Contextual Framework on the Barriers, Assessments and Treatments

Introduction

 Everyone experiences emotional ups and downs from time to time caused by certain events in our lives. Mental health related conditions go beyond these emotional reactions to specific situations. They are medical conditions that cause changes in how we think and feel and within our mood. But for individuals who identify as lesbian, gay, bisexual, transgender, queer/questioning, intersex, asexual, non-binary and others along the spectrum of sexual and gender identities (LGBTQ+), face significant mental and physical health disparities compared to their heterosexual and cisgender identified peers. Such differential outcomes are often attributed to a minority stress theory; which is chronic stress that is specific to one’s marginalized status and which is distinct from normal everyday life stressors for example (Outland, 2016). Other factors that contribute include, historical trauma, internalized stigma, and current policies. The LGBTQ+ population has a traumatic history with mental health services. That history, combined with internalized stigma, current policies and barriers to accessing services/treatment dictates that providers have an ethical obligation to be informed and competent. By looking at such factors, barriers, a minority stress theoretical model, and ethics, we can begin to look at the implications for practice regarding the best assessments and treatments for mental health services when working alongside with clients within the LGBTQ+ communities.

A.    Prevalence about the need for mental health services

 Dr. Pachankis (2016) states that in the past several years, psychologists and therapists have found that despite most LGBTQ+ individuals being resilient due to minority stress issues; also stating that LGBTQ+ individuals on average are significantly more likely than heterosexuals to report experiencing certain mental health symptoms like depression and anxiety, that LGBTQ+ individuals are more likely to utilize mental health services and lastly, Pachankis states that most therapists report seeing at least one LGBTQ+ individual within their practices. Further, he said that mental health disparities for those identifying as sexual minorities start relatively early in development and co-occur with several sexual and behavioral health risks, such as alcohol use and sex-risk behaviors. These statements show some of the key factors surrounding the need for mental health services that could serve the specific needs of the LGBTQ+ populations compared to others.

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 Further, there is statistical evidence that enlightens the reality of mental health-related issues needing to be addressed, particularly within the LGBTQ+ communities. According to Mental Health America (2018), there are approximately one in five adults in the U.S.—43.8 million, or 18%—experiencing mental illness in a given year. These numbers are shocking to anyone, but for those who identify as lesbian, gay, bisexual, transgender, queer +, it is even more alarming.

 “Mental Health America” (2016) states that as compared to people that identify as straight, LGBTQ+ individuals are three times more likely to experience a mental health related condition than compared to heterosexual or cisgender identified individuals. Further, this is not just regarding adults; as LGBTQ+ youth are four times more likely to attempt suicide, experience suicidal thoughts, and engage in self-harming behaviors, as compared to youths that are straight. For transgender individuals, 38-65% experience suicidal ideation tendencies. These mental health related issues, often lead to 20-30% of LGBTQ+ individuals abusing substances, compared to nine percent of the general population. Regarding alcohol, there is a 25% concern of LGBTQ+ individuals abusing alcohol, compared to 5-10% of the general population. And finally, Mental Health America (2016), states the LGBTQ+ population experiences 2.5 times more symptoms of depression, anxiety and substance misuse to name a few. These statistics show the alarming prevalence regarding the need for mental health services that can work more closely with these populations in addressing their specific co-occurring needs.  

B. History & Policy

 Historically, there have been factors such as traumatic conversion therapy outcomes, diagnosis changes regarding sexual orientation and gender, leading to misdiagnoses over the years for LGBTQ+ individuals (Meyer, 2003). Policies have also affected the proper treatment and care for these vulnerable populations when it comes to getting mental health services (Anastas, 2013).

 The Diagnostic and Statistical Manual of Mental Disorders (DSM), is a book published by the American Psychiatric Association (APA) that provides a set criterion regarding a diagnosis of mental health condition. The DSM is predominantly used by mental health practitioners in the United States to aid in diagnosing clients (American Psychiatric Association, 2019). It is also used for data collection and billing purposes when working with insurance companies. There has been controversy regarding certain diagnostic criteria in classifying disorders. Neel Burton from his article on Psychology Today’s website titled ‘When Homosexuality Stopped Being a Mental Disorder’ (2015) states that in 1968, the DSM-II edition listed homosexuality as a mental disorder. It was with this classification that produced homosexuality apart from typical sin-like beliefs from religious perspectives into an actual mental disorder classification. This new diagnosis created extreme backlash and protests from the LGBTQ+ communities on where they were getting the scientific proof that homosexuality was a mental disorder. Burton (2015) continues on to point out that in 1973, the APA had its members vote on whether they believed homosexuality to be a mental disorder. With the numbers coming back somewhat split, the APA compromised by removing homosexuality from the DSM, and replacing it with a “sexual disturbance” for people “in conflict with” their sexual orientation.  It was not until twenty years later in 1987 when homosexuality gets removed from the DSM. According to Burton (2015), “the evolution of the status of homosexuality in the classifications of mental disorders highlights that concepts of mental disorder can be rapidly evolving social constructs that change as society changes. Today, the standard of psychotherapy in the U.S. and Europe is gay affirmative psychotherapy, which encourages gay people to accept their sexual orientation.”

