DOI: 10.1002/jclp.22687
RESEARCH ARTICLE
Engaging in LGBQ+ affirmative psychotherapies
with all clients: Defining themes and practices
Bonnie Moradi1
|
Stephanie L. Budge2
1
Department of Psychology, Center for
Gender, Sexualities, and Women's Studies
Research, University of Florida, Gainesville,
Florida
2
Department of Counseling Psychology,
University of Wisconsin‐Madison, Madison,
Wisconsin
Correspondence
Bonnie Moradi, PhD, Department of
Psychology, University of Florida, Gainesville
32611‐2250, PO Box 112250, FL.
Email: moradib@ufl.edu
Abstract
The clinical need for lesbian, gay, bisexual, and queer (LGBQ+)
affirmative psychotherapies has been widely recognized; however, empirical research on the outcomes of such psychotherapies is limited. Moreover, key questions about whom such
psychotherapies are for and what they comprise require critical
consideration. We begin by offering definitions to answer these
questions and delineate four key themes of LGBQ+ affirmative
psychotherapies. We conceptualize LGBQ+ affirmative psychotherapies not as sexual orientation group‐specific, but rather
as considerations and practices that can be applied with all
clients. We then summarize our own search for studies to
attempt a meta‐analysis and we discuss limitations and
directions for research based on our literature review. We
end by delineating diversity considerations and recommending
therapeutic practices for advancing LGBQ+ affirmative psychotherapy with clients of all sexual orientations.
KEYWORDS
cultural competence, lesbian, gay, bisexual, and queer affirmative
therapy, psychotherapy, psychotherapy relationships, social justice
advocacy, social justice competence
1 | INTRODUCTION
The need for lesbian, gay, bisexual, and queer (LGBQ+) affirmative psychotherapies is widely recognized, though
empirical research on the outcomes of such therapies is nearly nonexistent (e.g., American Psychological
Association, 2012). Among the barriers that impede research on the outcomes of LGBQ+ affirmative
This article is adapted, by special permission of Oxford University Press, by the same authors in J. C. Norcross & B. E. Wampold (Eds.) (2018),
Psychotherapy relationships that work. volume 2 (3rd ed.). New York: Oxford University Press. The Interdivisional APA Task Force on Evidence-Based
Psychotherapy Relationships and Responsiveness was cosponsored by the APA divisions of Psychotherapy (29) and Counseling Psychology (17).
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© 2018 Wiley Periodicals, Inc.
wileyonlinelibrary.com/journal/jclp
J. Clin. Psychol. 2018;74:2028–2042.
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psychotherapies are complexities in defining whom LGBQ+ affirmative psychotherapies are for and what key
elements these therapies comprise. Wrestling with these “who” and “what” questions is fundamental to forging best
practices for LGBQ+ affirmative psychotherapies. In this article, we begin by providing definitions to answer these
who and what questions, delineate four key themes of LGBQ+ affirmative psychotherapies, offer measures and
assessment recommendations, and describe clinical examples. We then summarize our own search for studies to
attempt a meta‐analysis and we discuss limitations and directions for research based on our literature review. We
end by delineating diversity considerations and recommending therapeutic practices.
2 | DEFINITIONS A ND ME ASURES
2.1 | Sexual orientation
Estimates from population‐based surveys suggest that approximately 3.5% or 8 million adults in the United States
identify as LGB, 8.2% or 19 million report having engaged in same‐sex sexual behaviors, and 11% or 25.6 million
report having some same‐sex attraction (Gates, 2011). Conceptualizations of sexual orientation and sexual minority
status vary across cultural communities. The following definitions of key sexual orientation constructs reflect
dominant US cultural discourses (e.g., American Psychological Association, 2012; Dillon, Worthington, & Moradi,
2011; Moradi, 2016). Sexual orientation reflects the sex(es) and/or gender(s) to whom a person is attracted; it
includes multiple dimensions such as physical attraction, emotional attraction, and sexual behaviors which may or
may not align with one another at a given time or across a person’s life. Sexual identity (or sexual orientation
identity) captures a person’s identification or description of their sexual orientation to themselves and others (e.g.,
asexual, bisexual, gay, lesbian, queer, questionning). Sexual minority is an umbrella term that captures sexual
orientations and identities that are stigmatized and oppressed in current sociopolitical systems (i.e., LGBQ+).
Despite this multidimensionality, popular conceptualizations of sexual orientation and identity are often
grounded in a binary view of sex collapsed with gender (i.e., female = woman, male = man). Such a view has long
been critiqued by feminist scholars (e.g., Bem, 1993) who distinguished sex, or the biological and anatomical
characteristics used to assign people at birth to sex categories (e.g., female, intersex, male) from gender, as the social
meaning and collection of characteristics prescribed to sex categories in a given society or culture.
Nevertheless, grounded in the limitations of sex and gender binaries, popular views of sexual orientation
assume that a person assigned female at birth identifies as a woman and presents in feminine ways. If she is
attracted to other women, she is considered and compelled to identify as lesbian; if she is attracted to other men,
she is considered and compelled to identify as heterosexual or straight. Men are categorized in parallel fashion as
gay or heterosexual/straight. Problematically, within these binaries, bisexual, queer, and other sexual orientations
and identities are often rendered invisible or viewed as transitions toward an ultimate monosexual orientation and
identity (i.e., gay/lesbian or heterosexual/straight).
Best practices for assessing sexual orientation involve eschewing these binaries and assessing multiple
dimensions, such as sexual orientation identity, sexual attraction, and sexual behaviors, and including open
response options for people to self‐describe beyond predetermined categories (e.g., Sexual Minority Assessment
Research Team [SMART], 2009). For example, intake forms can assess self‐identification with “How do you self‐
identify?” and options of bisexual, gay, heterosexual/straight, lesbian, queer, and an open response. Response
options can be alphabetized to avoid conveying a hierarchy of identities. Sexual attraction can be assessed with
“People vary in their sexual attraction to other people. Which best describes your attraction?” and options to assess
levels of attraction to gender nonbinary people, men, women, and an open response. Sexual behavior can be
assessed with “Which best describes your sexual partners?” and options to assess sexual behavior with gender
nonbinary people, men, women, no sexual behavior, and an open response.
