Yale Psychiatry Grand Rounds: October 28, 2022

October 28, 2022

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"LGBTQ-Affirmative Mental Health Care: From Theory to Trials to Community Implementation and Global Dissemination"

John Pachankis, PhD, Susan Dwight Bliss Professor of Public Health (Social and Behavioral Sciences), Professor of Psychology and Professor of Psychiatry, Yale School of Medicine

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00:00For the for the invitation to be here today,
00:03to just speak to you all in the Department
00:07of Psychiatry about this increasingly
00:11important and increasingly visible.
00:14Topic and that is how to go about
00:18providing care to our LGBTQ clients and
00:21patients and how we can do that and
00:25scientifically informed evidence based
00:27ways and the mental health that you
00:30can say crisis affecting LGBTQ people
00:33and populations is one of the the the
00:35most pressing concerns of the LGBTQ
00:38community in the US and around the world.
00:40So it's really an honor and and and
00:43and often feels like an imperative.
00:45To to do this work to figure out how we
00:49can do do do best by our LGBTQ clientele.
00:52The the challenge the.
00:57Unity is quite simply defined,
00:59and it's that LGBTQ people represent one of
01:01the highest risk groups of any population.
01:03Risk groups for depression,
01:05anxiety, substance use problems,
01:07and suicidality.
01:08And now that we have high quality,
01:11nationally representative datasets
01:12that actually assess sex orientation
01:14and gender identity,
01:15diverse gender identities,
01:16something we didn't have until
01:18until surprisingly recently,
01:20we know that study after study
01:22has shown that LGBTQ people,
01:23or at least twice greater risk of
01:25of these mental health outcomes.
01:27And heterosexual cisgender populations.
01:29We also know that this disparity
01:31largely persists across the life course.
01:34This is true in nearly eight every
01:35data set in every country in
01:36which this has been examined,
01:38although most of these datasets are
01:40are are in more Westernized context.
01:42I want to address this challenge
01:44today in two broad parts.
01:45The first,
01:46we'll focus on the theoretical causes
01:47of this disparity and the second we'll
01:49focus on on on potential solutions
01:51to this disparity largely through
01:53research taking place at Yale.
01:55It's involving clinical trials and.
01:57Imitation science of of of LGBTQ
02:01affirmative cognitive behavioral therapy.
02:03Which is the first evidence based
02:05treatments developed by and for
02:07LGBTQ people's mental health.
02:09So we know that the most plausible
02:11cause of the mental health
02:12disparities affecting LGBTQ people
02:14is not biological or genetic.
02:16Is is is some people have argued,
02:18but rather probably stigma or simply
02:20the societal conditions that lead
02:22some people to be actively devalued
02:24and have less power than others.
02:262 prominent types of stigma that we
02:29can consider are the discriminatory
02:31societal structures that surround.
02:33Many minoritized groups called
02:36structural stigma.
02:37And also the stressful kind of more
02:40daily encounters with stigma that that
02:42happened in our interactions with
02:44other people, including strangers,
02:45peers, coworkers,
02:46and even prominently in the in
02:49the case of LGBTQ people,
02:50even from their own families.
02:51We'll call this interpersonal stigma,
02:53but we'll start with structural stigma,
02:55which is defined as unjust laws,
02:57policies,
02:57and community attitudes that deny
02:59or fail to protect the equal rights
03:01of the stigmatized.
03:02Until recently,
03:03though,
03:04structural stigma has been difficult
03:05to measure because it requires a few things.
03:08One is that you have large samples
03:10of the LGBTQ population,
03:11which as I said earlier have
03:13been have been relatively
03:15hard to come by.
03:16We also need the LGBTQ sample to
03:19have been recruited from from from
03:22geographically diverse structural context.
03:25You know most of our our studies
03:27especially with minoritized populations
03:28come from like 1 context like one
03:31community like New Haven or one college
03:32like Yale without much structural
03:34diversity and in the in the surroundings.
03:38And so we need to study the
03:40influence structural stigma,
03:40we need context with diverse structures
03:42and we also need an approach to
03:45quantifying structural stigma,
03:47those laws and policies that
03:49surround TQ people.
03:50Such a quantitative index might look
03:52like this where you can sum each
03:55country's present each country.
03:56I said, because I'll talk about
03:58doing this internationally first.
04:00You can send each country's presence
04:02or absence of discriminatory
04:04criminalizing laws and policies
04:06and also the those countries.
04:07Protective laws and policies and this
04:10objective approach to measuring stigma
04:13and also overcomes the limitations
04:15are more commonly used subjective
04:18measurements of stigma which we know
04:20are subject to the same source or to
04:22self report bias in which two people
04:24can have very different experiences
04:26of the same discriminatory event.
04:28Using an objective measure of
04:30structural stigma also overcomes
04:32limitations of same source reporting
04:34bias whereby the predictor and
04:35this case stigma and the outcome.
04:37Were measured using the same approach
04:39by asking people the perceptions of
04:41stigma and in their own mental health,
04:43which can produce artificially
04:44inflated estimates of the associations
04:46between those things.
04:47But using a quantitative,
04:48objective assessment of structural
04:50stigma like this overcomes at
04:52least those two limitations.
04:53So such an index can then be applied
04:56to suitable data opportunities.
04:58The EU LGBT survey and and also the
05:01European men who have sex with men
05:04Internet survey represent the two
05:06largest in terms of sample size.
05:09Datasets ever collected the LGBTQ
05:13population these datasets allow
05:15because they span such diverse
05:18context from countries like like
05:20Sweden and where I am right now,
05:22having about the lowest stigma,
05:25structural stigma towards LGBTQ
05:27people possible being at the vanguard
05:29of LGBT rights kind of right next
05:31door to countries like like like
05:34Romania or Hungary or Poland,
05:36which are some of the most
05:38stigmatizing countries.