 With the DSM’s misdiagnosis in classifying homosexuality as a mental disorder, there have historically been experimental, harmful, traumatic and controversial techniques to try and cure, alter or rid someone of their mental condition. One such treatment has been the use of conversion therapies. Jessica Horner in her article titled Undoing the Damage: Working with LGBT Clients in Post-Conversion Therapy (2010), talks about how the majority of licensed clinicians feel this type of practice is unethical and rare in occurrence. It is hard to give an exact number of where conversion therapy is predominantly done but Horner states that the individuals suffering from the adverse effects of conversion therapy appear even in diverse urban areas such as New York City. Horner (2010) states that “though we generally consider those who undergo conversion therapy to be bisexual, gay men, or lesbians, transgender individuals have also experienced conversion therapy since not all transpersons identify as heterosexual” (p. 8). Horner also mentions that it may affect anyone who identifies within the LGBT communities.  Further, Horner states that “as an historically undeserved sexual minority population subjected to homophobia and transphobia, LGBT clients present with symptoms of depression, anxiety, and post-traumatic stress disorder. These symptoms are the result of overt aggression, physical assault, living with limited civil liberties, microaggressions, and the overall unaccepting social climate of an inherently homophobic society.” (Horner, 2010 p.8)

 Horner references the National Association of Social Workers Committee on Lesbian, Gay, and Bisexual Issues (NCLGB) (2000); regarding their stance that such type of conversion therapies can produce severe emotional damages and provides no actual evidence-based data on the effectiveness of such treatments. In fact, they argue that such practices are harmful. Homelessness, suicidal ideations and substance abuse behaviors also correlate to the effects of conversion therapy clients. The Human Rights Campaign (2019) shares that highly rejected LGBTQ+ youth or those who have experienced conversion/reparative type treatments are eight times more likely to attempt suicide—six times more likely to experience higher levels of depression—three times more likely to use illegal drugs or substances, and three times more at risk for HIV and STDs diagnoses.  Further there are implications for best practices when working with clients affected from these treatments to help reduce such statistics from occurring which will be addressed.

 Policy issues are a constant factor for social workers, clinicians, therapists when working with individuals and families. Jeane Anastas (2013) discussed how even though some groups in the U.S do have some civil rights, goes on to mention that “lesbian, gay and bisexual people as well as those with differing gender expression, which includes those who identify as transgender, do not enjoy such protections.” In addition, Anastas references the National Association of Social Workers (NASWs) Code of Ethics from 2008, in which they state:

Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical disability. (p. 302)

 Furthermore, Anastas (2013) shares how “inequalities, inequities, and social exclusion are just as detrimental to the health, mental health, and human wellbeing of lesbian, gay, bisexual, transgender, and queer (LGBTQ) people as they are to the health and wellbeing of their heterosexual counterparts.” Lastly, Anastas (2013) sums up greatly how policy can impact those who identify as LGBTQ+. She argues that social policies are mental policies as it does affect one’s mental health and well-being on a daily basis. Though published in 2013, Anastas article shows how much has not changed regarding policies and LGBTQ+ individuals health policies.

 Employment for LGBTQ+ individuals continue to cause discrimination issues. The National Center for Transgender Equality website (n.d.) states that though most equal employment opportunity policies state that there is to be no discrimination based on someone’s sexual orientation, there continues to be lack of employment opportunities for LGBTQ+ individuals, particularly transgender people of color. The website (n.d.) argues that this lack of protection often explains lack of financial equality, access to work hours, compared to their heterosexual peers and that it also causes many to report having to change jobs to avoid discrimination, and that extreme levels of unemployment and poverty leads one in eight to become involved in underground economies (i.e. sex and drug work) in order to survive.

