(p. 25) Cognitive–Behavioral Therapy for Sexual and Gender Minority Youth Mental Health
Lesbian, Gay, Bisexual, and Trans* Youth Mental Health
Diverse Sexual Orientations and Gender Identities in Adolescence
Lesbian, gay, bisexual, and transgender (LGBT) youth exist in a developmental context of emerging and shifting identities. Whereas awareness of gender identity (i.e., one’s internal sense of being male, female, or something else) emerges in early childhood, adolescence is the developmental stage during which sexual orientation (i.e., romantic and/or sexual attraction to others) often plays an increasingly important role (Kitts, 2010). Awareness of a non-heterosexual identity has been shown to occur as early as age 12 years for some youth (Pew Research Center, 2013). Definitions of sexual orientation typically encompass attraction, behavior, and identity (e.g., heterosexual, bisexual, lesbian, and gay) (Institute of Medicine [IOM], 2011), which can evolve or change across the lifespan (Austin, Conron, Patel, & Freedner, 2007). The terms used to describe sexual identities are continuously changing, ranging from more traditional labels (e.g., heterosexual, gay, lesbian, and bisexual) to more contemporary ones (e.g., pansexual, greysexual, and queer) (McInroy & Craig, 2012). For varying reasons, some adolescents prefer not to adopt particular labels yet still engage in same-sex sexual behavior, experience same-sex attraction, and/or identify with a variety of non-heterosexual communities (Levine, 2013). Such identity development is considered normative (p. 26) (Reitman et al., 2013). A recent study of sexual and gender minority youth (SGMY; N = 6,309) found that pansexual (30%), bisexual (26%), and queer (21%) labels were used most frequently, compared to gay (16%), lesbian (16%), or others (e.g., homoflexible) (Craig et al., 2017). Such terms reflect the diversity of sexual identities among adolescents and the influence of history on the identity context (Russell & Fish, 2016).
Gender identity may also vary considerably among adolescents. Although the term transgender (often abbreviated as trans*) is frequently used as an umbrella term to encompass the full range of gender identities, other terms indicating a gender identity and/or expression that do not align with biological sex or societal expectations are also used (e.g., gender variant and gender nonconforming). It is becoming increasingly clear that gender identity comprises a multidimensional spectrum of experiences (Gray, Carter, & Levitt, 2012). Contemporary gender identities beyond the male/female binary include, but are certainly not limited to, transgender, gender creative, gender diverse, gender neutral, genderqueer, and agender. Craig et al. (2017) examined gender identity among LGBT youth using non-mutually exclusive terms, and they found that many used non-binary/gender nonconforming (24%) and genderqueer/genderfluid terms (20%). The youth also identified other gender identity labels, including female (41%), male (17%), and trans* (18%), as well as a range of emerging terms (e.g., demigender, bigender, and genderfluid). Such terms convey a broad, flexible range of gender expressions with interests and behaviors that are not limited by restrictive boundaries of what it purportedly means to be “girl” or “boy.” Genderfluidity may suggest that adolescents experience themselves as both a boy and a girl at the same time, that their gender identity varies from day to day or across circumstances, or that neither the term boy nor the term girl describes them accurately (IOM, 2011). However, the presentation and expression of gender associated with one’s gender identity may continue to develop over time. This is further discussed in Chapter 4.
Mental Health Disparities
LGBT adolescents experience significant mental health disparities that may have severe and enduring consequences. One community-based study found that 30% of LGBT adolescents (N = 246) reported clinical levels of mental distress during the past week (Mustanski, Garafalo, & Emerson, 2010). The high prevalence of depression among LGBT adolescents is particularly troubling (Marshal et al., 2011), and it is also concerning that these mental health problems have been shown to persist into adulthood (Russell & Fish, 2016). For example, LGBT adults have a high prevalence of anxiety disorders (Tjepkema, 2008), and bisexual women are more than twice as likely as heterosexual women to have severe anxiety and anger (Macleod, Bauer, Robinson, MacKay, & Ross, 2015). In a study of young women (N = 6,689), Kerr, Santurri, and Peters (2013) found that bisexual and lesbian undergraduates were 4.7 times more likely than heterosexuals to report intentional self-injury (e.g., cutting, burning, and bruising).
(p. 27) Many LGBT adolescents are also at high risk of suicide. According to a meta-analysis, the risk for suicidal thoughts and behaviors among LGB adolescents was three times greater than that for heterosexual adolescents, with the greatest risk among bisexuals (Marshal et al., 2013). LGB youth are also more likely to engage in suicidal behaviors, suicide attempts, and suicide completion (22.8% compared to 6.6% for non-LGB adolescents) (Mustanski & Liu, 2013). General risk factors such as depression, impulsivity, and hopelessness, as well as identity-based risks such as homophobic discrimination and victimization, are associated with high prevalence of suicidal behavior (IOM, 2011). Risks may be particularly exacerbated among certain subgroups. For example, White, Latino, and American Native/Pacific Islander LGBT adolescents have been shown to have a higher prevalence of suicide attempts compared to Black and Asian LGBT adolescents in some studies (Bostwick et al., 2014). The lower prevalence of suicide among Black and Asian LGBT adolescents is often attributed to negative cultural views of suicide (Bostwick et al., 2014). Transgender adolescents have an exceptionally high risk of elevated suicidality (Nuttbrock et al., 2010). According to the National Transgender Discrimination Survey (N = 6,400), 45% of young adult respondents (aged 18–24 years) reported having attempted suicide (Grant et al., 2011). However, Newcomb, Heinz, and Mustanski (2012) found that gender nonconformity was not associated with a suicide attempt history.