05:39In the EU,
05:40where same sex marriage isn't allowed,
05:41where where you can't update your
05:43gender identity on unofficial
05:45documents and things like this,
05:46so you have this patchwork of of a
05:49very diverse kind of structural context,
05:51really sitting right next to each other.
05:52And importantly, we have data.
05:58The populations living in those
06:00countries and in these datasets we
06:02see a strong association between
06:04country level structural stigma
06:05with this countries on the right,
06:07countries like Lebanon and Belarus,
06:09Ukraine being very high in
06:11terms of structural stigma,
06:13which countries on the left,
06:14countries like Netherlands,
06:14Denmark, Austria being very
06:16low on the on on that index,
06:18you see across that a strong linear
06:21association between the prevalence of
06:23of depression and the LGBTQ population.
06:26And structural stigma.
06:27Now these estimates are even controlling
06:29for average country level depression
06:31where people in in Lebanon have
06:33higher higher risk of depression in
06:35general than people in the Netherlands.
06:37Even over and above that
06:39you see that LGBT people.
06:42Um, risk of depression is um
06:44is is a strong linear function
06:47of of of the structural legal
06:50policy climate surrounding them.
06:54This is the same is true of suicidality,
06:56with about 15% of LGBTQ people
06:58in the Netherlands reporting
07:00past year suicidality on the PHQ,
07:02where's twice that percent of LGBTQ
07:04people report past year suicidality and
07:06more structurally stigmatizing context
07:08like like Belarus or North Macedonia.
07:10Again, this is over and above the fact that,
07:14that, that, that, that,
07:15that there's a higher prevalence,
07:17the depression,
07:17and in the general population and some of
07:20those more structurally stigmatizing context.
07:22So now I'll present.
07:24Evidence that interpersonal stigma,
07:25including interpersonal interactions with
07:27parents and peers due to ones LGBTQ status,
07:31predict the mental health outcomes known to
07:34just disproportionately affect LGBTQ people.
07:36Now the search for these interpersonal
07:38forms of stigma has to start early because
07:41we know that many young LGBTQ people
07:44experience mental health challenges.
07:46But how young and how much LGBTQ people?
07:49Young people disproportionately
07:50experience mental health challenges like
07:53depression compared to heterosexual,
07:55cisgender young people?
07:56It's still relatively unclear,
07:58largely because of the challenges of studying
08:00these topics among very young people.
08:02So my colleague Dan Klein at SUNY Stony
08:05Brook has been prospectively following
08:07a group of about 600 youth since they
08:10were aged 3 on Long Island, New York.
08:13The study started when I was in Graduate
08:14School at Stony Brook and every three years.
08:16Match that time,
08:17the the youth and their parents and
08:19teachers completed numerous assessments,
08:21including interviews including
08:23EG of you know of, of,
08:26of, of.
08:28Developmental and temperamental precursors
08:30to depression and then depression itself.
08:32As the kids aged a few years ago,
08:34we received support from NIH to to
08:36to study the timing and causes of
08:39the sexual orientation disparity and
08:41mental health problems in the sample.
08:43We started by asking the youth at age
08:4515 what gender they were attracted to.
08:48This allowed us to assess who
08:50probably is was being gay or bisexual,
08:53at least in terms of the gender
08:54or genders to which they reported
08:56being attracted,
08:56and in that sample about 11% of the youth.
08:59Did report same gender attractions and
09:01in their lives they had experienced
09:03a steep relative increase in
09:05depression and compared to other
09:06gender attractive youth from a
09:08pretty early age, with that disparity
09:11becoming quite pronounced by by
09:13by middle school and high school.
09:16By high school, we also see
09:17that many more of the youth
09:19recorded same gender attractions,
09:20reported poor relationships
09:22with their parents,
09:23and reported more bullying compared
09:24to youth through reported only being
09:26attracted to the other the other gender.
09:28In fact, the association between sexual
09:31orientation and age 15 depression was
09:33significantly mediated by age 12 exposure
09:36to poor relationships with parents and
09:38to exposure to to bullying from their peers.
09:41So results like this highlight the potential
09:44role of interpersonal stigma from.
09:46From,
09:46from parents and peers and LGBTQ peoples.
09:49Disproportionate exposure of depression.
09:51So these findings regarding structural
09:54stigma and interpersonal stigma,
09:56of which I just presented some some
09:59more recent analysis of of many,
10:01support the basic tenets of what's
10:03known as minority stress theory.
10:05Minority stress theory suggests that
10:07the causes of the sexual and gender
10:10minority disparity in mental health and
10:13related outcomes is a function of LGBTQ
10:15people's greater exposure to to stigma.
10:18Structural stigma interpersonal stigma,
10:19another key part of minority stress theory.
10:22Is that these forms of stigma give
10:24rise to minority stress reactions that
10:26serve as mediators of the association
10:29between stigma and poor mental health.
10:31But what's the minority stress reaction?
10:33Well,
10:33one of the reactions that I've
10:35spent a good deal of time studying
10:37is identity concealment.
10:39So because they possess a
10:41relatively concealable stigma,
10:42LGBT people face the choice of
10:44whether or not to come out.
10:46And although models of stigma
10:48concealment suggest that the
10:50environment should ultimately determine.
10:53An LGBTQ persons person.
10:55So.
10:59Or or cost of concealment versus coming out.
11:01Very few studies have have
11:03actually examined the environment.
11:04Is A is A is a determinant of concealment.
11:06So using the same large cross country
11:08EU data set that I mentioned earlier,
11:11we found that in countries like the UK
11:13that scored low on structural stigma,
11:15the vast majority like 90%
11:17of LGBTQ people are out.
11:19In countries like Romania that
11:20scored higher on this index,
11:22the majority of section minority
11:23people are actually in the closet.