In therapy sessions or intake interviews, it is important to listen carefully to clients’ self‐descriptions and the
specific terms they use to refer to themselves (e.g., bisexual, lesbian, queer) and their romantic partners (e.g.,
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partner, spouse, wife, girlfriend), and to mirror these terms. It is also helpful to check with clients in open ended
ways to facilitate their personal descriptions. For example, broad questions such as “what are some important
aspects of who you are?” can be a starting point for rich self‐description of personal identities. Such questions can
be followed with specific questions about sexual orientation identity and romantic relationships, such as “What
terms or identities do you prefer to describe your sexual orientation or romantic attractions?” or “How do you
prefer to refer to your partner?” Some clients may resist such identity categories altogether (e.g., “I don’t identify
with any sexual orientation label” or “my attractions are not based on gender”) and these are also self‐definitions to
be respected and affirmed.
Best practices for assessing sexual orientation also require disaggregating sexual orientation, sex, and gender.
Assessing sex requires careful consideration to include intersex individuals. One approach is assessing sex assigned
at birth with the options available on birth certificates (i.e., female and male), and using a separate question to
assess whether individuals are also intersex (The GenIUSS Group, 2014). Assessment of gender identity can include
categories for transwoman, transman, and nonbinary gender identities (e.g., genderqueer), and an open response
option for respondents to self‐describe (The GenIUSS Group, 2014). The aforementioned in‐session recommendations for facilitating self‐descriptions also apply to assessing sex and gender. Psychotherapists can routinely assess
sexual orientation, sex, and gender along with other demographics such as age, class, ethnicity, and race.
2.2 | LGBQ+ affirmative psychotherapies
We favor a conceptualization of LGBQ+ affirmative psychotherapy, not as sexual orientation group‐specific, but
rather as principles and practices that can be applied with all clients and ultimately, in all psychotherapies (e.g.,
Matthews, 2007). This inclusive position addresses important pragmatic realities. Specifically, practitioners may not
be aware of clients’ LGBQ+ identities. Even if therapists routinely assess LGBQ+ identities, clients may not want to
or be ready to disclose these identities, especially in early phases of psychotherapy. In fact, clients’ disclosure of
LGBQ+ identities may be predicated on therapists first creating the very conditions of LGBQ+ affirmativeness to
facilitate such disclosure (e.g., Dorland & Fischer, 2001). Moreover, many clients who do not identify as LGBQ+ may
want (and warrant) LGBQ+ affirmative therapy (e.g., children of LGBQ+ parents).
For these reasons, we endorse a conceptualization of LGBQ+ affirmative psychotherapy that acknowledges the
unequal power inherent in the client‐therapist dyad, which may prove more pronounced in dyads involving LGBQ+
clients and heterosexual therapists, and that places the responsibility of providing affirmative methods on the
clinician rather than on the client. Thus, we contend that the answer to the first question “whom are LGBQ+
Affirmative Psychotherapies for?” is simply, everyone.
This vision does not mean that LGBQ+ affirmative psychotherapy is “generic” therapy as currently practiced.
Rather, it requires elevating all psychotherapies to integrate the key themes of LGBQ+ affirmative psychotherapy.
Drawing from prior conceptualizations of psychotherapy with LGBQ+ people (e.g., American Psychological
Association, 2012; Fassinger, 2017; Harrison, 2000; Johnson, 2012; King, Semlyen, Killaspy, Nazareth, & Osborn,
2007), we define LGBQ+ affirmative psychotherapies as comprising four key themes: (a) counteracting anti‐LGBQ+
therapist attitudes and enacting LGBQ+ affirmative attitudes, (b) acquiring accurate knowledge about
LGBQ+ people’s experiences and their heterogeneity, (c) calibrating integration of accurate knowledge about
LGBQ+ people’s experiences and their heterogeneity into therapeutic actions, and (d) engaging in and affirming
challenges to power inequities. Across these themes, it is important not to confuse the absence of inappropriate
therapy (e.g., acting on anti‐LGBQ+ bias or inadequate knowledge) with the presence of affirmative therapy.
A number of existing measures assess therapists’ or trainees’ self‐reported perceptions of their own
competencies in working with LGBQ+ clients (see Table 1). Although these are not measures of LGBQ+ affirmative
ingredients per se, these measures are the closest available approximations of operationalizing those ingredients.
The Lesbian, Gay, and Bisexual Affirmative Counseling Self‐Efficacy Inventory (Dillon & Worthington, 2003) and its
short form (Dillon et al., 2015) are among the fullest in scope, assessing the application of knowledge, therapy
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T A B L E 1 Measures of self‐reported LGBQ+ affirmative psychotherapy competencies
Refernces
Measure name
Purpose
Sample items
Bidell (2005)
Sexual Orientation
Counselor Competency
Scale (SOCCS)
29 items assess counselors’
attitudes, skills, and
knowledge in working with
LGB clients
Attitudes: “The lifestyle of a
LGB client is unnatural or
immoral” (reversed)
Skills: “I have experience
counseling gay male clients”
Knowledge: “Being born a
heterosexual person in this
society carries with it certain
advantages”
Burkard, Pruitt,
Medler, and
Stark‐Booth (2009)
Lesbian, Gay, and Bisexual
Working Alliance
Self‐Efficacy Scales
(LGB‐WASES)
32 items assess counselor‐
trainees self‐efficacy in
establishing working
alliance with LGB clients
Emotional bond: “I can express
empathy for an LGB client”
Establishing tasks: “I can help
LGB clients to establish social
relationships in the gay
community”
Cultural competence: “An LGB
client and I can mutually
agree on an important
purpose for counseling”
Crisp (2006)
Dillon and
Worthington (2003);
Dillon et al. (2015)
Gay Affirmative Practice
Scale (GAP)
Lesbian, Gay, and Bisexual
Affirmative Counseling
Self‐Efficacy Inventory
(LGB‐CSI), original and
short form
30 items assess clinicians’
beliefs and behaviors in
practice with gay and
lesbian clients
32 items (original) and 15
items (short form) assess
counselors’ self‐efficacy to
perform LGB affirmative
counseling behaviors
Beliefs: “Practitioners should
educate themselves about
gay/lesbian lifestyles”
Behaviors: “I acknowledge to
clients the impact of living in
a homophobic society”
Application of knowledge:
“Assist LGB clients to develop
effective strategies to deal
with heterosexism and
homophobia”
Relationship: “Establish a safe
space for LGB couples to
explore parenting”
Assessment: “Assess for post‐
traumatic stress felt by LGB
victims of hate crimes based
on their sexual orientations/
identities”
Advocacy skills: “Refer LGB
clients to affirmative legal and
social supports”
Self‐awareness: “Identify my
own feelings about my own
sexual orientation and how it
may influence a client”
(Continues)
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(Continued)
Refernces
Measure name
Purpose
Sample items
Logie, Bridge, and
Bridge (2007)
LGBT Assessment Scale
(LGBTAS)
26 items assess social work
graduate students’
“phobias, attitudes, and
cultural competence” in
working with LGBT clients
Phobias: “I would feel
comfortable working closely
with a gay man”
Attitudes: “Bisexuality is
merely a different kind of
lifestyle that should not be
condemned”
Cultural competence: “I am
knowledgeable about the
issues and challenges facing
LGBT people and feel
competent in my ability to
work effectively with this
population”
Note. LGBQ: lesbian, gay, bisexual, and queer; LGBT: lesbian, gay, bisexual, and transgender.
