe for SGM individuals to access, also suggest novel treatment dissemination strategies, including online or mobile delivery. The efficient delivery of evidence-based mental health services to high-need, hard-to-reach popula- tions represents a pressing global health need overall and
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one in which future research on SGM mental health has the potential to lead the way.
Other than a few notable exceptions (e.g., Cochran, Mays, Alegria, Ortega, & Takeuchi, 2007), very little population- based data has examined the basic question of whether racial and ethnic minority SGMs are disproportionately affected by mental health problems. Further, no mental health treatment studies with SGM individuals have strati- fied efficacy results by race or ethnicity. Existing data, from randomized controlled trials and naturalistic treatment set- tings, offer researchers a straightforward means for address- ing these gaps. Such research might consider the utility of adopting an intersectional lens to capture the multiple sources of stigma-related disadvantage that affect diverse SGM subpopulations. Minority stress processes themselves represent another potential treatment outcome moderator that has only recently received empirical attention (Millar, Wang, & Pachankis, 2016). Similarly, age and developmen- tal stage, including stage of SGM identity development, would be important to consider as treatment moderators in future research using data from existing or ongoing treat- ment studies.
Toward a Program of SGM-Affirmative Mental Health Treatment Research
A recent program of research highlights several possibil- ities for how the above questions might be pursued. First, we recently tested the efficacy of an SGM-affirmative ad- aptation of CBT for young sexual minority men experienc- ing internalizing psychopathology and HIV-risk behavior (Pachankis, Hatzenbuehler, Rendina, et al., 2015). We cre- ated this treatment by consulting both the emerging empir- ical research regarding minority stress mechanisms under- lying SGM mental health disparities (e.g., Hatzenbuehler, 2009; Meyer, 2003) and the expert advice of SGM- affirmative clinical experts. Both sources of information yielded several SGM-affirmative techniques and principles (e.g., attributing distress to stigma rather than self, self- monitoring the emotional impact of stigma-related stress on one’s daily life; Pachankis, 2014) that we incorporated into an existing cognitive– behavioral treatment. In a waitlist controlled trial, this treatment, called ESTEEM, signifi- cantly reduced depression, alcohol abuse, and HIV-risk behaviors. This merging of empirical evidence and clinical wisdom in the first randomized controlled trial of an SGM- affirmative mental health treatment lays the groundwork for a future program of SGM-affirmative mental health treat- ment research.
Drawing upon this initial success, we then set out to address several other pressing research questions, including whether evidence-based SGM-affirmative practice might work (a) better than standard SGM-affirmative therapy in the community, (b) by reducing minority stress mecha-
nisms, (c) better for some SGMs than others, and (d) in high-stigma locales delivered via efficient technologies. For instance, we are now comparing ESTEEM to SGM- affirmative community treatment to determine the compar- ative benefit of addressing empirically derived SGM- specific treatment targets. Process data from this study can also identify themes of highly successful SGM-affirmative community treatment and determine whether in-session be- haviors (e.g., therapist reactions to sexuality-related con- cerns) influence treatment. This trial, with multiple follow-up periods, allows opportunities to test whether re- ductions in minority stress processes, such as rejection sensitivity and internalized homophobia, mediate treatment outcome, which our waitlist study preliminarily suggests might be the case (Pachankis, Hatzenbuehler, Rendina, et al., 2015). Data from this new study will also suggest treatment moderators, including client race/ethnicity, SGM developmental stage, or therapist– client SGM match. In fact, results from the initial waitlist trial showed that ESTEEM was more efficacious for men who reported higher levels of implicit internalized homophobia, suggest- ing that SGM-affirmative treatment might be more benefi- cial for SGM individuals who experience more minority stress (Millar et al., 2016).
Related research, conducted in high-stigma contexts (e.g., Eastern Europe, prisons), has found preliminary support for adapting similar SGM-affirmative interventions to address SGM-related structural barriers in these contexts, training providers to develop SGM-affirmative skills despite these barriers, and delivering evidence-based SGM-affirmative practice via mobile devices (e.g., Lelutiu-Weinberger et al., in press; Lelutiu-Weinberger & Pachankis, 2017; White Hughto et al., 2017). Pilot studies are also in progress to examine the efficacy of similar approaches for young sexual minority women; hopefully, similar studies for gender mi- norities soon follow. Overall, this program of research pro- vides concrete opportunities for bringing a stronger evi- dence base to SGM-affirmative practice.
Conclusion
The time has arrived for mental health professionals to deliver evidence-based practice to SGM individuals. The profession’s historic perpetuation of harmful practices with SGM individuals alone justifies this endeavor. Far from the field’s early manipulation of the varnish of science to attain political ends, recent clinical research triangulates across numerous high-quality methodologies drawn from countless samples of SGM research participants to paint possibilities of the content, mechanisms, and delivery of SGM- affirmative treatments (Pachankis & Safren, in press). For professional and scientific reasons, mental health profes- sionals should continue advocating for the necessary re- sources to continue collecting empirically sound, clinically
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1215EVIDENCE-BASED AFFIRMATIVE PRACTICE
useful data for treating SGM individuals in need of mental health treatment. Mental health professionals should also ensure that advancements in evidence-based SGM- affirmative practice reach all SGM individuals in need, not just those who possess the knowledge, socioeconomic cap- ital, and other resources necessary for attaining high-quality care. Otherwise, inequitable access to treatment advances can exacerbate existing health inequities (Bränström et al., 2016; Link & Phelan, 2001). By promoting evidence-based SGM-affirmative treatments and their equitable distribu- tion, the mental health profession will play an essential role in ensuring the continued visibility, vibrancy, and mental health of the global SGM population.
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Received March 22, 2018 Revision received May 26, 2018
Accepted May 29, 2018 �
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1219EVIDENCE-BASED AFFIRMATIVE PRACTICE
- The Scientific Pursuit of Sexual and Gender Minority Mental Health Treatments: Toward Evidence-B ...
- Deriving Scientific Evidence Amid Political Terrain
- Progress Toward Evidence-Based SGM-Affirmative Practice
- Identifying Clear SGM-Affirmative Treatment Targets
- Conducting Studies on SGM-Affirmative Treatments
- Documenting SGM Status in Existing Treatment Research
- Reducing Stigma as a Barrier to SGM-Affirmative Treatment Research
- Future Scientific Directions in Evidence-Based SGM-Affirmative Practice
- Do Existing Evidence-Based Treatments Need To Be Adapted to Address SGM-Specific Concerns?
- How Should Existing Evidence-Based Interventions Be Adapted to Address SGM-Specific Concerns?
- Why Do SGM-Affirmative Treatments Work?
- For Whom and Under What Conditions Do SGM-Affirmative Treatments Work Best?
- Toward a Program of SGM-Affirmative Mental Health Treatment Research
- Conclusion
- References