Suicide is just one of many behavioral risks facing LGBT adolescents. The Centers for Disease Control and Prevention reports that compared to students who are not LGBT, “a disproportionate number of . . . [LGBT] students engage in a wide range of health risk behaviors” (Kann et al., 2011, p. 49). In their meta-analysis, Marshal and colleagues (2008) found that LGBT adolescents report earlier onset and heightened rates of substance use (nearly twice those of their non-LGBT peers), and they determined that certain subgroups experience even greater disparities. For example, bisexual adolescents demonstrate rates of substance use three times higher than those of heterosexual adolescents. Given these significant challenges, it is critical for clinicians to effectively address the mental health of LGBT adolescents.
Stigma, Discrimination, and Victimization
LGBT adolescents are disproportionately exposed to stigma and discrimination, as well as verbal, physical, and sexual victimization (Birkett, Newcomb, & Mustanski, 2015; Goldblum et al., 2012). The victimization of LGBT children and adolescents “pervades their school, family, religious, and community environments” (Dragowski, Halkitis, Grossman, & D’Augelli, 2011, p. 228). In a sample of LGBT adolescents (aged 14–21 years; N = 350), Dragowski et al. found that nearly three-fourths were verbally abused (72%), had objects thrown at them (13%), and/or were physically attacked (11%) because of their LGBT identities. Moreover, many young adults who identify with a nondominant sexuality face (p. 28) harassment and bullying for not conforming to normative expectations for sexual identity expression (Alessi, Kahn, & Chatterji, 2016).
Mounting research demonstrates pervasive experiences of bullying by LGBT adolescents in schools. The 2015 GLSEN National School Climate Survey (Kosciw, Greytak, Giga, Villenas, & Danischewski, 2015) explored feelings of safety and experiences of school-based victimization among 10,528 LGBT students (aged 13–21 years). An overwhelming majority experienced verbal harassment as a result of being LGBT (85%) and/or gender nonconforming (54%), with almost half (49%) being victimized through online formats (e.g., text messages and postings on social media), indicating that cyberbullying has become a major concern. Blumenfeld and Cooper (2010) found that 54% of LGBT youth (N = 3,502) reported being victims of cyberbullying in the 30 days prior to the survey and reported feeling depressed (45%) and suicidal (25%) because of these experiences.
In addition to school-based discrimination, research suggests that LGBT adolescents experience disparate rates of physical and sexual victimization by parents or caretakers. A meta-analysis of 37 studies conducted by Friedman and colleagues (2011) determined that LGBT adolescents were 3.8 times more likely to experience childhood sexual abuse and 1.2 times more likely to be physically abused by a parent or caretaker compared to non-LGBT peers. Trans* adolescents are at particular risk, encountering higher prevalence of all types of victimization (i.e., physical, sexual, verbal, and psychological abuse) by family members compared to adolescents whose presentation and behavior are gender-normative (D’Augelli, Grossman, & Starks, 2006). Family support is particularly critical to the mental health of LGBT youth. Needham and Austin (2010) found that (1) LGBT young adults experienced lower levels of parental support than their non-LGBT counterparts; (2) parental support was inversely related to health outcomes, including depression, substance use, and suicidal thoughts; and (3) parental support partially mediated associations between sexual orientation and marijuana and hard drug use among young lesbian women. Parental support can also be helpful for trans* adolescents. One study showed that for transgender adolescents (aged 12–24 years), the presence of parental support was correlated with greater life satisfaction and less depression (Simons, Schrager, Clark, Belzer, & Olson, 2013).
Conflict with parents is an important factor to consider with LGBT adolescents because it has been found to contribute to the increased likelihood of homelessness (Walls, Hancock, & Wisneski, 2007). In fact, LGBT adolescents comprise a disproportionate number of the adolescent homeless population (approximately 40%), with transgender and racial and ethnic minorities particularly overrepresented (Cray, Miller, & Durso, 2013). LGBT adolescents are also overrepresented in the child welfare and foster care systems due to higher rates of family victimization (Gallegos et al., 2011).
Victimization and discrimination may have devastating and lingering consequences for LGBT youth. Goldblum et al. (2012) found that transgender adults who experienced identity-based discrimination in school were four times more likely to have a history of suicide attempts compared to those who did not experience this type of discrimination. In addition to overt victimization, LGBT (p. 29) adolescents and emerging adults are also exposed to incessant LGBT-phobic stigma and microaggressions (i.e., frequent and brief verbal insults) across multiple life domains (Alessi, Sapiro, Kahn, & Craig, 2017; Nadal, Whitman, Davis, Erazo, & Davidoff, 2016). Such identity-based discrimination may manifest as family rejection (Alessi, Martin, Gyamerah, & Meyer, 2013); lack of inclusive legal protections (Grant et al., 2011); the absence of safe and inclusive school and community spaces (Birkett, Espelage, & Koenig, 2009); and discrimination by school personnel, religious institutions, and health care providers (Nadal et al., 2016). Studies indicate that experiences of discrimination, victimization, and rejection from others result in the internalization of homophobic and transphobic stigma (i.e., negative views of one’s LGBT identity) (Mizock & Mueser, 2014; Vogel, Bitman, Hammer, & Wade, 2013). LGBT adolescents are at risk of internalizing implicit and explicit messages of homophobic and transphobic hate experienced on a daily basis (Kosciw et al., 2015). This is of notable concern because internalized stigma has been linked with poor mental health outcomes (Newcomb & Mustanski, 2010).