relationship, assessment, advocacy skills, and self‐awareness. However, the measures outlined in Table 1 also have
key limitations. Specifically, they tend to place greater emphasis on assessing anti‐LGBQ+ attitudes and feelings
than on assessing LGBQ+ affirmative therapy behaviors, some use problematic language (e.g., referring to LGBQ+
identities as a lifestyle), some have psychometric limitations and gaps, and all rely on therapists’ self‐reports. None
of these measures directly assesses the fourth theme of LGBQ+ affirmative psychotherapy ingredients: Engaging in
and affirming challenges to power inequities.
3 | CLIN IC AL EXAMP LES
Examples of how clinicians can implement LGBQ+ affirmative psychotherapies illustrate the transtheoretical,
transdiagnostic, and transpopulation scope of such psychotherapies. One such example illustrates the calibrated
integration of accurate knowledge. Specifically, Russell and Hawkey (2017) delineated how clinicians can integrate
knowledge about anti‐LGBQ+ stigma in a “stigma‐informed” approach to psychotherapy. They emphasize the
client’s appraisal of the stigma along with the use of positive coping strategies to mitigate the impact of stigma on
the client. First, this approach requires that the therapist acquire accurate knowledge about the context of stigma
that LGBQ+ people experience. In addition to the scholarly literature, public resources are available through
national organizations such as the American Psychological Association (APA) Public Interest Directorate, APA
Society for the Psychological Study of LGBT Issues, Lambda Legal, National LGBTQ Task Force, and The Williams
Institute. Next, grounded in such knowledge, the therapist builds on the individualized understanding of the client
to situate stigma and oppression in external contexts rather than in the client’s self‐blaming internalization. The
therapist facilitates sociopolitical analysis that connects heterosexism with other systems of stigmatization and
oppression (e.g., racism, sexism). Finally, the therapist promotes positive coping and support for the client; this
could include the therapist and client engaging in immediate advocacy and in broader social justice activism. Such
strategies could include recognizing and challenging signs of internalized stigma in oneself, drawing on social
support systems and affirmative communities, and engaging in collective social and political action.
Another clinical example of a stigma‐informed psychotherapy is called Effective Skills to Empower Effective
Men (ESTEEM). ESTEEM is a 10‐session individual treatment designed as a transdiagnostic minority stress therapy
for gay and bisexual cisgender men. Pachankis (2014) and Pachankis, Hatzenbuehler, Rendina, Safren, and
Parsons (2015) developed this intervention by drawing from theory that minority stressors, including
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discrimination and oppression, vigilance and anticipation of stigma, self‐blaming internalization of stigma, and
concealment of stigmatized identity, can tax LGBQ+ people’s mental health (Meyer, 2003). In ESTEEM,
psychotherapists work with clients to (a) normalize and acknowledge the adverse impact of minority stressors,
(b) facilitate emotion awareness and regulation, (c) reduce avoidance of difficult and painful emotions, (d) promote
assertive communication, (e) restructure minority stress cognitions (e.g., anticipation of rejection), (f) validate
clients’ strengths, (g) build support relationships, and (h) affirm healthy and rewarding expressions of sexuality.
These treatment principles are posited to disrupt the pathways between minority stressors and psychological
symptomatology. Across these domains, and especially with restructuring minority stress cognitions, it is important
to remain grounded in the reality of clients’ experiences of minority stressors and not to minimize these
experiences. Again, LGBQ+ affirmative psychotherapy involves calibrating the integration of such strategies with
an individualized understanding of the client’s experiences.
As a final example, Fassinger (2017) offers a clinical illustration that moves away from a preoccupation with
affirming specific LGBQ+ identities to affirming the client’s transgression of restrictive sexual orientation‐ and
gender‐related norms and power inequities. Fassinger described this as a transgression‐affirmative nested‐
narrative identity construction and enactment (NICE) therapy. Consider a client with whom Fassinger (2017)
worked for many years. The client was a 34‐year‐old, single, professional African American woman who presented
with job‐related stress and psychological symptomatology. Through the course of therapy, the client gradually
discussed her attraction to women, and the implications of this for various aspects of her life such as her family,
religious community, and career. There was not a single moment of sexual orientation disclosure and invocation of
LGBQ+ affirmative psychotherapy behaviors. Rather, the entire process of therapy involved a feminist affirmative
approach.
Fassinger explained, “I provided openness, collaboration, support, education, and validation of whoever and
wherever she was in her identity journey—which eventually led her to romantic relationships with women”
(pp. 19–20). She also described that the therapy could have been improved by a more deliberate transgression‐
affirmative approach that involved “collaborative coconstruction of a life story needing some deconstruction‐
examination and possible reconstruction/revision” (Fassinger, 2017, p. 44). Such therapy aims to help clients
build a coherent life narrative that includes their gender and sexuality, rather than focusing on a sexual
orientation identity label and tailored therapy behaviors. Of paramount importance, this approach reclaims the
transgression of systems of inequity (e.g., same‐sex sexual attractions) as a strength and source of power. This
affirmation of clients’ transgressions of systems of inequity is a core aim of the therapy and a form of social
justice activism.
4 | RES EA RC H RE VI EW
To determine the feasibility of a meta‐analysis of the outcomes of LGBQ+ affirmative psychotherapies, we searched
for relevant studies. We considered studies that (a) compared the outcomes of LGBQ+ tailored or affirmative
psychotherapies with outcomes of another form of psychotherapy, and/or (b) compared psychotherapy outcomes
for LGBQ+ people with outcomes for heterosexual people. In defining psychotherapies, we focused on treatments
carried out as psychotherapy or counseling, based on psychological principles and addressing psychological
symptoms (as opposed to other forms of interventions such as psychoeducation, support groups, or highly specific
interventions focusing on HIV or sexual behaviors). We also focused our search on studies reported in English after
1990, given substantial historical shifts in conceptualizations and contexts for psychotherapy with LGBQ+ people.