11:24They say that they've told very few
11:26people are or know people in their lives.
11:28With their LGBTQ and and again you
11:30see a strong linear association
11:32between between really how LGBTQ
11:34people live their lives.
11:36I mean this isn't you know this
11:38isn't abstract this this is you know
11:41consuming is something that that that
11:43that affects the day-to-day decisions
11:45the day-to-day self presentation how
11:47what people share what they choose
11:50to silence within themselves and we
11:52know that the concealment can not only
11:54take a mental health toll especially.
11:56Didn't see one about a personally
11:59important aspect of oneself.
12:00And again,
12:01you have you have people living
12:03basically right next door to each other.
12:05Um, depending, you know,
12:07countries like like countries like
12:10Sweden being right next door to,
12:12to,
12:13to countries like Russia or
12:14Ukraine or Belarus,
12:16where the the lived experience of
12:17LGBTQ people in terms of this one
12:19factor concealment looks very,
12:21very different with them with with,
12:23with actually concomitant impacts on,
12:26on mental health.
12:27Because in fact we see that the
12:29association between structural
12:30stigma and outcomes like suicidality
12:33are significantly mediated by
12:35by how much people conceal.
12:36The same is true for internalized stigma
12:40or the direction of negative societal
12:43attitudes towards the towards the South.
12:46So this is like responding to to question
12:48like I wish I could be straight,
12:51if I could take a pill to to
12:53be heterosexual I would.
12:54That's the type of items that that
12:56indicate internalized stigma and
12:58again you see a similar association
12:59between country level structural
13:00stigma and that type in that
13:02type of outcome and a similar
13:04mediation mediation association.
13:06I mean structural stigma,
13:07internalized stigma and and outcomes
13:10like depression and anxiety.
13:12So the final minority stress reaction
13:15that that that we've examined
13:18is called rejection sensitivity.
13:19So rejection sensitivity is the
13:21tendency to anxiously expect
13:23and severely react to rejection
13:25among stigmatized populations.
13:27Rejection sensitivity is understood
13:29to be an interpersonal schema
13:31that emerges and upon repeated
13:33exposure to stigma based rejection.
13:36And we studied sexual orientation
13:38differences and rejection
13:39sensitivity in that,
13:40in that longitudinal study from
13:41Stony Brook that I mentioned earlier,
13:43the the the 500 or so youth
13:46on Long Island at age 15,
13:48those youth completed a
13:49game called Island Getaway.
13:51It's like based on the TV show Survivor,
13:53whereby participants are told they're
13:55traveling through the Hawaiian Islands,
13:57they share a little about themselves.
14:01And then are voted on by their
14:03peers as they
14:04themselves vote for the peers that
14:06they want to proceed or kick off
14:08and to to move to the next island.
14:10Unbeknownst to the participant and the
14:12other kids were all computer generated,
14:15but there was a good cover story
14:16and that the kids would believe
14:18that there were other kids and
14:20completing the task at the same time.
14:22So our primary behavioral outcome was,
14:25was ingratiation,
14:26namely how many of the peers who
14:28had rejected the participant.
14:30Did the participant nonetheless
14:32vote to to stay on for the next
14:35round through the Hawaiian Islands
14:37and this Island getaway task?
14:39And what we found was that sexual
14:41minority youth did in fact display more
14:43ingratiation than their heterosexual peers.
14:45And this ingratiation is a behavioral
14:48marker of rejection sensitivity.
14:50During the island getaway task,
14:52EG data were also recorded,
14:54which also allowed us to
14:56to collect an ERP data.
14:58We are particularly interested
14:59in an ERP that measures.
15:00Individual differences in neural
15:03reactivity to rewarding stimuli as
15:05opposed to to neutral or punishing
15:08stimuli to study sexual orientation
15:10differences in this reward positivity
15:13or rupee average ERP's were calculated
15:16across both the acceptance and
15:18rejection conditions after about 300
15:20milliseconds and after after the
15:21social feedback was given where it
15:23was maximal in the overall sample.
15:25The top panel shows the mean data from
15:27the heterosexual participants in the
15:29bottom panel shows the mean data from the.
15:31Sexual minority participants
15:33and the line in red indicates.
15:37The line and red indicates the responses
15:40to to neural responses to rejection
15:43and the line in green indicates
15:46ERP responses to to acceptance.
15:49And what you see is that there was
15:50a trend towards a small sexual
15:52orientation difference such that
15:54sexual minorities showed showed.
15:58Response positive feedback,
15:59which other research,
16:01including research using this sample,
16:02has shown to be predictive of of
16:04the development of depression.
16:05Importantly, this main effect was
16:07qualified by an interaction with parental
16:09support such that the sex orientation
16:11difference and repeat wasn't significant.
16:14It averaged or high levels of family support,
16:17but but was only significant
16:18low levels of family support.
16:20Now, unfortunately,
16:20as I showed earlier,
16:22LGBT youth are much less likely
16:25and consistently.
16:26More likely to report and poor parental
16:29lack of parental support in their lives,
16:32which which is unfortunate given given
16:35the known importance of parental support
16:37as a buffer against against depression
16:40and an evidence here suggests through
16:43mechanisms that might drive depression.
16:45So overall,
16:46the results that I just reviewed support
16:49the tenants of minority stress theory.
16:52You have structural and interpersonal forms
16:54of stigma being strongly associated with.
16:57Or mental health and you have this
16:59association being mediated by minority
17:01stress reactions like identity concealment,
17:03internalized stigma,
17:04rejection sensitivity that lead
17:06LGBTQ people to respectively,
17:09hide their true selves,
17:10feel ashamed and expect,
17:11and anxiously expect and poorly
17:14react to rejection.
17:15At the same time,
17:17because these reactions all
17:20represent cognitive, affective,
17:21and behavioral reactions within the person,
17:24these reactions at least can be affirmatively
17:27addressed through psychotherapy.