LGBT Youth and Minority Stress
Given the severity and enduring nature of victimization and stigmatization experienced by LGBT adolescents, health disparities among this population must be understood through a minority stress lens (Alessi, 2014; Meyer, 2003; Meyer, Dietrich, & Schwartz, 2008). Minority stress theory provides a framework for understanding the impact of stress associated with the persistent and pervasive devaluation and marginalization of an individual’s minority identity (Meyer, 2003). An elaboration of stress and coping theory (Lazarus & Folkman, 1984), minority stress theory proposes that individuals from marginalized populations experience a unique form of stress due to conflict between their internal sense of self and their experiences of majority social norms and expectations (DiPlacido, 1998). Because LGBT children and adolescents do not usually share their LGBT identity with family members, they may not learn identity-specific coping strategies as many adolescents in other minority communities do (Craig, Austin, & Alessi, 2013). This leaves LGBT adolescents more vulnerable to health and mental health threats (Kelleher, 2009) as well as at increased likelihood of engaging in risky behaviors (Birkett et al., 2009). Minority stress stems from objective experiences of discrimination; internal processes, including internalized homophobia; expectations of rejection based on sexual orientation (i.e., perceived stigma); and feeling the need to conceal sexual orientation (Meyer, 2003). For LGBT adolescents, minority stress contributes to the development of mental and behavioral health issues during adolescence and adulthood. Hatzenbuehler and Pachankis (2016) identified that the stigma experienced by LGBT individuals can “disrupt cognitive, affective, interpersonal and physiologic processes” (p. 986) that may negatively impact health. For example, Newcomb et al. (2012) suggest that LGBT adolescents may struggle with emotion regulation because consistent (p. 30) exposure to discrimination can lead to more negative emotions, which in turn may contribute to maladaptive coping behaviors such as alcohol consumption. Minority stress can also negatively modify cognitive functioning (Hatzenbuehler, 2009). Specifically, the impact of discrimination can be seen in the cognitive appraisal of potential threats, and this in turn can be associated with depression for LGBT populations (Alessi, 2014; Hatzenbuehler & Pachankis, 2016). Cognitive appraisals assign meaning to stressful events (e.g., viewing stress as a challenge or a threat) and explain why the same experience contributes to differing levels of distress across individuals (Hojat, Gonnella, Erdmann, & Vogel, 2003). Such appraisals are important to coping with stressful events because they enable emotional regulation of responses (Steptoe & Voegele, 1986). These general psychological processes (e.g., cognitive appraisals, coping, and emotional regulation) may mediate the LGBT experiences of minority stress and mental health problems (Hatzenbuehler, 2009). Thus, because patterns of adolescent cognitive appraisal ultimately contribute to long-term mental health (Rowley, Roesch, Jurica, & Vaughn, 2005), attending to the psychological processes such as cognitive appraisals that are associated with minority stress may have a notable lifelong impact on emotions and behaviors (Safren, Hollander, Hart, & Heimberg, 2001). To counter negative appraisals, clinicians must incorporate affirmative approaches when using cognitive–behavioral therapy (CBT) with LGBT adolescents (Craig & Austin, 2016). An affirmative clinical approach recognizes that LGBT adolescents disproportionately experience identity-based stressors and that these stressors negatively impact the mental health of LGBT adolescents. Next, we review the relevance of CBT for LGBT youth.
Cognitive–Behavioral Therapy for LGBT Youth
Introduction to Affirmative Cognitive–Behavioral Therapy for Youth and Relevant Empirical Support
Cognitive–behavioral therapy is considered an effective treatment for adolescents with mental health problems such as social anxiety (Baer & Garland, 2005), depression (Richardson, Stallard, & Velleman, 2010; Treatment for Adolescents with Depression Study, 2004), and suicidal ideation (Stanley et al., 2009). Evidence indicates that CBT can also facilitate resilience (or constructive adaptation; Pachankis, 2014) and improve self-esteem (Hyun, Chung, & Lee, 2005). Although practice literature suggests that CBT is an effective method for treating depression among lesbian and gay adults (Martell, Safren, & Prince, 2004)—and can enable clients to manage their own mental health, cope with identity disclosure, and establish social support (Safren & Rogers, 2001)—only recently have researchers applied CBT to LGBT adolescent populations (Duarté-Vélez, Bernal, & Bonilla, 2010).
Affirmative CBT (A-CBT) explores and validates the positive expression of LGBT identities and recognizes the impact of discrimination on mental health (p. 31) using the empirical framework of CBT (Craig et al., 2013). A-CBT holds particular promise for treating mental health problems among LGBT adolescents. For one, CBT focuses on changing maladaptive behaviors by changing problematic ways of thinking. Identifying as an LGBT person can negatively impact one’s thoughts and beliefs, which in turn may cause feelings of low self-worth, anxiety, and depression. According to Pachankis, Goldfried, and Ramrattan (2008), the internalization of homophobia may negatively impact LGBT adolescents’ self-perceptions and interactions with others, such as the ability to be assertive interpersonally. Challenging one’s negative thoughts about their LGBT identity in a safe and supportive environment may help decrease internalized homophobia and transphobia. For example, a pansexual adolescent who believes she can never feel “happy or normal” because of her sexual orientation can learn to challenge these thoughts and replace them with more positive and realistic ones (e.g., “LGBT people create happy and satisfying lives”). CBT also helps clients recognize how their thoughts impact their behaviors. LGBT adolescents are taught to replace maladaptive coping skills (e.g., isolating from friends and family) with more effective ones (e.g., talking to an ally about family problems). These new skills are modeled and reinforced throughout the intervention process. Integrating new coping strategies is particularly important for LGBT adolescents who—as a result of fear, shame, and guilt associated with experiences of discrimination—may have learned to rely on unhealthy coping mechanisms, including substance abuse, disordered eating, or skipping school. By addressing maladaptive thoughts and beliefs regarding one’s LGBT identity and subsequently teaching proactive coping skills to deal with stressors, CBT facilitates the use of adaptive, flexible thinking that can foster healthy emotional and behavioral functioning among LGBT adolescents (Craig et al., 2013).