We conducted keyword searches via ProQuest’s PsycINFO. The final search combined two sets of terms to
capture (a) psychotherapy trials (e.g., counseling, psychotherapy, “random* control* trial,” “therapy n5
effectiveness”) and (b) LGBQ+ populations (e.g., asexual, bisexual*, gay, homosexual*, lesbian, sexual minority, queer).
For LGBQ+ populations, we used terms to capture LGBQ as well as transgender populations because studies often
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collapse across these groups. In addition to this search, we distributed a call for unpublished data to the following
professional listserves: APA Divisions 12, 29, 17 (overall and LGBT section), 44, 35, 49, and 51, as well as POWR‐L,
a feminist psychology list.
4.1 | Results
As illustrated in Figure 1, the initial search on June 1, 2017 for psychotherapy trials and LGBTQ+ studies
resulted in k = 2,257. The call for data to professional listservs and review of references from key articles
yielded an additional three studies. After all duplicates were deleted, the search resulted in k = 2,191.
All abstracts were downloaded and screened along the following categories: (a) May meet inclusion for meta‐
analysis, (b) addresses psychotherapy and LGBTQ+ people without data, (c) includes data related
to psychotherapy with LGBTQ+ people, (d) addresses nonpsychotherapy interventions with LGBTQ+ people,
and (e) discard.
A total of 22 abstracts, including all from category (a) and potentially relevant abstracts from category (c)
and (d), were retrieved for full‐text evaluation. Full‐text review revealed that these publications did not meet
the meta‐analysis inclusion criteria. Specifically, these publications comprised studies that did not use a control
Identification
or comparison group to evaluate the psychotherapeutic intervention (k = 4), were correlational or nonempirical
Records identified through database
searching
(k = 2,257)
Additional records identified
through other sources
(k = 3)
Screening
Records after duplicates removed
(k = 2,191)
Records screened
(k = 2,191)
Eligibility
Full-text articles excluded (k = 22):
Full-text articles assessed
for eligibility
(k = 22)
Included
Studies included in
meta-analysis
(k = 0)
FIGURE 1
PRISMA flow diagram
• k = 4 no control or comparison
to evaluate the
psychotherapeutic intervention
• k = 4 correlational or nonempirical
• k = 3 evaluated treatments for
HIV risk reduction
• k = 3 included only participants
with HIV+ status
• k = 8 did not meet but
approximated inclusion criteria
(results described in review)
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T A B L E 2 Characteristics of eight psychotherapy studies
References
Purpose
Sample
Primary findings
Fals‐Stewart,
O’Farrell, and
Lam (2009)
Compared outcomes of
individual plus couples’
therapy with outcomes of
individual therapy alone
Gay and lesbian people with
alcohol use disorder
Better drinking and
relationship adjustment
outcomes for those who
received individual plus
couples therapy than those
who received individual
therapy alone
Mondragon,
Lambert, Nielsen,
and Erikson (2015)
Compared outcomes of
psychotherapy for clients
categorized as sexual
minority with clients not
categorized as sexual
minority
University counseling and
career center clients
Generally no posttreatment
group differences on
distress
Morgenstern
et al. (2007)
Compared outcomes of
motivational interviewing
(four sessions),
motivational interviewing
plus coping skills training
(12 sessions), and
declining treatment
HIV‐negative MSM with
alcohol use disorders
Morgenstern
et al. (2012)
Problem drinking MSM
Behavioral self‐control
Compared outcomes of
seeking to reduce but not quit therapy reduced problem
naltrexone, behavioral
drinking
drinking and there was no
self‐control therapy,
advantage to adding
naltrexone plus behavioral
naltrexone
self‐control therapy, and
placebo
Pachankis
et al. (2015)
Gay and bisexual cisgender
Compared outcomes of
Compared to the waitlist
ESTEEM, a transdiagnostic men, 18–35 years old, English control condition, treatment
minority stress adapted
fluent, HIV‐negative status,
resulted in improvements on
engaging in HIV risk
psychotherapy with
a range of symptomatology,
behaviors, experiencing
outcomes of waitlist
including alcohol use
symptoms of depression or
control group
problems, depressive
anxiety, not receiving regular
symptoms, sexual
mental health services
compulsivity, condom use
self‐efficacy, and anxiety
Higher pretreatment distress
for clients reporting distress
related to sexual orientation
than for control group not
matched on pretreatment
distress
Posttreatment drinking was
reduced across all
conditions and there was no
significant difference
between treatment
conditions
Many improvements
maintained at six‐month
follow‐up
Similar improvement found in
pooled analyses comparing all
participants pretreatment and
posttreatment
No treatment effects for
minority stress or general
risk factors
(Continues)
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(Continued)
References
Purpose
Reback and
Shoptaw (2014)
Compared outcomes of
Gay and bisexual men seeking
tailored cognitive
treatment for
behavioral therapy and
methamphetamine abuse
tailored social support
therapy in the samples
from Shoptaw et al. (2005)
and (2008) with outcomes
of a tailored cognitive
behavioral therapy plus
contingency management
treatment in a new sample
All treatment conditions were
associated with improved
outcomes
A few advantages in
substance use outcomes for
the tailored cognitive
behavioral therapy
A few advantages in sexual
risk behavior outcomes for
the tailored cognitive
behavioral therapy plus
contingency management
Shoptaw
et al. (2005)
Compared outcomes of
cognitive behavioral
therapy, contingency
management, cognitive
behavioral therapy plus
contingency management,
and a tailored cognitive
behavioral therapy that
included group‐specific
content for gay and
bisexual men
All treatments were
associated with improved
outcomes
Shoptaw
et al. (2008)
Sample
Gay and bisexual men seeking
outpatient treatment for
methamphetamine
dependence
Gay and bisexual men seeking
Compared outcomes of
treatment for any stimulant
tailored cognitive
and/or alcohol abuse
behavioral and tailored
social support substance
use treatments for gay and
bisexual men
Primary findings
A few advantages observed
for treatments that included
contingency management,
though generally few
significant differences
between treatment
conditions
Both treatment conditions
were associated with
reductions in substance use
and sexual risk behaviors
A few advantages observed
for the tailored cognitive
behavioral therapy over the
tailored social support
therapy
(k = 4), evaluated treatments for HIV risk reduction (k = 3), and included only participants with HIV+ status
thereby precluding disaggregation of sexual orientation from HIV+ status (k = 3). Importantly, 16 of the 22
studies included only men; the studies generally did not specify inclusion or exclusion of transgender people,
though one study specifically excluded transgender people.