 Anastas (2013) discusses the recent use of “conscience clauses” when trying to protect health care professionals, and religious-affiliated organizations or agencies who refuse to provide services to LGBTQ+ individuals based on their religious beliefs. Examples she provided includes a counseling student who refused to work with a gay client on their same-sex relational issues, to foster care and adoption options for same-sex couples or fostering LGBTQ+ youth with LGBTQ+ foster parents. Though these types of clauses are new regarding LGBTQ+ people, it is something that needs to be observed. One could argue that putting an LGBTQ+ client in the care of a provider who does not affirm or support their identities or lifestyle could be seen as unethical when working on any mental health concerns, based on Anastas reference to the NASW Code of Ethics from 2008.

 There continues to be health disparities among the LGBTQ+ population. Health is an important factor in mental health and wellbeing, and stresses related to health problems and/or caregiving are a common reason for seeking mental health care (Anastas, 2013). As stated previously on the high prevalence’s of depression, anxiety, PTSD, suicidal ideation, substance abuse, risk behaviors leading to potential HIV/STD diagnoses, there is also high levels of discrimination and trauma, relating to a minority stress perspective when working with these clients.

 The NASW has always strongly advocated for the availability for health and mental health services for the LGBTQ+ populations including HIV prevention and treatments, substance abuse treatment, suicide prevention, psychological stress prevention and trauma informed care techniques. It is essential that LGBTQ+ individuals are allowed proper equal access to legal, medical and psychological care similar to any other civil or federal liberties in place. Anastas (2013) lists that such policy issues affecting the health and well-being of LGBTQ+ people include such things as: lack of preventative measures from harassment, work policies surrounding fair family medical leave opportunities for same-sex couples and barriers regarding visitations or medical decision-making factors for ill domestic partners.

C. Barriers

 The health disparities and policy issues surrounding lack of proper care for LGBTQ+ communities have created barriers on both micro and macro levels. From a micro perspective, factors such as internalized shame/oppression, attachment/trauma, and addiction/codependency issues have been a result of heterosexist victimization.  Scheer, Harney, Esposito and Wolfe (2019) wrote on the role of shame and the disproportionality LGBTQ+ individuals face in potential exposures to traumatic events in their lifetime. They discuss how feelings of shame following traumatic events can be additive and long lasting and that internalized stigma-related stressors, including shame, mediate the relationship between discrimination experiences and mental health. The studies also demonstrate that increased levels of shame related to a marginalized sexual or gender identity predict greater engagement in substance use behaviors. The authors found that although there are few studies documenting the adverse impact of shame on physical health among this population, some research does suggest that shame contributes to physical distress (e.g., back pain, migraines) among sexual minorities. Shame also has shown prevalence among intimate partner violence within the LGBTQ+ population, in part due to feelings of inferiority and powerlessness from social exclusion and stigmatization regarding their social status. Finally, their findings underscore the need for healthcare providers to sufficiently address persistent negative core beliefs relating to the marginalized identities of LGBTQ+ populations in addition to the traumatic events they experience.

 Since the micro factors surrounding mental health and LGBTQ+ populations were addressed, here is an example of a macro issue. One such macro issue regarding mental health for this population is the limited access of supports for LGBTQ+ individuals.  Regarding rural LGBT health, authors Rosenkrantz, Black, Abreu, Aleshire, and Fallin-Bennet (2017) share the significance of mental health in the LGBT population and various aspects of rural LGBT mental health through a systematic review of articles. They found LGBT mental health present in 23 articles, with the most common subtheme of peer review articles including: “high prevalence of depression  and when compared with their urban counterparts, higher rates of depression were found in rural LGBT adults rural transgender persons, and sexual minority females” (Rosenkrantz et al., 2017 p. 223). Further, the authors mention how some results showed increased suicidal ideation among rural LGB youth and rural transmen. As cited in Rosenkrantz’s (et al., 2017) review of articles, they mention findings of how LGBT “participants were met with hostility from providers, being questioned about their relationships, being joked about, being the target of heterosexist comments, and being turned away from care” (p. 234).

 These barriers along with the micro factors of shame, stigma and discrimination, many rural LGBTQ+ individuals to become isolated, and experience a lack of social supports or engagements. Although these factors occur in urban populations, the authors continue to show the need for further research into implications for best practices when working with this marginalized population.

D. Minority Stress

 In order to look at what the recommended treatments and implications for best practices when working with this population, it is best to understand the theoretical model associated with providing some recent top research and evidence-based results showing that the LGBTQ+ populations are suffering from what is referred to as minority stress when it comes to the effects of their mental health. Ilan Meyer (2003) states that evidence from this research suggests that compared with their heterosexual counterparts, LGBTQ+ individuals suffer from more mental health problems including substance use disorders, affective disorders, and suicide and the preferred explanation for the cause of the higher prevalence of disorders among LGBTQ+ people is that stigma, prejudice, and discrimination create a stressful social environment that can lead to mental health problems in people who belong to stigmatized minority groups; or minority stress (Meyer, 2003).