17:28Even if the broad structures,
17:29or even if if people's
17:31day-to-day interactions can't be,
17:33can't be easily changed,
17:35get until recently,
17:36no empirically supported mental health
17:38treatment had been created to address
17:40these reactions and and examined in
17:43RCT specifically for LGBTQ individuals.
17:45So therefore,
17:46over the past several years,
17:47our team here at Yale has been in
17:49the process of developing and testing
17:51the efficacy of an intervention
17:52that affirmatively responds to
17:54stigma and addresses minority stress
17:55reactions to improve mental health.
17:58So to create such a treatment,
18:00we interviewed numerous mental health
18:01professionals around the country,
18:03people who spent their entire
18:04careers working with LGBTQ people.
18:06We asked them how we should adapt CBT,
18:09just standard cognitive behavior
18:11therapy to best support LGBTQ people
18:15and ability to to to adaptively
18:18respond to minority stress.
18:20We also interviewed many dozen LGBTQ
18:23people who themselves were were
18:25currently experiencing depression,
18:27anxiety, suicidality, and substance use.
18:30And and and we packaged all those that
18:33kind of qualitative and expert input into a.
18:37Into a CBT treatment manual that that
18:40provides LGBTQ people with the tools
18:42to understand and challenge the ways
18:44that minority stress impacts their lives.
18:46And they're in their mental health.
18:48So the mental health professionals
18:50told us about the way they've
18:52seen LGBTQ people grow past the
18:54painful lessons of stigma by first
18:57acknowledging the existence of stigma,
18:58kind of raising their awareness of the
19:01fact that stigma is is a reality and
19:03that that that that has to be coped
19:05with in the lives of LGBTQ people.
19:08Learning skills for standing up
19:09to stigma is kind of insidious
19:11and harmful impact.
19:13But within within oneself,
19:15learning it how stigma can can
19:18shape biases like internalized internalized
19:22**** negativity or internalized transphobia,
19:24leading people to believe that they're
19:26inferior to heterosexual cisgender people,
19:29leading people to kind of chronically
19:31anxiously expect rejection even, you know,
19:33in their in their close relationships
19:35or even even among other LGBTQ people.
19:38Um, learning new empowered.
19:40Um, ways of of of behaving
19:42and finding support, meaning,
19:44and purpose, including from within
19:46the LGBTQ community as they do so.
19:49So like I said,
19:50we packaged that expertise that
19:52that qualitative feedback into
19:54into a treatment package and LGBTQ
19:57affirmative CBT quite simply,
19:59and then tested the treatment success
20:01and an initial randomized control trial.
20:03And keep in mind,
20:05until this research no.
20:06Despite the the fact that LGBT people
20:08are one of the highest risk groups for
20:10for these mental health challenges,
20:12no mental health treatment for
20:14LGBTQ people had ever been tested
20:16in an RCT to see if it worked so.
20:18Unfortunately don't have time to go
20:20into the the exact content of the
20:22treatment but I'll I'll I'll summarize
20:24by saying that it's guided by a
20:26personally tailored minority stress
20:28case conceptualization that specifies
20:31techniques for addressing various
20:33minority stressors that that LGBTQ
20:35people might be facing and then and
20:38and and then provides a set of of.
20:42The principles and techniques,
20:44both based in CBT and the integration
20:46of CBT with minority stress theory,
20:49that help LGBT people raise
20:51awareness of the existence of early
20:53and ongoing sources of minority.
20:59That help LGBTQ people reduce
21:01characteristic ways of avoiding the
21:03emotional consequences of minority stress,
21:06such as drinking alcohol use, self harm
21:09and other forms of emotional numbing,
21:11asserting oneself against the emotional
21:13consequences of minority stress to
21:15break social withdrawal tendencies.
21:17Reworking. Internalized.
21:21Umm, homophobic, biphobic,
21:23transphobic, and cultural ideologies.
21:26Importantly, not challenging the veracity
21:28of of discrimination in the world,
21:31but instead challenging the veracity
21:33of their internalization that one is
21:35rejectable or that one is not lovable,
21:37or that one is inferior to to to others.
21:40And then intentionally building and
21:42drawing on cues of of social safety and
21:45and and and and and people's worlds,
21:48including from within the LGBT
21:49community and the broader community.
21:51So this this treatment overall
21:54teaches people these cognitive,
21:56affective,
21:56and behavioral skills to help them
21:59start overcoming the the patterns
22:02of thinking and behaving that they.
22:04People often have a root and minority
22:07stress and often are kind of have
22:09a deeply planted root that that
22:11characterizes a lot of their a lot of
22:13their behavior and that sets in a lot
22:15of their reactions to stress that can
22:17set them up for mental health risk.
22:20So in an initial weightless control
22:22trial with with 60 young game asexual
22:24men in New York City we found initial
22:26evidence for the promise of this treatment.
22:29So looking at the lines in blue which
22:31is the effect of the from having.
22:34Received the treatment compared to the
22:36lines and Gray which is the effect
22:38from from being put on a wait list.
22:39We found that the treatment helps
22:41these young gay bisexual men feel
22:44less depressed less anxious,
22:45drink less and and have safer sex
22:48at three months following the the
22:51the treatment or the the wait list.
22:53We do very similar study with 60 young
22:57sexual minority women in New York City
22:59many of whom were were transgender
23:01or gender non binary similar to
23:02the pilot study with young gay and.
23:04Sexual men we found that compared
23:06to waitlists the treatment was
23:08associated with significantly greater
23:09reductions and and and depression and
23:12anxiety and an unhealthy alcohol use.
23:14All these outcomes that that are
23:17particularly disproportionately
23:19likely to affect LGBTQ people.