Eight publications came closest to the inclusion criteria, though they did not meet these criteria and were too
diverse in focus and methodology for meta‐analysis. Table 2 summarizes the studies that approached our criteria
and provided useful research information on the practice of LGBQ+ affirmative psychotherapy.
5 | L I M I T A T I O N S O F TH E R E S E A R C H
As the present review reveals, there is a dearth of research on the outcomes of LGBQ+ affirmative
psychotherapies. Fundamental to advancing research in this area is the need to move beyond sole reliance on
therapists’ self‐report measures of their own attitudes and knowledge, and to design and evaluate measures of
client, therapist, and observer appraisals of the presence of the key LGBQ+ affirmative themes.
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In addition, the implicit assumption that LGBQ+ psychotherapies are tailored specifically for LGBQ+ people and
not others can be challenged. Research is needed to investigate the outcomes of LGBQ+ affirmative
psychotherapies with all clients, across the spectrum of sexual orientations and identities. In such research,
analyses would compare the outcomes of psychotherapies with and without LGBQ+ affirmative ingredients, though
ethical practice limits experimental manipulation of some ingredients with clients (e.g., anti‐LGBQ+ attitudes).
Similarly, research is needed to broaden the range of presenting problems for which (a) psychotherapies are
examined with LGBQ+ populations and (b) LGBQ+ affirmative psychotherapies are examined with all populations.
While sexual risk behaviors and substance abuse are important foci, there is a near exclusive focus on treatment
evaluations with these presenting concerns. Research is needed to investigate the full range of psychological
symptoms and life challenges (e.g., depression, body image, relationship distress, vocational issues).
Moreover, the centrality of the context of oppression requires expanding the range of psychotherapy outcomes
considered. Traditional conceptualizations of favorable outcomes include decreases in symptomatology and
increases in psychological well‐being. However, a functional response to anti‐LGBQ+ discrimination and oppression
may include increased anger, sadness, and discontent. In fact, these “symptoms” may prove indicators of the
important emotional work involved in recognizing oppressive systems, taking constructive action, and developing a
social justice orientation (e.g., Hercus, 1999; Moradi, 2012). Thus, such outcomes can be measured and
conceptualized as favorable psychotherapy outcomes. Measures of symptom reduction can also be supplemented
with measures of targeted outcomes, such as minority stressors, including anticipation of stigma, internalized
prejudice, and concealment of sexual orientation (e.g., Pachankis et al., 2015). Additional outcomes could include
clients’ perceptions of key mechanisms for change, engagement in everyday activism and collective action, and
social justice orientation.
Finally, sociodemographic and other forms of diversity among LGBQ+ populations remain underexamined in
psychotherapy research. Nearly all of the studies that emerged for full‐text examination in our review focused on
cisgender men, mostly recruited for HIV+ status and/or substance use problems. In these studies, the inclusion or
exclusion of transgender men was generally unacknowledged or transgender men were explicitly excluded.
Similarly, women (transgender inclusive) and people with nonbinary or other gender identities were not included.
Psychotherapy research that includes LGBQ+ people of all genders and LGBQ+ populations beyond only those with
HIV+ status and substance abuse is needed. Strategies delineated for recruiting diverse samples across age, class,
gender, ethnicity, race, and other sociodemographics can be used (e.g., DeBlaere, Brewster, Sarkees, & Moradi,
2010). Beyond sociodemographic diversity, individual differences in levels of minority stressors (e.g., experiences of
discrimination, internalized stigma) could interact with LGBQ+ affirmative psychotherapy ingredients to shape
outcomes. Similarly, LGBQ+ affirmative psychotherapy ingredients may interact with clients’ expressed sexual
orientation such that outcomes differ for LGBQ+ identified and nonidentified clients. Moderators such as sexual
orientation identities and levels of minority stressors may be points for calibrating psychotherapy ingredients
across clients.
6 | D IV E R S I T Y C O N S I D E R A T I O N S
LGBQ+ identities are diverse, culturally situated, and dynamic, as reflected in the expanding inclusivity of sexual
identity labels (e.g., L, G, B, Q). Moreover, LGBQ+ people as a group represent all ages, classes, genders, ethnicities,
races, and other sociodemographic characteristics. Acknowledging this diversity among LGBQ+ populations is
critical.
To this end, it is helpful to distinguish strong intersectional analysis from superficial considerations of multiple/
intersecting identities that involve blanket application of group‐level information or presumed cultural
characteristics to individual clients (Moradi, 2017; Moradi & Grzanka, 2017). Strong feminist intersectional
analysis (e.g., Collins, 1990/2000; Crenshaw, 1989) requires understanding how multiple systems of oppression and
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privilege function simultaneously in clients’ lives and enacting interventions that attend to and challenge these
inequities. Psychotherapy practice and research informed by intersectional analysis articulates, assesses, and
analyzes the system‐level constructs (e.g., experiences of classism, heterosexism, racism, sexism) for which
demographic variables are implicit proxies.
Intersectional analysis may also challenge the epistemology and power inequities in how we evaluate
psychotherapy outcomes (Moradi & Grzanka, 2017). This includes valuing statistical significance of outcomes along
with (rather than in lieu of) clients’ experiences and the benefits of psychotherapy to clients in real‐world contexts.
While RCTs are considered a gold standard, they present limitations in evaluating LGBQ+ affirmative
psychotherapies. For example, LGBQ+ affirmative ingredients are to be applied across psychotherapy methods,
diagnoses, and populations. This breadth can conflict with the pressures for a high degree of control in RCTs, for
example, in ensuring fidelity of interventions or in defining patient populations in terms of demographics and/or
diagnoses.
A complementary alternative is practice‐based evidence (Barkham & Mellor‐Clark, 2000), which focuses on high‐
quality data derived from clients and practitioners in naturalistic settings with their contextual complexities intact.
Indeed, data that capture rather than control the complexity of LGBQ+ people and their presenting concerns can
address many of the limitations of prior research (e.g., inclusion criteria that focus narrowly on cisgender men living
with HIV). Practice‐based evidence is also consistent with intersectional analysis and the defining themes of LGBQ+
affirmative psychotherapies in that it foregrounds diversity in context, clients, practitioners, and real‐world
complexity as integral to evaluating psychotherapy, rather than as confounds to be controlled.
7 | THERAPEUT IC PRACTICES
We conclude by advancing therapeutic practices along the four key themes of LGBQ+ affirmative psychotherapies
based on the available literature.