Finally, A-CBT can promote cognitive reappraisal for LGBT adolescents. In their study of adolescent appraisal, Rowley et al. (2005) found that efficacious coping such as “active coping, positive reinterpretation, and growth were positively related to appraising stress as a challenge and maladaptive coping such as substance use, denial and emotional venting was associated with assessing stress as a threat” (p. 554). CBT can effectively address the complex stressors that exacerbate depression and psychological distress for LGBT adolescents by helping them evaluate the sources of, perceptions of, and reactions to stress, as well as mitigate feelings of self-blame and shame associated with discrimination (Craig et al., 2013; Lucassen, Merry, Hatcher, & Frampton, 2015). Table 2.1 highlights the A-CBT therapeutic framework. Three studies of small-scale, brief CBT interventions created and tested with LGBT adolescents can be used to highlight CBT’s utility with LGBT youth: (1) a computerized intervention for LGBQ adolescents (Rainbow SPARX), (2) a community-based intervention for a range of LGBT adolescent identities (AFFIRM), and (3) a transdiagnostic intervention for gay and bisexual young adults (Effective Skills to Empower Effective Men [ESTEEM]).
Table 2.1. Affirmative Cognitive–Behavioral Therapy (CBT) with LGBT Adolescents: Therapeutic Framework
Key Therapeutic Task
Clinical Concern/Description (Rationale)
Establish affirmative therapeutic context.
By the time they enter therapy, most LGBT adolescents have been exposed to a host of homo/bi/transphobic beliefs, attitudes, and behaviors from peers, adults, and relevant institutions in their lives.
A key to affirmative CBT is the immediate establishment of an LGBT affirming therapeutic stance and clinical context for intervention.
An affirmative approach is particularly important because harmful and unethical reparative and conversion efforts aimed at LGBT youth continue to permeate religious and cultural communities in the United States and abroad.
Create visibly affirming spaces (e.g., rainbow stickers or posters, books, brochures, and magazines highlighting the lives of diverse LGBT people).
Use intake forms with inclusive options for sexual orientation and gender identity and that allow for the use of a chosen/preferred name.
Include statements on websites and/or other marketing material that affirm LGBT adolescents.
When making initial introductions, include a statement that explicitly affirms LGBT adolescents (e.g., “I want to let you know that I embrace and value all sexual orientations and gender identities; this is a space where you are free to be who you really are and express yourself authentically.”).
Contemporary CBT approaches emphasize collaboration (rather than confrontation), and therapeutic collaboration may be even more important for LGBT adolescents who often have trouble finding supportive adults.
The structure of CBT allows the therapist to provide a clear description of the rationale and process of the sessions, which can empower LGBT youth and foster collaboration.
While explaining the process of CBT, clinicians should utilize terms familiar to LGBT adolescents so that they can make informed choices about their treatment.
Explain each step while encouraging collaboration and feedback. For example, “These counseling meetings are like a team project. I will explain the plan and then you can let me know if we need to change or add anything. For this session we will talk more about how discrimination makes you think and feel because our thoughts and feelings often influence what we do.”
Affirm LGBT identities during assessment.
Assessment clarifies the client’s needs, informs the direction of treatment, and provides a starting point for initiating behavioral change.
With LGBT adolescents, it is critical to affirm their identities during assessment.
Actively reflect with youth during the initial assessment and examine the extent to which they have experienced affirmation of their LGBT sexual and/or gender identities and how this impacted the engagement process.
“How would you describe your sexual and gender identity? Just a reminder that all identities are welcome and supported here.”
At the end of each session, the clinician could give the LGBT adolescent a feedback sheet in which statements such as “Please describe the ways in which you felt particularly affirmed in today’s session,” “The areas of today’s session that didn’t feel as good to me were,” and “These are ideas for what to do next time” are presented with the ability for short qualitative responses.
Identify adolescent’s comfort with their LGBT identity.
To appropriately tailor the treatment to the developmental stage of the LGBT adolescent, it is important to assess the affirmative stance of LGBT youth as well as those in their spheres.
Have the LGBT adolescent list positive feelings about identifying as xxx (e.g., pansexual).
If this is challenging, have the youth identify positive traits related to other LGBT individuals (e.g., celebrities, icons, teachers, and friends).
To fully understand their comfort with their identity, have the adolescent also list any negative feelings or about identifying as xxx (e.g., lesbian)
Identify minority stressors.
Clinicians should acknowledge the impact of discrimination and address the impact of homo/bi/transphobia on their lived experiences.
A functional assessment of the antecedents and consequences of the client’s stress can encourage the youth to share their perspective about how environmental conditions contributed to their mental health concerns.
Clinicians should openly communicate that they want to understand the impact of oppression on the client’s lived experience.
“Given that you have stated that your identity is xxx, can you share some of the ways in which you have experienced discrimination?” or “In what ways has anyone made you feel bad about your identity/who you are/being xxx.”
“Can you describe some of the ways that these experiences have impacted you and your life?”
For example, clinicians can ask clients to list their minority stressors on an erasable board. Then the practitioner and client can talk about each stressor together. Using this method conveys that the practitioner is different from other adults who have minimized the client’s problem or even rejected the client for being LGBT.
Validate experiences of discrimination.
Although CBT encourages the exploration of other hypotheses to determine the “cause” of a problem, this may be perceived as doubting or minimizing the youth’s experience.