23:22We then asked whether this treatment
23:24might be more efficacious than
23:25existing treatments for LGBTQ people.
23:27So in a trial with 254 young gay and
23:30bisexual men in Miami and in New York City,
23:32we compared this LGBTQ affirmative
23:34CBT to supportive counseling in the
23:37community and to a single session
23:39of HIV testing and referral.
23:41That we chose HIV testing and single
23:43session HIV testing and and and referral
23:46because it's the most common way that
23:48young gay and bisexual men encounter
23:50and LGBT specific healthcare services.
23:52I'm in the US testing for HIV,
23:55that is,
23:56with the with the.
23:59In a in a in an HIV STI screening
24:02appointment takes,
24:03you know 20-30 minutes and it's
24:05and it's a frequently used service
24:06in the lives of LGBTQ people.
24:08But we thought we'd use that
24:09as a as a quite weak control.
24:11And what we found was that LGBTQ
24:13affirmative CBT was associated with
24:15small to moderately relative benefit
24:17compared to to the two other treatments.
24:20Effect sizes were the largest for substance
24:22use problems with LGBTQ affirmative CBT,
24:25yielding significantly greater
24:26impact on the substance use problems
24:28than the other two conditions.
24:30Also consistent with the trans
24:32diagnostic basis of the treatment,
24:34the targets minority stress reactions
24:36theorized to underlie all of the
24:39multiple Co occurring outcomes that
24:41disproportionately affect LGBTQ people.
24:43We also found that the treatment
24:45was associated with significantly
24:47stronger efficacy for reducing
24:49comorbidity across depression,
24:50anxiety, substance use, and HIV risk.
24:52Then the then the two comparison conditions.
24:57We then performed what's called
24:59a treatment effect heterogeneity
25:01analysis to identify the strongest
25:03moderator of set of moderators of
25:05LGBTQ affirmative CBT's efficacy.
25:06So we did this by asking the the,
25:09the the therapist over the the
25:11four or five years of this study.
25:13So we surveyed them at the end of the
25:15study to nominate any and all factors
25:17that they thought may have led some
25:19participants to benefit more from
25:20LGBTQ affirmative CBT than others.
25:22They suggested a list of 20 potential
25:24moderators that we then subjected
25:26to a machine.
25:27Learning approach to identify
25:29the top moderators.
25:31So we pre registered this analysis
25:33and with the primary outcome of our
25:35comorbidity count of depression, anxiety,
25:38HIV risk behavior and substance use.
25:41Only one moderator emerged as significant,
25:45namely race and ethnicity,
25:46such that Black and Latinx participants
25:49who compose the majority of the sample
25:51experience significantly more reduction in
25:53comorbid conditions from LGBTQ affirming.
26:00So we haven't been able to empirically
26:02identify the reasons for this moderation.
26:04But clinically, we noted that
26:05black and white Max participants
26:07seem more amenable to the minority
26:08stress focus of the treatment.
26:10Perhaps because they were they
26:11were better able to to draw,
26:12they were able to drop on the
26:14racial socialization experiences,
26:15to incorporate the minority stress
26:18focus of LGBTQ affirmative CPT and
26:21into and into into their lives,
26:23or perhaps perhaps because
26:25LGBTQ affirmative CBT.
26:27Addressed not only minority stress,
26:29sexual minority stress,
26:30but all identity related stress in their
26:33interactions and and in reality it.
26:35It would be hard if not impossible
26:37to kind of tease apart how
26:39people are are incorporating an
26:41identity focused lens of CBT.
26:42And separately depending on the all
26:44the the different social identities
26:46they might they might identify.
26:48For example the assertiveness
26:49practice in the treatment wouldn't be
26:52limited only to 1 aspect of someone's
26:54identity who would naturally apply
26:55even to racially hostile situations.
26:57As well.
26:59So we're now studying whether this
27:01treatment can can lend itself to to,
27:03to maybe even more efficient reach
27:05by using an asynchronous form of the
27:08treatment whereby LGBTQ young people,
27:09in this case anywhere in the US,
27:11can receive 1010 weeks of the
27:13psychoeducational content about minority
27:15stress and CBT and learn skills for
27:17addressing its emotional impact.
27:19They can read about this online,
27:20they can share their written reactions
27:22and try out the CBT skills through
27:24through homework exercises in their lives,
27:27and they can receive and and.
27:29They do receive weekly feedback
27:31from from the therapist this we're
27:33in the process of comparing this
27:35treatment to to to relatively weak
27:37control condition just simple self
27:39monitoring and mood and minority
27:41stress and then and then this will
27:43set us up to eventually compare this
27:46this perhaps more efficient way of
27:48delivering the treatment to to to
27:51perhaps the more time intensive
27:52standard you know kind of 50 minute
27:55session once a week that would and
27:57that we've that we've used in our other.
28:00This will allow us to to to weigh
28:02the relative benefits of this
28:04delivery modality capable of of
28:08potentially wider reach.
28:10So these are initial trials.
28:16Oh, wait, sorry. So, so Speaking of REACH
28:20and I now want to highlight our team's
28:22efforts to ensure the implementation of
28:25this effective treatment and our local
28:27communities and to ensure that our treatment
28:30response to the needs of those communities.
28:32So we know that that LGBTQ identities
28:35don't exist in isolation, but rather
28:37they Co occur with other identities.
28:39We also know that if current rates continue,
28:42a black gay man in the US has
28:43a one in two chance of becoming
28:45infected with HIV in his lifetime,
28:47the average Latinx.
28:48Scared bisexual man.
28:49So one in three chance of becoming infected
28:51with HIV in his lifetime at current rates,
28:54with the source of this disproportionate
28:56risk being solely in intersecting
28:58sources of structural discrimination
29:00towards LGBTQ people and and
29:02racism towards people of color.