7.1 | Counteracting anti‐LGBQ+ therapist attitudes and enacting LGBQ+ affirmative
attitudes
1. Counteract biases that may pathologize and oppress LGBQ+ identities and people. Examples of such behaviors
include assuming that sexual orientation is the cause of presenting concerns, avoiding or minimizing discussions
of sexual orientation, overidentifying with LGBQ+ clients in ways that are defensive or objectifying (e.g., “I have
a gay friend”), operating on stereotypes about LGBQ+ people or on heteronormative assumptions and biases,
and enacting pathologizing assumptions that LGBQ+ people need therapy or that LGBQ+ identities are
dangerous or problematic (Shelton & Delgado‐Romero, 2011).
2. Use inclusive language and clients’ preferred language. In clinical contacts and measures, until the client’s preferred
terminology is assessed, use inclusive language such as “your partner or spouse” rather than language that
assumes partner/spouse gender. Use of inclusive language is associated with LGB people’s positive views of
therapists, greater willingness and comfort to disclose sexual orientation identity, and greater likelihood to
return to psychotherapy (Dorland & Fischer, 2001). Moreover, contrary to speculation that LGBQ+ inclusive
language might confuse or alienate heterosexual clients, inclusive language was unrelated to heterosexual
people’s perceptions of therapist credibility and utilization intent, and was related positively to their willingness
to disclose (Ross, Waehler, & Gray, 2013). In addition, pay attention to and inquire about the language clients
prefer to describe themselves and their relationships (e.g., “How do you prefer to describe your sexual
orientation or romantic attractions?” “How do you prefer to refer to your partner?”), and mirror clients’
preferred language.
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3. Demonstrate an inclusive stance in professional materials and in the therapy environment. There is evidence that
LGBQ+ clients notice heteronormative bias in the therapy environment, for example, in the absence of LGBQ+
representation in displays and materials, and experience such bias as a form of subtle discrimination in therapy
(Shelton & Delgado‐Romero, 2011). Examples of strategies for demonstrating an inclusive stance include
assessing sexual orientation using best practices (see Section 2), and using brochures, displays, and artwork that
are inclusive and affirmative of LGBQ+ people.
7.2 | Acquiring accurate knowledge about LGBQ+ people’s experiences and their
heterogeneity
1. Acquire accurate knowledge about the sociopolitical oppression of LGBQ+ people and about their broader life
experiences. It is important to acquire knowledge about anti‐LGBQ+ stigma, minority stress, identity
formation and management (e.g., concealment and disclosure strategies and their consequences), family
structures (e.g., families of choice, marriage, partnerships, consensual nonmonogomy, parenting within and
outside of legal status), workplace experiences (discriminatory and antidiscrimination policies and laws,
hostile or affirming careers), LGBQ+ affirmative support communities, and the heterogeneity of LGBQ+
people and their needs across dimensions of sociodemographic diversity (e.g., American Psychological
Association, 2012).
2. Recognize LGBQ+ strengths and resilience that may promote well‐being and mitigate minority stress and engage these
strengths in psychotherapy. LGBQ+ people describe developing a number strengths, including actively pursuing
authenticity in self‐definition, developing freedom from gender‐specific roles, cultivating cognitive flexibility,
and being involved in social justice activism (e.g., Brewster, Moradi, DeBlaere, & Velez, 2013; Riggle, Whitman,
Olson, Rostosky, & Strong, 2008). As one example, cognitive flexibility buffered bisexual people’s mental health
against experiences of antibisexual prejudice (Brewster et al., 2013). Thus, therapists can explore how LGBQ+
clients’ life experiences may foster cognitive flexibility and how this strength can be integrated in interventions
to promote positive psychotherapy outcomes.
7.3 | Calibrating integration of accurate knowledge about LGBQ+ people’s experiences
and their heterogeneity into therapeutic actions
1. Individualize understanding and treatment of a given client, without overemphasizing or underemphasizing the
centrality of LGBQ+ status. We caution against an “apply knowledge and stir” approach in which knowledge
about LGBQ+ populations is invoked uncritically with all (assumed) LGBQ+ clients. Such an approach
objectifies clients as a stereotypic monolith. Instead, the integration of group‐specific knowledge can be
calibrated to the experiences and needs of the specific client. Individualization of knowledge about LGBQ+
people is consistent with an “informed not‐knowing stance” (Laird, 2000) whereby the therapist expresses
genuine curiosity to understand the client more deeply, rather than assume a preconceived understanding.
This ability to understand the client is coupled with, and in fact predicated on, therapists taking
responsibility to acquire accurate background knowledge about LGBQ+ people, rather than expecting
clients to educate them.
2. Consider individual differences in how stigma and minority stressors shape clients’ lives and psychotherapy. Draw
from the stigma‐informed approach to therapy (Russell & Hawkey, 2017) and the promising empirical evidence
for ESTEEM (Pachankis, 2014, 2015) to assess and integrate individual differences in minority stress
experiences. In these approaches, practitioners first acquire knowledge about anti‐LGBQ+ stigma and
oppression, then work with clients to develop an individualized understanding of how such stigma manifests in
clients’ experiences.
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7.4 | Engaging in and affirming challenges to power inequities
1. Affirm clients’ challenging of power inequities and engage in such challenging outside of therapy. Consider using the
transgression‐affirming NICE model (Fassinger, 2017), which emphasizes fostering an affirmative stance toward the
client’s transgression of restrictive norms and power inequities. In our view, it is important to couple LGBQ+
affirmative attitudes, knowledge, and actions in the therapy room with practicing the themes of LGBQ+ affirmation
in everyday actions outside of the therapy room. Drawing from Steinem’s (1983) examples of anti‐sexist “outrageous
acts and everyday rebellions,” LGBQ+ affirmative actions in and outside of psychotherapy might include challenging
anti‐LGBQ+ humor and discourse, displaying LGBQ+ affirming images and information in the office, using LGBQ+
inclusive language consistently, asking one’s organizations and communities about their stance and actions toward
LGBQ+ people, refusing to contribute to or participate in organizations with anti‐LGBQ+ practices, or publicizing or
joining local social justice efforts (e.g., bookstore, community center).