Meyer (2003) cites from various sources that:

 To distinguish the excess stress to which individuals from stigmatized social categories are exposed as a result of their social, often a minority, position. The foundation for a model of minority stress is not found in one theory, nor is the term minority stress commonly used. Rather, a minority stress model is inferred from several sociological and social psychological theories. Relevant theories discuss the adverse effect of social conditions, such as prejudice and stigma, on the lives of affected individuals and groups.-(p. 675)

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 Dr. Michael Dentato (2012) talks about the minority stress perspective in his article from a psychology and AIDS newsletter. In it, Dentato states that “the minority stress perspective adds significant insight into the critical application and evaluation of theory regarding the impact of homophobia and links HIV risk-taking behaviors among gay and bisexual men and other sexual minorities.” Stressors such as homophobia or sexual stigma that may arise from the environment require an individual to adapt but also cause significant stress, which ultimately affects physical and mental health outcomes (Dentato, 2012). He argues that understanding these factors plays a role in better helping these populations. The everyday factors of social stigma, microaggressions, internalized shame, create a state of constant toxic environments for LGBTQ+ individuals leading to increased risks for mental health issues from minority stress (Outland, 2016).

E. Treatments and Implications for practice

 Implications for practice and treatments moving forward based on this theoretical research, are based on the following: type of therapy, ethical considerations regarding a good therapist, importance of ongoing professional development, and various other options such as a transdiagnostic approach and compassionate care. When choosing the proper therapeutic approach when working with clients as social workers in mental health, it varies. Working with the LGBTQ+ population regarding mental health, I visited the LGBTQ Counseling Center (2019) located at the University of Iowa campus and met with their program director. Dr. Jacob Priest is the head of the program that has both faculty and counseling/MSW students providing mental health services for this population of individuals. Priest (J. Priest, personal communication, February 15, 2019) mentions that they work with various clients who are among the LGBTQ+ spectrum. He shared that recently there have been more transgender persons coming to the clinic from all over the state seeking counseling and evaluations regarding letters for hormone therapy treatments. Priest (2019), says predominantly they use cognitive behavioral therapy and dialectical behavioral therapy as their main types of effective therapeutic forms, though he did say it varies with each client on the type of therapeutic form to use regarding mental health counseling.

 Dr. John Pachankis (2016) has been working on an evidence-based transdiagnostic treatment approach for alleviating co-occurring mental, behavioral, and sexual health issues among LGBTQ+ individuals. His team worked closely with LGBTQ+ communities that produced efficacy from those treatments that specifically addresses issues that LGBTQ+ individuals face concerning mental health. Further, he discusses the resiliency abilities LGB individuals possess regarding mental health and how these groups tend to engage in mental health services compared to heterosexual individuals when addressing symptoms of depression and anxiety.

 Pachankis looked at the APA guidelines for best psychological practices with LGBT individuals to help focus what are the main issues affecting this population. His research gathered empirical evidence for interpreting their guidance into empirically supported practices, through in-depth interviews with mental health providers, and LGBT individuals who were diagnosed with depression and anxiety symptoms. These individuals offered feedback and suggestions for adapting a standard practice when addressing and treating the specific needs of the LGBTQ+ population. Pachankis (2016) outlined a number of standard guidelines for working with LGBTQ+ individuals. Three of these guidelines align with empowerment practices within social work. The first is through the use of empower assertive communication.

Pachankis (2016) states:

Minority stress can teach LGB individuals that they are underserving of the same rights and opportunities afforded to heterosexuals. Previous exposure to stigma can lead LGB individuals to self-silence, even in situations in which it would be most adaptive to openly express one’s needs, opinions, wants, and desires. This principle seeks to empower LGB individuals to assert themselves in situations in which it is safe and healthy to do so. (2016)

 Certain groups through minority stress factors can end up feeling a sense of powerlessness in finding their authentic voice, this use of empowering assertiveness can help social workers assist in providing tools for the LGBT+ populations in gaining the opportunity to assert themselves in more healthy and empowering ways that can make an individual in this group feel heard and validated.