29:04We also know that the fastest
29:06increases in new new incident cases
29:07of HIV are occurring among young
29:09black gay and bisexual men in small
29:12urban areas places like New Haven.
29:13So I was approached by by medical provider
29:16what one of the medical directors.
29:19Working at the Fairhaven Community Health
29:21Center and FQHC here in New Haven,
29:23who was witnessing this epidemic first hand.
29:26She reached out to me after a particularly
29:29hard month of of diagnosing several of her,
29:32her young black and white next gay
29:34patients with with HIV and said that,
29:37that that that,
29:39that she was,
29:41that she was very motivated to try
29:43to address the the kind of holistic
29:45circumstances in their lives that that set
29:47them up for this risk and she knew about.
29:49This Umm this LGBTQ affirmative
29:51CBT treatment that we had done and
29:54and asked if if we could perhaps
29:56deliver the treatment at Fair Haven
29:58do it in a group based setting.
30:00Because she had the the sense that
30:02that her patients could benefit from
30:04talking to each other to help them
30:06see that they that they weren't alone
30:07to help them see that they were going
30:10through similar struggles to build
30:12community and so and so we did that.
30:14And, and doctor Skyler Jackson,
30:16who was at the time of postdoc in my lab,
30:18now Sistant professor in our department.
30:21He he he he he brought the study.
30:23He was also one of the the therapist
30:25on the study.
30:26And then before we deliver the treatment,
30:28we interviewed about a dozen game
30:30bisexual men of color in New Haven to
30:32get a sense of their interlocking forms
30:34of stigma and how they influence their
30:36mental health, their day-to-day lives,
30:38and their sense of community and connection.
30:40We then packaged the results of
30:42those interviews into the LGBT.
30:44Affirmative CBT treatment to make sure
30:46that the therapist can be prepared
30:49and responsive to the to the unique.
30:51Challenges and and resiliencies
30:53experienced by by, by this community.
30:59For the treatment and this pilot study
31:01to to 21 black and Latino gay and
31:03bisexual men that they are having.
31:05I should say that Doctor Jackson has
31:07since received a K award to expand
31:09this work to to to similar communities.
31:11It's it's similar similar locales
31:13like in bisexual men living there
31:16in the in the US S so in this small
31:18pilot that we did a fair haven we
31:20found reductions in the expected
31:21direction for for almost all of the
31:23outcomes and perhaps most relevant for
31:25this pilot study we found evidence.
31:27That this intersectionality adapted group
31:29based format of LGBTQ affirmative CBT
31:32could be implemented quite feasibly.
31:34Most of the participants showed up
31:36to to to nearly all of the sessions,
31:39but perhaps looking at how they
31:41talked about the treatment in their
31:43own words kind of drives the the,
31:45the, the, the,
31:45the point and the purpose of this
31:48intervention home quite well,
31:49for example.
31:52One participant said I used to think
31:53that being gay was a bad thing and
31:55that I should be ashamed of myself,
31:56that I should try and be straight
31:57and that I shouldn't hang out
31:59with like other gay people.
32:00Now, after the treatment,
32:02it's it's the exact opposite, another said.
32:04After the study.
32:05I came out to my mom,
32:06I came out to a lot more friends.
32:07Now I'm just like,
32:08I'm just living my best life,
32:09as people say,
32:10going back to that kind of the the the
32:12cost of of hiding a part of oneself,
32:15including from from one's own parents,
32:17and kind of the the the challenges,
32:19but also potential benefits.
32:21Of coming out,
32:22which this treatment helped
32:23this this one young man do,
32:25another participant said.
32:26It helped me a lot to how do I say it?
32:27Be happy with myself like except myself.
32:29In the session,
32:30people actually listened and
32:31cared about what I had to say,
32:33so the treatment helps
32:34strengthen their identities,
32:35as gained bisexual men most consistently,
32:39most participants noted a simple but
32:41impactful take away illustrated by
32:43this this last participants quote
32:45simply that the treatment made
32:47them feel like they weren't alone,
32:49which is something that.
32:50That the providers working at Fairhaven
32:52had been seeing in their patients.
32:54They had the sense of isolation,
32:56the sense of loneliness,
32:57and the treatment was was
32:59actually a self against that.
33:00So with the goal of assessing whether
33:03LGBTQ affirmative CBT can continue
33:05to be implemented and compete in
33:07community settings across the country,
33:09we identified an ideal network of
33:11settings where this can happen.
33:12So.
33:13You know,
33:14the US doesn't have a universal
33:17healthcare system.
33:18But but it does.
33:19But it does have kind of this amazing
33:21resource that was created by the LGBTQ
33:24community in the in the 1950s and 60s.
33:26Specifically,
33:27the US has more than 300
33:30LGBTQ community clinics.
33:31These are these are grassroots
33:33clinics established and in
33:34many cases and during the gay
33:36rights movement of the 60s
33:38where LGBTQ people were were were not having
33:41their their needs their their healthcare,
33:43mental health care needs met.
33:45So they they they did it themselves.
33:47These centers got even more attention
33:49during the the the AIDS epidemic in
33:51the 80s and 90s in particular where
33:53where where they became a kind of an
33:55indispensable place to to to do the
33:57outreach and provide the care that they
33:59continue to be neglected by more formal.
34:01Settings. About 40% of these of
34:05these clinics provide mental
34:07health services to to a combined.
34:10The report is it's a combined 50,000 people,
34:13LGBT people each year.
34:14Because they often provide free or heavily
34:17subsidized mental health services,
34:19they're providing these services to people
34:21who otherwise wouldn't be able to get care.
34:22I'm including individuals with lower
34:24incomes and LGBT people of color,
34:26trans women.
34:27So we specifically partnered with Centrelink,
34:29which is the coordinating hub of
34:31the US's 300 plus LGBTQ centers,
34:34to survey the directors and CEO's
34:36of these centers to get a sense
34:38of their capacity and interest
34:39and willingness to implement.