LGBT youth may also experience this response as a subtle form of homo/bi/transphobia, which could undermine the therapeutic relationship.
Acknowledging the presence and impact of discrimination may increase youth engagement and further understanding of clinical concerns.
When an LGBT adolescent reports an incident of discrimination, the therapist should not automatically universalize it (e.g., “All youth are teased”) or search for alternative reasons for the bully’s behavior (e.g., “Doesn’t he make fun of everyone?”).
Instead, it is important that the therapist provide a validating response (e.g., “It must be really painful to be teased in front of everyone”).
Rainbow SPARX is a brief computerized CBT (seven sessions) designed specifically for LGBQ adolescents aged 13–19 years (N = 21; 11 male-identified: 15 New Zealand European, 4 Asian, and 2 Maori) (Lucassen et al., 2015). Rainbow (p. 32) (p. 33) (p. 34) (p. 35) SPARX is an adaptation of SPARX, a computerized intervention shown to be efficacious for general populations of adolescents (N = 187; aged 12–19 years) with mild to moderate depression in a multicenter randomized controlled trial (RCT; Merry et al., 2012). With a focus on building and practicing core CBT skills (i.e., relaxation training, behavioral activation, social skills training, naming cognitive distortions, problem-solving, cognitive restructuring, and hope), SPARX has users identify the components of a “shield against depression” (Lucassen et al., 2015, p. 205). Rainbow SPARX closely follows the same format as SPARX with a seven-module interactive fantasy game using avatars that strive to destroy negative emotions but with specific content for LGBQ adolescents. Modules highlight strengths of being a sexual minority, social skills, and problem-solving around fears of disclosure. They also reflect upon the impact of homophobia, help clients reframe cognitive distortions, and offer them options for gender and sexual identities. Grounded in the results of the SPARX RCT, Rainbow SPARX was designed as an open pilot trial and collected data at three time points (pre-test, post-test, and 3-month follow-up). Lucassen et al. found that participants’ depressive symptoms significantly decreased following the intervention (p < .0001), and these results persisted after 3 months. Rainbow SPARX had high acceptability with 80% of participants stating they would “recommend [it] to a friend” and that they learned about “depression” and “relaxing–slow breathing” (Lucassen et al., 2015, p. 212).
AFFIRM is a brief affirmative cognitive–behavioral coping skills group intervention (eight modules) with LGBT adolescents, adapted from a manualized depression intervention for culturally diverse youth (Rosselló & Bernal, 2007) and carefully developed through ongoing community partnerships (Craig & Austin, 2016). A diverse sample of LGBT participants aged 15–18 years (N = 30) in the pilot feasibility trial identified with the non-mutually exclusive gender identity categories of female (57%), trans*/gender nonconforming (31%), and/or male (18%), as well as the sexual orientation categories of pansexual (29%), lesbian (25%), queer (21%), bisexual (18%), and/or gay (11%). Measures of depression and stress appraisal were completed at three time points. Significant reductions were found in depression (η2 = .23, p < .05) and appraising stress as a threat (η2 = .17, p < .05) following the intervention. A significant increase was found in perceiving stress as a challenge (η2 = .52, p < .001). Depression was positively correlated with threat appraisals and negatively correlated with challenge appraisals. The relationship between depression and cognitive appraisal indicates the potential importance of targeting perceptions of minority stressors within interventions designed to reduce psychological distress among LGBT adolescents. Consistent with the CBT model, findings suggest that LGBT adolescents developed a more adaptive way of appraising stressful situations as a result of participating in AFFIRM. Adolescents intended to “apply what they learned” (97%) and gleaned skills to “connect thoughts, feelings and behaviors” (90%) (Craig & Austin, 2016, p. 140).
Cognitive–behavioral therapy was also shown to effectively address the multiple health risks of young adult gay and bisexual males in the ESTEEM RCT. Participants were aged 18–35 years (58 identifying as gay and 5 as bisexual). (p. 36) Compared to the waitlist (n = 31), participants in the intervention group (n = 32) experienced significant reductions in depressive symptoms, alcohol use problems, as well as risky sexual behaviors (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). These findings indicate the promise of CBT using a transdiagnostic (i.e., unified) approach to positively impact intersecting risks for multiple and concurrent mental health problems linked by minority stress processes (Pachankis et al., 2015).
Affirmative Cognitive–Behavioral Therapy for LGBT Adolescents: Clinical Approaches
This section identifies critical components of A-CBT for LGBT adolescents and examines clinically relevant strategies, followed by a case example. The results of the studies described in the previous section underscore the promise of using a CBT-based approach that affirms LGBT identities, attends to minority stressors, actively targets maladaptive responses to stressors, and builds effective coping skills (Craig & Austin, 2016). As noted in Beck’s (1993) approach to CBT, emotions and behaviors are influenced by how we perceive events. A-CBT encourages individuals to formulate alternative ways of thinking about situations and problems, which in turn prompts emotional and behavioral changes. However, prior to helping clients change their ways of thinking and engaging in cognitive or behavioral change strategies, A-CBT requires clinicians to validate the reality of stigma. In addition, clinicians must affirm the identities of LGBT adolescents. Doing so is more than just about being politically correct (Alessi, 2013); it is about celebrating LGBT identities. An affirmative approach, coupled with specific strategies to address the impact of discrimination, is critical for LGBT adolescents (Craig & Austin, 2016). The effectiveness of A-CBT is based on the competent delivery of CBT that attends to both process and content elements (Thordarson, Keller, Sullivan, Trafalis, & Friedberg, 2016). Thus, A-CBT should be a collaborative and individualized process (Craig et al., 2013).