2. Engage in sociopolitical analysis as a necessary component of LGBQ+ affirmative psychotherapies, distinct from
cultural tailoring. Without careful sociopolitical analysis, cultural tailoring efforts may blur into cultural
stereotyping identified by LGBQ+ clients as subtle biases in psychotherapy (Shelton & Delgado‐Romero,
2011). For example, culturally tailored substance use treatments may discuss LGBQ+ bars and clubs as
cultural triggers for substance abuse or draw parallels between disclosing one’s drug problems and
disclosing one’s sexual identity. Instead, sociopolitical analysis in psychotherapy would situate LGBQ+ bars
as outcomes of heterosexist systems that necessitate such safer social spaces, destigmatize these spaces by
acknowledging that heterosexual‐dominant bars also trigger substance use, and frame coming out as an
outcome of heteronormative assumptions that make it necessary for LGBQ+ people, but not heterosexual
people, to constantly judge the context of anti‐LGBQ+ threat.
3. Apply LGBQ+ affirmative principles to all clients. All clients have a narrative—articulated or not—about how their
life is shaped by gender, sexualities, and other sociopolitical systems; all clients’ life narratives and how they
transgress systems of inequity can be examined constructively and collaboratively in therapy; and
transgressions that challenge systems of inequity can be affirmed in all clients. This approach can help all
clients strive for more self and collective authenticity, actualization, and equity.
REFERENC ES
American Psychological Association (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients.
American Psychologist, 67, 10–42. https://doi.org/10.1037/a0024659
Barkham, M., & Mellor‐Clark, J. (2000). Rigour and relevance: Practice‐based evidence in the psychological therapies.
In N. Rowland, & S. Goss (Eds.), Evidence‐based counselling and psychological therapies (pp. 127–144). London, England:
Routledge.
Bem, S. L. (1993). The lenses of gender: Transforming the debate on sexual inequality. New Haven, CT: Yale.
Bidell, M. P. (2005). The Sexual Orientation Counselor Competency Scale: Assessing attitudes, skills, and knowledge of
counselors working with lesbian, gay, and bisexual clients. Counselor Education and Supervision, 44, 267–279. https://doi.
org/10.1002/j.1556‐6978.2005.tb01755.x
Brewster, M. E., Moradi, B., DeBlaere, C., & Velez, B. L. (2013). Navigating the borderlands: The roles of minority stressors,
bicultural self‐efficacy, and cognitive flexibility in the mental health of bisexual individuals. Journal of Counseling
Psychology, 60, 543–556. https://doi.org/10.1037/a0033224
Burkard, A. W., Pruitt, N. T., Medler, B. R., & Stark‐Booth, A. M. (2009). Validity and reliability of the lesbian, gay, bisexual
working alliance self‐efficacy scales. Training and Education in Professional Psychology, 3, 37–46. https://doi.org/10.1037/
1931‐3918.3.1.37
Collins, P. H. (2000). Black feminist thought: Knowledge, consciousness, and the politics of empowerment. New York, NY:
Routledge. (Original work published 1990)
Crenshaw, K. W. (1989). Demarginalizing the intersection of race and sex: A Black feminist critique of antidiscrimination
doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 140, 139–167.
MORADI
AND
BUDGE
|
2041
Crisp, C. (2006). The Gay Affirmative Practice Scale (GAP): A new measure for assessing cultural competency with gay and
lesbian clients. Social Work, 51, 115–126. https://doi.org/10.1093/sw/51.2.115
DeBlaere, C., Brewster, M. E., Sarkees, A., & Moradi, B. (2010). Conducting research with LGB people of color:
Methodological challenges and strategies. The Counseling Psychologist, 38, 331–362. https://doi.org/10.1177/
0011000009335257
Dillon, F. R., Alessi, E. J., Craig, S., Ebersole, R. C., Kumar, S. M., & Spadola, C. (2015). Development of the lesbian, gay, and
bisexual affirmative counseling self‐efficacy inventory–short form (LGB‐CSI‐SF). Psychology of Sexual Orientation and
Gender Diversity, 2(1), 86–95. https://doi.org/10.1037/sgd0000087
Dillon, F. R., & Worthington, R. L. (2003). The lesbian, gay, and bisexual affirmative counseling self‐efficacy inventory
(LGB‐CSI): Development, validation, and training implications. Journal of Counseling Psychology, 50, 235–251. https://doi.
org/10.1037/0022‐0167.50.2.235
Dillon, F. R., Worthington, R. L., & Moradi, B. (2011). Sexual identity as a universal process. In S. J. Schwartz, K. Luyckx, & V.
L. Vignoles (Eds.), Handbook of identity theory and research (Vols 1 and 2, pp. 649–670). New York, NY: Springer.
Dorland, J. M., & Fischer, A. R. (2001). Gay, lesbian, and bisexual individuals’ perceptions: An analogue study. The Counseling
Psychologist, 29, 532–547. https://doi.org/10.1177/0011000001294004
Fals‐Stewart, W., O’Farrell, T. J., & Lam, W. K. K. (2009). Behavioral couple therapy for gay and lesbian couples with alcohol
use disorders. Journal of Substance Abuse Treatment, 37, 379–387. https://doi.org/10.1016/j.jsat.2009.05.001
Fassinger, R. E. (2017). Considering constructions: A new model of affirmative therapy. In K. A. DeBord, A. R. Fischer, K. J.
Bieschke, & R. M. Perez (Eds.), Handbook of sexual orientation and gender diversity in counseling and psychotherapy (pp. 19–
50). Washington, DC: American Psychological Association.
Gates, G. J. (2011). How many people are lesbian, gay, bisexual, and transgender? Los Angeles, CA: Williams Institute.
Harrison, N. (2000). Gay affirmative therapy: A critical analysis of the literature. British Journal of Guidance and Counselling,
28, 37–53. https://doi.org/10.1080/030698800109600
Hercus, C. (1999). Identity, emotion, and feminist collective action. Gender and Society, 13, 34–55. https://doi.org/10.1177/
089124399013001003
Johnson, S. D. (2012). Gay affirmative psychotherapy with lesbian, gay, and bisexual individuals: Implications for
contemporary psychotherapy research. American Journal of Orthopsychiatry, 82, 516–522. https://doi.org/10.1111/j.