 The second guideline Pachankis (2016) discusses that aligns with empowerment practice is to validate sexual minority individuals’ unique strengths. With this Pachankis states:

This principle helps LGB individuals appreciate their unique personal strengths and experiences, such as navigating the coming out process, for example, and to draw on those strengths as sources of pride and optimism. This principle also helps LGB individuals connect with the remarkable resilience shown by LGBT communities currently and across history. (2016)

 This guideline focuses on empowerment practices through a strength perspective, in which social workers focus away from an individual’s problem areas or shortfalls, and instead center on their abilities, talents, and resources available through the power of resiliency. 

 Lastly, the third guideline Pachankis (2016) outlined as a standard guideline for working with LGBTQ+ individuals, that align with empowerment practice is through building supportive relationships. This type of collaborative process by building supportive relationships shows how “Given the importance of social support for buffering against minority stress, this principle helps LGB individuals build supportive families, relationships, and communities, and strengthen existing connections” (Pachankis, 2016). By utilizing these three guidelines principles, it shows how a clinical social worker is both professional and ethical when working with the LGBTQ+ population on mental health concerns or issues by way of treatments and considering implications for practice.

F. Best Practices

 By looking at treatments and implications for practice can social workers look at best practices regarding mental health services for the LGBTQ+ population. One example of best practices and for good assessments is through the characteristics of what makes a good therapist. According to Priest (J. Priest, personal communication, February 15, 2019) of what makes a good clinician working with the LGBTQ+ population is having an unbiased perspective, and allied views of being non-judgmental when addressing mental health related issues with this population. Further, Priest mentions how having these characteristics is also taking a more compassionate person-centered care approach when working with LGBTQ+ clients.

 Other things to consider for best practice ethically as a social worker when working with the LGBTQ+ populations regarding mental health services, is the importance of competence. According to the NASW (2017), it is within our ethical obligation of responsibility towards clients under the standard regarding competence in which the NASW states: “(a) Social workers should provide services and represent themselves as competent only within the boundaries of their education, training, license, certification, consultation received, supervised experience, or other relevant professional experience” (1.04 a). Also, under this standard the NASW mentions how social workers should also have the ability to recognize within proper judgements if further training, educational/professional development opportunities, or supervision for example is needed in order “to ensure the competence of their work and to protect clients from harm” (NASW, 2017). By following this ethical standard of competence, can social workers then have the capacity to engage in what the NASW (2017) has as a second standard of principles which is cultural awareness and social diversity. It is under this standard that the NASW states the following:

Social workers should obtain education about and seek to understand the nature of social diversity and oppression with respect to race, ethnicity, national origin, color, sex, sexual orientation, gender identity or expression, age, marital status, political belief, religion, immigration status, and mental or physical ability. (1.05 c)

 By following the NASW (2017) code of ethics, social workers gain the right principles and standards for providing professional conduct when working with the LGBTQ+ populations that is fair and just.

 A second thing to consider for best practice, is the physical environment or space in which social workers are providing services. J.M Stroupe (2014) discusses how having a warm and inviting safe spaces allow for individuals to be their authentic selves. It is by taking this holistic approach in which Stroupe (2014) states: “Treatment facilities should be designed to be safe and comfortable, emphasizing personal empowerment and individual dignity, thus becoming a catalyst for improving health care practices and enabling patients to take control of their own healing process.”

 Cultural competence/humility is a third option for best practices when working with the LGBTQ+ population. The Human Rights Campaign (n.d.) mentions the importance of how paperwork should be modified to show not just an organization’s cultural competence, but also their inclusiveness towards the LGBTQ community. They also give the examples of  “amending all patient-history intake forms” and including things like “domestic partnership” as an option compared to the standard options listed. Also, the Human Rights Campaign (n.d.) state that “whenever gender is listed as a characteristic, transgender should be included (both male-to-female and female-to-male) as an option.”

 These examples of best practices, although just a few of many options available through research and peer reviews of those in the social work and mental health fields, show an importance of empowerment and advocacy as social workers to marginalized populations, which includes the LGBTQ+ communities regarding mental health services.

 G. Conclusions/Wrap-up

 In conclusion, though everyone experiences some form of mental health-related symptoms or conditions, individuals who identify as LGBTQ+ face significant mental health disparities compared to their heterosexual and cisgender identified peers. These outcomes come from minority stress factors, internalized stigma, historical traumas, and policies that have affected barriers in accessing effective treatments or mental health services.  As social workers it is within our ethical obligation to the NASW code of ethics in being informed and competent when working with potential LGBTQ+ clients. Performing best practices through use of safe environments, paperwork and cultural competence/humility through empowerment practices creates successful outcomes regarding the mental health and well-being of LGBTQ+ individuals.

References

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