A-CBT is relevant to clinical practice with LGBT adolescents in three primary ways. First, A-CBT targets behaviors for change with adolescents through a respectful, culturally responsive assessment that explores strengths, social supports, and goals. Clinicians working with LGBT adolescents must initially develop a comprehensive case conceptualization that incorporates the complex intersections often present in the lived experiences of these adolescents (e.g., being an African American lesbian female youth with a trauma history). Based on that formulation, clinicians should design CBT interventions that identify and subsequently address their maladaptive reactions to their social and psychological stressors while understanding that for some LGBT youth, the root cause of their psychosocial distress may persist (Thordarson et al., 2016).
Second, following an exploration of environmental factors, which includes a comprehensive examination of particular stressors related to prejudice and discrimination, CBT practitioners utilize cognitive restructuring interventions (p. 37) (e.g., evidence testing and decatastrophizing) to address obstacles (e.g., cognitive distortions and automatic thoughts) to clients’ long-term goals (Hays, 2009). For example, an LGBT adolescent who dreams of becoming a computer animator but consistently has been skipping school because of bullying due to her sexual orientation and is at risk of failing 12th grade may benefit from A-CBT. Because A-CBT promotes personal agency (Pachankis, 2014), the initial step is to explore the adolescent’s environmental obstacles, including safety within the school and the need for possible environmental changes (e.g., intervention with school staff and changing schools). Subsequently, through the identification of proactive coping skills to deal with stressors, CBT facilitates the use of flexible or adaptive thinking, which can foster healthy emotional and behavioral functioning among LGBT adolescents.
Third, A-CBT encourages alternative ways of thinking. For example, because A-CBT may positively impact stress appraisals and emotion regulation related to minority stress (Craig & Austin, 2016; Pachankis, 2014), clinicians can incorporate interventions to help LGBT adolescents manage perceived discrimination. For example, in the case of an LGBT adolescent who is reporting increased anxiety due to verbal harassment, the clinician should first validate the discrimination (“It sounds like it must be really painful to be bullied for just being yourself. This should not be happening to you.”). After exploring the client’s feelings and thoughts associated with this discrimination, the clinician might consider having the youth discuss their current coping strategies. If they are maladaptive, the clinician might state, “What might be one other way that you can deal with this bullying?” The clinician can then ask the client to try this strategy out at least twice this week and then in the next session discuss what it was like to try this strategy. Table 2.2 further illustrates these key clinical strategies and tasks for A-CBT with LGBT adolescents, and the following section explores the application of A-CBT through a detailed case study.
Table 2.2. Affirmative Cognitive–Behavioral Therapy (CBT) with LGBT Adolescents: Session Tasks
Key Therapeutic Task
Help youth distinguish issues based on structural causes and those rooted in dysfunctional thoughts.
This is particularly important for CBT with LGBT adolescents who may struggle with situations outside of their control (e.g., biphobic bullying). LGBT adolescents may encounter events (e.g., rejection by family member) that cannot be easily changed by modifying dysfunctional thoughts or changing behavior. Failing to acknowledge that certain stressful circumstances stem from homo/bi/transphobic social conditions may be dangerous to the well-being of LGBT adolescents.
Clinicians should validate their concerns and frustrations as well as teach them skills for coping with situations that are beyond their control (e.g., living with a rejecting parent until they start college).
For example, clinicians working with homeless LGBT adolescents should initially focus on the external factors (e.g., lack of safe, permanent housing) contributing to the client’s feelings of hopelessness and subsequently address the dysfunctional thought patterns (e.g., things will never get better).
Question the helpfulness of the thought or belief.
An affirmative approach to cognitive restructuring includes evaluating the utility of the belief. This technique helps LGBT adolescents recognize dysfunctional thoughts that work against their long-term goals and also helps decrease feelings of hopelessness.
The therapist might ask, “Is it helpful for you to say that if you come out you will be homeless, or to hold onto this belief, or to repeat this thought or image to yourself?”
Encourage youth to consider the advantages or disadvantages of each belief to assess whether it is currently helping them. For example, make a pro and con list for coming out to your grandmother, and then use the “helpful thoughts vs. not helpful thoughts” framework to assess the current utility of these thoughts.
Questioning whether a thought is irrational or invalid may be interpreted by some LGBT adolescents as not affirmative or naive. For example, in an effort to demonstrate the irrational fear of coming out to one’s family, a less-skilled practitioner might ask, “So what’s the worst that could happen?” However, this question could intensify the client’s realistic fears and may even backfire because some youth experience serious consequences after coming out to family members (e.g., violence, homelessness, or being disowned).
Help youth develop their cognitive appraisal skill.
Specific negative experiences may contribute to LGBT adolescents’ assumptions that they will always face similar results.
LGBT adolescents may also perceive that their previous experiences of discrimination mean that all similar situations will result in their experiencing discrimination. As such, it is important that therapists provide opportunities for youth to reconsider their limiting ideas.
“When I came to this school, I was bullied all the time for being gay. If I have to go to a new school because of my mom’s new job, I am sure it will happen again.”
Clinicians can help youth search for evidence to support a reappraisal of the damaging experience and cultivate an alternative belief. For example, “When you were bullied, you say it happened all the time. Can you think of just one time when it didn’t happen? Can you think of a time when someone was kind to you at your school? So can you say that bullying happened all the time?”
“I went to that one support group in Toronto and that didn’t help. Therefore I won’t go to any other groups because they won’t help either.”
Clinician: “Help me understand that experience. When you went to that support group and you say it didn’t help, what were you looking for help with? Can you think of one small thing that was good or helpful about the group? So perhaps there may be some ways in which support groups could be helpful to you?”