1939‐0025.2012.01180.x
King, M., Semlyen, J., Killaspy, H., Nazareth, I., & Osborn, D. (2007). A systematic review of research on counseling and
psychotherapy for lesbian, gay, bisexual & transgender people. Lutterworth, Leicestershire: British Association for
Counseling and Psychotherapy. Retrieved from https://www.peter‐ould.net/wp‐content/uploads/king‐systematic‐
review‐1.pdf
Laird, J. (2000). Theorizing culture: Narrative ideas and practice principles. Journal of Feminist Family Therapy, 11, 99–114.
https://doi.org/10.1300/J086v11n04_08
Logie, C., Bridge, T. J., & Bridge, P. D. (2007). Evaluating the phobias, attitudes, and cultural competence of Master of Social
Work students toward the LGBT populations. Journal of Homosexuality, 53, 201–221. https://doi.org/10.1080/
00918360802103472
Matthews, C. R. (2007). Affirmative lesbian, gay, and bisexual counseling with all clients. In K. J. Bieschke, R. M. Perez, & K.
A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed, pp.
201–219). Washington, DC: American Psychological Association.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues
and research evidence. Psychological Bulletin, 129, 674–697. https://doi.org/10.1037/0033‐2909.129.5.674
Mondragon, S. A., Lambert, M. J., Nielsen, S. L., & Erikson, D. (2015). Comparative psychotherapy outcomes of sexual
minority clients and controls. International Journal of Education & Social Science, 2(4), 14–30. Retrieved from http://www.
ijessnet.com
Moradi, B. (2012). Feminist social justice orientation: An indicator of optimal functioning? The Counseling Psychologist, 40,
1133–1148. https://doi.org/10.1177/0011000012439612
Moradi, B. (2016). Lesbian, gay, bisexual, and transgender issues. In H. S. Friedman (Ed.), Encyclopedia of Mental Health
(2nd ed., Vol. 3, pp. 19–24). Oxford, England: Elsevier.
Moradi, B. (2017). (Re)focusing intersectionality in psychology: From social identities back to systems of oppression and
privilege. In K. DeBord, R. M. Perez, A. R. Fischer, & K. J. Bieschke (Eds.), The handbook of sexual orientation and gender
diversity in counseling and psychotherapy (3rd ed., pp. 105–127). Washington, DC: American Psychological Association.
Moradi, B., & Grzanka, P. R. (2017). Using intersectionality responsibly: Toward critical epistemology, structural analysis,
and social justice activism. Journal of Counseling Psychology, 64, 500–513. https://doi.org/10.1037/cou0000203
Morgenstern, J., Irwin, T. W., Wainberg, M. L., Parsons, J. T., Muench, F., Bux, D. A., … Schulz‐Heik, J. (2007). A randomized
controlled trial of goal choice interventions for alcohol use disorders among men who have sex with men. Journal of
Consulting and Clinical Psychology, 75, 72–84. https://doi.org/10.1037/0022‐006X.75.1.72
2042
|
MORADI
AND
BUDGE
Morgenstern, J., Kuerbis, A. N., Chen, A. C., Kahler, C. W., Bux, D. A., & Kranzler, H. R. (2012). A randomized clinical trial of
naltrexone and behavioral therapy for problem drinking men who have sex with men. Journal of Consulting and Clinical
Psychology, 80, 863–875. https://doi.org/10.1037/a0028615
Pachankis, J. E. (2014). Uncovering clinical principles and techniques to address minority stress, mental health, and related
health risks among gay and bisexual men. Clinical Psychology: Science and Practice, 21, 313–330. https://doi.org/10.1111/
cpsp.12078
Pachankis, J. E. (2015). A transdiagnostic minority stress treatment approach for gay and bisexual men’s syndemic health
conditions. Archives of Sexual Behavior, 44, 1843–1860. https://doi.org/10.1007/s10508‐015‐0480‐x
Pachankis, J. E., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB‐affirmative cognitive‐
behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority
stress approach. Journal of Consulting and Clinical Psychology, 83, 875–889. https://doi.org/10.1037/ccp0000037
Reback, C. J., & Shoptaw, S. (2014). Development of an evidence‐based, gay‐specific cognitive behavioral therapy
intervention for methamphetamine‐abusing gay and bisexual men. Addictive Behaviors, 39, 1286–1291. https://doi.org/
10.1016/j.addbeh.2011.11.029
Riggle, E. D. B., Whitman, J. S., Olson, A., Rostosky, S. S., & Strong, S. (2008). The positive aspects of being a lesbian or gay
man. Professional Psychology: Research and Practice, 39, 210–217. https://doi.org/10.1037/0735‐7028.39.2.210
Ross, A. D., Waehler, C. A., & Gray, T. N. (2013). Heterosexual persons’ perceptions regarding language use in counseling:
Extending Dorland and Fischer (2001). The Counseling Psychologist, 41, 918–930.
Russell, G. M., & Hawkey, C. G. (2017). Context, stigma, and therapeutic practice. In K. A. DeBord, A. R. Fischer, K. J.
Bieschke, & R. M. Perez (Eds.), Handbook of sexual orientation and gender diversity in counseling and psychotherapy (pp. 75104). Washington, DC: American Psychological Association.
Shelton, K., & Delgado‐Romero, E. A. (2011). Sexual orientation microaggressions: The experience of lesbian, gay, bisexual,
and queer clients in psychotherapy. Journal of Counseling Psychology, 58, 210–221. https://doi.org/10.1037/a0022251
Shoptaw, S., Reback, C. J., Larkins, S., Wang, P. C., Rotheram‐Fuller, E., Dang, J., & Yang, X. (2008). Outcomes using two
tailored behavioral treatments for substance abuse in urban gay and bisexual men. Journal of Substance Abuse
Treatment, 35, 285–293. https://doi.org/10.1016/j.jsat.2007.11.004
Shoptaw, S., Reback, C. J., Peck, J. A., Yang, X., Rotheram‐Fuller, E., Larkins, S., … Hucks‐Ortiz, C. (2005). Behavioral
treatment approaches for methamphetamine dependence and HIV‐related sexual risk behaviors among urban gay and
bisexual men. Drug and Alcohol Dependence, 78, 125–134. https://doi.org/10.1016/j.drugalcdep.2004.10.004
SMART Sexual Minority Assessment Research Team (SMART) (2009). Best practices for asking questions about sexual
orientation on surveys. Los Angeles, CA: The Williams Institute.
Steinem, G. (1983). Far from the opposite shore. In Outrageous acts and everyday rebellions (pp. 341–362).
The GenIUSS Group (2014). Best practices for asking questions to identify transgender and other gender minority respondents on
population‐based surveys. J. L. Herman (Ed.). Los Angeles, CA: The Williams Institute.
How to cite this article: Moradi B, Budge SL. Engaging in LGBQ+ affirmative psychotherapies with all
clients: Defining themes and practices. J. Clin. Psychol. 2018;74:2028–2042.
https://doi.org/10.1002/jclp.22687