34:41Our LGBTQ affirmative CBT
34:43intervention and as you can see.
34:46Most.
34:46Of the CEO's and directors reported
34:50that they saw room to improve their
34:52their current mental health offerings.
34:54Most also reported that their staff can
34:56benefit and being trained in an evidence
34:59based treatment like LGBTQ affirmative CBT.
35:01And 100% of them said that they'd be
35:03willing to provide the administrative
35:05support and staff time necessary
35:06for their mental health staff to be
35:09trained and an LGBTQ affirmative CBT.
35:11So we train them,
35:13but not only that,
35:14we use implementation science to determine
35:15whether the training was efficacious.
35:17Namely we used a weightless control
35:19trial over 11 week training and
35:22LGBTQ affirmative CBT to to about
35:24130 providers in this initial pilot
35:26test working in LGBTQ community
35:28centers across 21 states.
35:30This was this,
35:31this took place during the pandemic
35:33when we were all everyone in my lab
35:35was kind of sitting at home with
35:37kind of wondering what to do and
35:38how to do it and and and this was
35:40kind of an ideal opportunity to take
35:42advantage of the ability to train
35:44people remotely to do work that they
35:46that they were continuing to do.
35:47And and and and we're kind of in in
35:50in great need of support for doing
35:52it given the increasing demands
35:54including among LGBT people for from.
36:00So we we we organized like a lunchtime
36:04webinar, training live every week for
36:0611 weeks and randomly assigned half of
36:08the providers to the to to receive the
36:11training immediately the other half.
36:13So wait list where they received
36:14the training after four months.
36:16And what we see looking at the lines in blue,
36:17which is the effect of receiving the
36:19training compared to the lines in red,
36:20which is the effect of receiving
36:22the wait list.
36:22Our analysis showed that the training
36:24was associated with significantly
36:26greater increases in LGBTQ affirmative.
36:28Cultural competence,
36:29minority knowledge of minority,
36:31stress theory and how it can
36:33be applied in practice.
36:34CBT knowledge and familiarity with
36:36the LGBTQ affirmative CBT skills.
36:39And then we took this cool thing where
36:42we hired young LGBTQ actors in in
36:45Hollywood to role play being LGBTQ client.
36:48We gave them kind of a script of
36:49how to role play being kind of a
36:52characteristic young LGBT person
36:53going through a hard time.
36:54We then showed that video to each
36:56of the providers individually
36:57and then had the providers.
36:59Describe how, what,
37:01what tools,
37:02what skills and approaches they
37:03would use just in free form
37:05writing to help that person.
37:06And then we had research
37:08assistants code the writing for
37:11the presence of LGBTQ affirmative
37:13CBT content and and and this last.
37:15Kind of box of skills used shows that
37:18that the providers are much more
37:21likely to describe applying LGBTQ
37:23affirmative CBT to the to the to
37:25the role played client from before
37:27the training compared to after the
37:29training and the coders were masked
37:31to whether the the description came
37:33from the control group the the
37:35active training condition or whether
37:37they were submitted at baseline
37:39or or following the training.
37:41So finally,
37:42we wanted to know whether this we
37:44wouldn't know whether the streaming can
37:46be disseminated to other high need,
37:48high stigma locales.
37:51So first,
37:52we're working with our colleagues
37:53in Changsha,
37:54China and Hunan province to adapt
37:57LGBTQ affirmative and CBT to respond
37:59to the intersections of Chinese
38:01culture and LGBTQ identities there.
38:03Given that the the experience of of
38:06LGBTQ people can look quite different
38:08than than than LGBT people in settings.
38:11Like the US with them with with with
38:14kind of marriages of convenience
38:16being highly highly common something
38:19like 70% of young LGBT people
38:21report being and I'm and I'm in a
38:23heterosexual marriage where both
38:25partners know we're both parties
38:26know that I'm that that one or both
38:28of the others or themselves LGBT
38:30and and and this is done you know
38:33to uphold a kind of Chinese family
38:36values and and and and and other
38:39pressures that young LGBT people in China.
38:41Will report related to their to
38:43their sexual identity.
38:45And so we used,
38:46I should say they used the the team
38:48in China has really done a fantastic
38:49job carefully adapting the treatment model,
38:52working with the LGBTQ community to
38:54ensure that the resulting treatment
38:56was appropriate and resonant with them,
38:58the young LGBT people that they work with.
39:01This included meeting with experts
39:04community demonstrations training
39:06the therapist and doing a initially
39:08a small open trial which showed
39:10you know early promise of the of
39:12of the ability of the session to
39:15impact depression and and anxiety.
39:17We're not testing this adaptive treatment
39:19using our asynchronous delivery
39:21platform that I showed earlier and
39:23in RCT with them with with with 120
39:25young gay and bisexual men and and and
39:28working with colleagues in China has.
39:31Has been rewarding because of
39:34connections to like the China CDC and
39:37the the the interest in in government
39:40officials and and and and and kind of.
39:42And in addressing the the spread
39:45of HIV among getting bisexual men
39:47and doing that through through.
39:49They're delivering tailored healthcare so.
39:52So we have buy in of of of not only
39:54community partners but also on government
39:56and and and and healthcare officials
39:58who who can who can work to to uptake
40:01and and implement this intervention if
40:03it continues to show to show promise.
40:06Another side of our work is Romania and
40:08which is one of the most normatively
40:10anti LGBTQ countries in Europe where
40:12identity concealment is the norm
40:14where and where LGBTQ affirmative
40:16mental health services are are are
40:18pretty much whacking completely.
40:20So in addition, you know,
40:21we had received funding to do these RCT's
40:24of mostly of HIV prevention interventions
40:26with young gay bisexual men in Romania.