Help youth build their skills for interacting with the social environment.
Affirmative CBT can help LGBT adolescents cope with stressful situations, even if they are unable to change their environment. Because they will undoubtedly encounter homophobia and heterosexism at different times in their lives, learning to effectively cope with such situations (e.g., challenging negative thoughts and replacing harmful behaviors with healthier ones) is essential.
For example, an LGBT adolescent that is experiencing bullying in the neighborhood can role play telling a parent or speaking up to the bully.
When a youth is feeling angry about how they are being treated, they can practice some deep breathing and relaxation techniques that they have learned in session.
To counter immobilization or rumination related to discriminatory experiences, therapists can suggest behavioral activation techniques such as trying out different activities, volunteering, or joining an online community.
Help youth increase supports.
Specific support for LGBT identity is critical to adolescent well-being. Clinicians should probe for affirmative sources of supports and identify areas in which supports could be strengthened.
Identify affirmative supports by asking who and how LGBT adolescents are supported by family of origin and family of choice (e.g., boyfriend’s/girlfriend’s family or best friend’s family), informal supports (e.g., friends and partners), formal peer supports (e.g., Gay–Straight Alliances), and community groups (e.g., SMY support group).
To help develop support, suggest LGBT adolescents’ (1) participate in Gay–Straight Alliances or school-based support groups, (2) advocate for other vulnerable groups, and (3) attend Parents, Families and Friends of Lesbians and Gays (PFLAG) groups to connect with positive parental role models.
Help youth identify strengths.
Acknowledging strengths is an important component of resilience. When LGBT adolescents try to create new thoughts to replace less helpful ones, the list of specific strengths generated during the initial assessment can be a concrete reminder of past successes.
New “minority strengths” related to the increasing acceptance of their LGBT identities can also be identified and expressed.
Past successes can be formulated into positive self-statements, such as the following: “All the barriers I have coped with in the past has made me strong”; “If I got through last year, I can get through anything”; and “My differences are what make me unique and special.” Youth can add these new thoughts and beliefs to their notes section of their phone or on a piece of paper to take with them. Have youth count the number of positive thoughts (generally and about being LGBT) and then try to increase them by 10% each week.
Have youth write down one negative thought, but write down two positive thoughts to counteract it.
Assign affirmative homework that is congruent with stage of identity development.
Clinicians should be aware that some LGBT adolescents experience unique barriers with regard to engaging in activities of their choice. For example, spending time with a romantic partner may be something that the adolescent identifies as both enjoyable and useful for “combating” negative thoughts and feelings. However, parents who reject a youth’s LGBT identity may not permit such activities. Clinicians should attend to this reality when “assigning” homework to LGBT adolescents.
Consider renaming homework with the client (e.g., wellness plan). Review with the youth the short amount of time it will take to complete. Identify how likely they are to complete it (look for a high likelihood).
Ensure assignments are tailored to the client’s stage of the coming out process. For example, while helping youth identify an “affirmative activity list,” youth who are not yet out may not want to attend a Pride parade or join the Gay–Straight Alliance. However, they might feel comfortable watching an LGBT-affirmative movie, spending time with a straight ally, or watching gay affirmative videos on YouTube. In these instances, it may be helpful to ask the youth, “What is one small step that you can take to help you feel like you are making a difference with your problem?” In this case, the youth might attempt to socialize through Instagram or email rather than attend a support group.
The following case example of Bianca provides a description of minority stressors experienced by an LGBT adolescent (pansexual and genderqueer) and offers some approaches based on A-CBT that can be used by clinicians to help reduce symptomology and encourage alternate coping strategies.
Bianca is a 15-year-old female adolescent who identifies as pansexual, genderqueer, and Latinx. During the assessment, Bianca presents with symptoms of anxiety. She discloses that she worries about what her family and people at her school think about her sexuality. She worries about attracting attention to herself and also worries about her grades and appearance. She has thoughts such as “They (p. 38) (p. 39) (p. 40) (p. 41) (p. 42) think I am stupid,” “I am embarrassing my parents,” and “I am the only pan girl in California”:
therapist: Thank you for sharing these experiences and feelings with me. They sound like they are causing some painful feelings.
bianca: I do find it very stressful.
therapist: I bet it is. It is especially hard when you have to constantly worry about what people are thinking of you.
bianca: Exactly. It feels like a lot sometimes.
therapist: What happens when you start to have thoughts that you are embarrassing your parents or that you are the only pan girl in California?
bianca: I feel anxious and nervous.
therapist: What do you do when that happens?
bianca: I go online to look at Tumbler or Facebook to not have to think about my situation.
therapist: Does that help?
bianca: Yes, I feel better.
therapist: Figuring out ways to soothe yourself is really important when you are feeling anxious. Can we talk some more about why do you think your thoughts cause you to feel stressed?
bianca: Maybe because I feel bad about being pan.
therapist: I want you to know that this is a place where all identities are respected and I believe you deserve a lot of respect for being open and honest with me. Being pan is the way that many young people identify and many are happy and healthy but it is important that we are able to talk through your feelings together.
After the therapist validates Bianca’s pansexual identity and her experiences, Bianca and the therapist discuss how, after taking time away from her troubled thoughts and putting space between her and her daily life, she sometimes feels a bit better. The therapist explains how thoughts impact feelings and behavior and has Bianca sketch out the cognitive triad. The therapist explores with Bianca the idea of thinking about her anxiety as a “person” who makes statements, similar to her online friends. With this frame, Bianca can then “talk back” in comments to her anxiety. To facilitate this approach, the therapist draws a box on a paper (to illustrate Facebook) and writes a statement from Bianca’s anxiety like it is a Facebook post. Then Bianca can talk back to the Facebook post with a comment. In addition, Bianca can go online to gather evidence about her beliefs and slow down her thoughts as she finds evidence that refutes those beliefs. For example, instead of thinking she is “weird” because she is pansexual, Bianca can identify online examples of adolescents who have come out as pansexual.
