Study finds shortcomings in therapy for sexual minorities

Sexual minority individuals experience depression and anxiety at higher rates than their heterosexual counterparts, yet both the individuals and therapists report experiencing difficulties in treatment. A University of Kansas researcher has published a study that examines the research on psychotherapy interventions for sexual minorities and provides recommendations for improving services.

"Sexual minorities often express frustration with their mental health services such as experiencing microaggressions. Service providers also express frustration at not being prepared to fully serve sexual minority individuals," said Briana McGeough, assistant professor of social welfare at KU.

The study, which McGeough co-wrote with Adrian Aguilera of the University of California-Berkeley, was published in the Journal of Gay & Lesbian Social Services.

In analyzing books and scholarly articles aimed at improving mental health services for sexual minorities, McGeough and Aguilera provided a taxonomy of approaches, writing that services fall into three categories:

• Protocol-based approaches provide services via manuals that proscribe specific, formulaic approaches to services, such as discussing coming out in a certain session and internalized homophobia in another certain session, McGeough said.
• The second category is principles-based approaches, in which providers use tools they have at their disposal to address a client's challenge that is specifically related to sexual orientation. For example, providers can use cognitive restructuring to urge people to change how they think about an issue related to their sexual orientation, such as internalized homophobia, that is causing distress.
• The final category is relationship-based approaches. In that method, therapists participate in cultural competency trainings to learn how to relate to and work with different populations, including sexual minorities, similar to trainings that are commonly used in the workplace to teach individuals how to work with diverse populations.

All three approaches are lacking in key areas, the authors wrote. Furthermore, insufficient research exists documenting how effective these approaches are in improving the mental health of sexual minority clients.

"I'm concerned that they tend not to be well-evaluated," McGeough said of protocol-based approaches. "We don't have data, to my knowledge, about if sexual minority people who experience interventions adapted for sexual orientation are having better outcomes than those experiencing standard, non-adapted interventions."

Principles-based approaches are likely to be the most effective, but research is needed there as well to determine what tools work best and when they are appropriate to be employed.

"Often, therapists don't see that the tools they already have at their disposal could be relevant. I think this research highlights the importance of assessment," McGeough said. "Does the client want to discuss elements of sexual orientation? Is their sexual orientation relevant to why the individual is in therapy?"

Focusing on sexual orientation and gender identity, even if it is not directly related to why a person is seeking treatment, can lead to problems in the therapist/client relationship, McGeough said. When the therapist focuses on the client's sexual orientation when that isn't a primary concern for the client, the client may feel stereotyped for judged and may not actually receive the services that they would most benefit from.

Sexual minority clients may be particularly attuned to sexual orientation-related microaggressions and judgment from therapists because of the broader context of mental health services—homosexuality was classified as a mental health disorder by the American Psychological Association for many years, she said.

In addition to further research on each individual approach, testing interventions against each other in controlled settings could further improve understanding of their effectiveness, the authors wrote. They also recommended testing interventions for mental disorders beyond depression and anxiety, further understanding and minimizing the effects of microaggressions, understanding therapists' barriers to effectively serving sexual minority clients, and selecting and targeting interventions based on the unique challenges the client is experiencing.

In her future research, McGeough hopes to further draw upon established approaches for improving mental health services for people of color to identify strategies for better serving clients who are both people of color and sexual minorities, as well as to apply some of the valuable lessons about supporting members of marginalized populations that may be relevant for tailoring services for sexual minorities generally. She is also leading a grant project to better understand and improve how LGBTQ individuals experience 12-step programs for alcohol and substance abuse.

"I think we have an incredible opportunity here," McGeough said. "Sexual minority individuals tend to use therapy at a higher rate than their heterosexual peers, so hopefully we can continue to improve mental health services for the many individuals seeking help."