40:29But at the same time we
40:31were hearing all these,
40:32you know,
40:33very moving and compelling stories
40:35about how these men existed in in
40:38in a situation where they couldn't
40:40receive any other mental or sexual
40:43health support outside of our study.
40:45So, you know,
40:46it raises this kind of quandary
40:48of here delivering individually.
40:50Focus things like CBT to to
40:53population what you're sending them.
40:56You know, but you know.
41:00Doctors that that can't that can't
41:02be supportive outside of the
41:04context of that of that study.
41:06So what we do is we started building a
41:08cadre of of of mental health professionals
41:11who could who could work to to kind
41:13of change the attitudes of the mental
41:16health professionals in Romania to
41:17to to be more LGBTQ affirmative.
41:20So one of the things we did for
41:22example was invite a kind of a network
41:24of of mental health professionals
41:26in remaining to to attend.
41:28The training that we did of
41:31LGBTQ affirmative therapy and.
41:34200 people showed up and then we
41:36randomized them to either received the
41:37training in person or to receive it remotely.
41:39And this is an important.
41:42Implication from kind of global
41:45implementation perspective and that you know,
41:48it's hard and and challenging to to
41:50show up in person to every country
41:52where such a training might be needed.
41:54But if we can show that remote online
41:56training works works just as well,
41:58it really has implications for feasibility
42:00and cost and time effectiveness
42:02and in fact that's what we found.
42:04So the lines here whether people
42:06were the providers were either
42:08randomized to receive the training
42:09in person or to receive it online.
42:12Regardless of whether providers
42:13received it in person or online,
42:15we found that we found significant
42:17reductions in explicit bias and even
42:2015 months after the the treatment
42:22and reductions in in implicit bias
42:25towards LGBT people and uptake
42:27in LGBTQ affirmative practice.
42:28Skills, beliefs,
42:29behaviors and the effect sizes here are
42:32very small because they're comparing the,
42:35the, the, the, the,
42:36the impact of delivering of delivering the
42:39treatment in person versus versus online,
42:41so, so.
42:42Some kind of important test of
42:44preparing for future implementation.
42:46So, so future research directions,
42:49I think,
42:50involve continuing to be curious and
42:52open about whether and how we need
42:55to adapt existing treatments for for
42:57sexual and gender minority populations.
42:59While at the same time I may be
43:02moving beyond RCT's to speed up
43:03the dissemination of treatments
43:04that we already have,
43:05including so we have we we have
43:08many evidence based psychotherapies.
43:11For example, for for the general population,
43:15those therapies can be adapted right
43:17now using using kind of evidence based.
43:22LGBTQ tailored case conceptualizations
43:24and so like we've derived this type
43:27of guidance and published it of how
43:29people who were delivering whether it's
43:31IP T or or more expensive experiential
43:34or emotion focused therapies or more
43:37more interpersonally focused therapies
43:39can can can all borrow from the the
43:42general quite general LGBTQ affirmative
43:44principles that that that we use to
43:47adapt and CBT to to think creatively and
43:49carefully about how to make existing.
43:52Evidence based practice more responsive
43:54to to the LGBTQ population without
43:56going through the you know 1015 years
43:59of of effort needed to develop the
44:01treatments from scratch to adapt them
44:02test them in RCT's and then I'm and
44:04then ultimately hope that they'll be,
44:06that they'll be implemented.
44:08I'm Speaking of implementation.
44:10What our what our lab is currently
44:12working on is using the tools of
44:14implementation science including from
44:15global mental health context where
44:17where you know evidence based practice
44:19is being scaled up using tech and
44:21task shifting to ensure that providers
44:23are trained in treatments that are
44:25responsive to the needs of of local
44:27communities especially in in high need
44:29settings across the US and and globally.
44:32So a lot of excitement about about
44:34about moving this work forward to
44:36to to reach those who who could
44:39continue to benefit from it.
44:41So in conclusion,
44:42you know from the beginning of the LGBTQ
44:44rights movement and affirmative stance
44:46towards mental health was you know,
44:49one of the few basic demands
44:51of the LGBTQ community.
44:53We have to keep in mind that you know,
44:54the, the, the, the,
44:56the mental health profession,
44:57you know,
44:58it's historic role in the mental
45:00health of LGBTQ people was to use
45:03its power to pathologize LGBTQ people
45:05through through pathologizing,
45:07diagnosis,
45:07abusive conversion therapies and
45:09things that justified the.
45:11The criminalization and kind of and
45:14kind of you know spending ones life you
45:17know as a as a persecuted population
45:20you know spent in solitude and sickness.
45:24But the fields come a long way
45:25and I think we can,
45:26we,
45:26we can and should be proud of that and
45:29we now have scientific evidence that
45:31LGBTQ affirmative CBT's are efficacious.
45:33They're capable of community
45:35implementation and they're capable
45:36of relatively efficient dissemination
45:38to high to high stigma settings
45:40worldwide and where that.
45:41Without legacy and and all too
45:44often unfortunately persist in our
45:46continued application of research
45:47to the to this express need of
45:50the LGBTQ population and will only
45:53hopefully continue to ensure its
45:54continued and equity and and thriving.
46:01All of you for showing up.
46:02Thank you to the Department of Psychiatry
46:04for being one of my professional one of
46:07my two professional homes here at Yale.
46:09Thank you for the support of of
46:11this topic and through the LGBTQ and
46:13advocacy and practice and research
46:14efforts and Department of Psychiatry
46:16the research presented here today is
46:18there is the result of the hard work
46:20of of the committed caring people
46:21shown here and and and and and several
46:24others who who've who've been part
46:25of our initiative and in the past.
46:28Most of whom are listed here as long as,
46:31as well as the funding sources
46:32and our collaborators.
46:33So thank you all and I eagerly
46:35look forward to your questions.
46:37Thank you.