As can be seen in the example, the goal of A-CBT is to help Bianca change some of her negative thoughts. However, the therapist does not question the validity of these thoughts. The therapist acknowledges that Bianca lives in a society that marginalizes LGBT identities and that LGBT people have to manage interactions (p. 43) during which they may experience discrimination. The therapist explains that Bianca is not the problem but that homophobia, biphobia, and transphobia contribute to her feeling bad about herself. The therapist talks about the importance of managing her thoughts and engaging in activities that not only distract her from her negative thoughts but also affirm her identity, such as reading Ellen’s DeGeneres biography (a person she respects). Thus, A-CBT has an important psychoeducational component that provides a rationale for the affirmative interventions. Clients are instructed not only to manage their negative thoughts but also to transform this negativity into something constructive. For example, the therapist might suggest Bianca join an online group or Gay–Straight Alliance (Alessi, 2014).
Emerging Trends in Cognitive–Behavioral Therapy for LGBT Adolescents and Promising Practices
Several emerging trends may impact A-CBT for LGBT adolescents. This section addresses the increased focus on resilience and the role of information and communication technologies (ICTs).
The adversity encountered by LGBT adolescents necessitates a focus on the factors that support the development of resilience (Craig, McInroy, McCready, & Alaggia, 2015). Resilience includes minimization of perceived threats to well-being as well as creating meaning out of challenges (Craig et al., 2015; Goldstein & Brooks, 2005). For LGBT youth, threats to their well-being are real, and therapists should explore the existence of those challenges and provide concrete support as needed (e.g., calling child protective services for a child experiencing abuse or asking the adolescent’s permission to speak to a principal or a parent if an LGBT youth is currently being bullied). Resilience and healthy coping skills are associated with better overall health, healthier decision-making, and lower likelihood of risky behaviors in adolescence (Levine, 2013). Social support, connectedness, and feelings of belonging have been found to positively influence self-esteem and contribute to reduced mental health challenges for adolescents (Snapp, Watson, Russell, Diaz, & Ryan, 2015). High self-esteem and social support may be negatively correlated with suicidality for some LGBT adolescents (Grossman & Kerner, 1998). However, Mustanksi, Newcomb, and Garofalo (2011) determined that social support contributes to better mental health but does not moderate the negative impact of victimization on psychological distress. Thus, LGBT adolescents need to learn skills to combat the effects of victimization on their own mental health. CBT can enhance resilience in vulnerable populations by providing opportunities to develop social support and skills to combat stigma and manage mental health (p. 44) (Eamon, 2008). To enhance resilience for LGBT adolescents, clinicians should promote critical individual, interpersonal, and environmental factors (e.g., caring adults, role models, and positive school environments) (Hatzenbuehler, 2011; Higa et al., 2014). Group-based CBT may offer particular advantages for LGBT adolescents because group contexts offer opportunities for learning, observing, and practicing skills (Rosselló et al., 2008) and can support the development of the social supports necessary to combat minority stressors. Although this evidence suggests that A-CBT may contribute to the resilience of LGBT adolescents, future applications should consider utilizing empirical measures of resilience, such as the Brief Resilience Scale (Smith et al., 2008) or the Child Youth Resilience Measure (Ungar et al., 2008), in clinical and research activities.
Information and Communication Technologies
Due to their rapid uptake and broad accessibility, ICTs (e.g., internet, social media, smartphones, and mobile applications) have the potential to promote resilience among LGBT children and adolescents (Craig & McInroy, 2014). ICTs may be utilized to gain education, explore identity, and locate affirmative providers with expertise in adolescent-specific issues (Ybarra, Mitchell, Palmer, & Reisner, 2015). ICTs represent particularly critical avenues for enhancing LGBT adolescent well-being due to minority stressors that are exacerbated by geographic or social exclusion (Austin, 2016; Craig et al., 2015). ICTs have potential to facilitate the uptake of evidence-based interventions (Berry & Lai, 2014; Mustanski, Greene, Ryan, & Whitton, 2015). Because the majority of LGBT adolescents cannot or do not access professional support, and even fewer are likely to see a CBT-trained therapist (Richardson et al., 2010), computerized CBT (CCBT) is an important emerging area (Berry & Lai, 2014). As noted previously (Lucassen et al., 2015), CCBT is an effective way to engage adolescents and offers positive effects comparable to those of traditional CBT (Richardson et al., 2010). Furthermore, the structured format of CBT and online presentation allow for a certain anonymity, which may thus allow LGBT adolescents to more easily share personal information with a therapist (MacGregor, Hayward Peck, & Wilkes, 2009). Although there are challenges to widespread implementation, such as high attrition or programs that target inappropriate developmental stages (Stallard, 2004), CCBT could significantly increase access for underserved populations. Given the potential of A-CBT to promote well-being among LGBT adolescents, the possibility of further impacting youth mental health through integration into ICT platforms represents an exciting opportunity.
Based on the significant empirical foundation of CBT and emerging research on its utility for LGBT populations, A-CBT represents an important intervention approach for clinical practice with LGBT adolescents. Despite the vast array of minority stressors encountered by LGBT adolescents, A-CBT can disrupt the psychosocial stress trajectories that can lead to poor mental health. Future manifestations of A-CBT may include a focus on resilience and ICTs.
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