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People who identify as LGBTQIA+ face unique stressors that can make it difficult to find mental health care that meets their needs. They experience violence, discrimination, and stigma at far higher rates than those outside of this community, which can lead to anxiety about their jobs, relationships, and physical safety. LGBTQIA+ individuals are more than twice as likely as heterosexual and cisgender people to have a mental health disorder in their lifetime. One approach that can be effective is affirmative therapy, which is inclusive, respectful, and affirming of all sexual and gender identities. We’ll explore affirmative psychotherapy, why it’s important to LGBTQIA+ mental health, and how to find an LGBTQIA+-affirming therapist.
Affirmative psychotherapy validates and advocates for the needs of LGBTQIA+ clients through verbal and nonverbal techniques. “At the heart of it, affirmative therapy ensures that care is fully validating and affirming of clients’ experiences and asserts that all sexuality and genders are healthy,” said Keren Lehavot, PhD, Lyra Health’s senior clinical training lead of culturally responsive care. Affirmative therapy’s origins are rooted in LGBTQIA+ communities and the term is specific to LGBTQIA+ care, but the principles are similar to culturally responsive care, a treatment approach that’s inclusive of all cultures, identities, backgrounds, and experiences.
“Just the term ‘affirmative therapy’ represents how far we’ve come from the days when being a sexual minority was considered a mental health disorder,” said Lehavot. “It’s the antithesis of conversion therapy and is the official stance of mental health and medical organizations like the American Psychological Association and National Association of Social Workers.”
LGBTQIA+ affirmative therapy can be integrated into any evidence-based therapy such as cognitive behavioral therapy (CBT), dialectical behavior therapy (DBT), and motivational interviewing. “Regardless of the specific treatment approach providers use, they can integrate affirmative therapy into their practice,” said Lehavot. “Similar to culturally responsive care, it’s an approach to care.”
Affirmative therapy begins before a session starts; one of the best practices of LGBTQIA+-affirming therapy is being mindful of the therapeutic space, whether that’s virtual or in person. Therapy takes place in a setting that’s welcoming and free of indicators or symbols that would make clients feel uncomfortable or discriminated against, and may include ones that show alliance with the LGBTQIA+ community.
The LGBTQIA+-affirming therapist doesn’t assume that LGBTQIA+ clients enter therapy due to issues related to their sexuality or gender identity. They use inclusive language and mirror terminology the client uses to describe themselves, their relationship status, and their sexual and gender identities. Care providers build trust by reflecting and validating what the client says about themselves, their identity, and their experience. All identities are welcomed into the space, including those around religion, race and ethnicity, and disabilities.
Affirmative therapy has been shown to be effective with evidence-based approaches like CBT and shown to improve the mental health of LGBTQIA+ women, men, and transgender, gender diverse, and nonbinary youth. Affirmative counseling is designed to help LGBTQIA+ clients feel comfortable and affirmed by their therapist. People can expect that a therapist who practices LGBTQIA+-affirming therapy takes a stance that all sexuality and gender exists on a continuum and is healthy and natural.
“Therapy is a really private, personal, and vulnerable space,” said Lehavot. “If stressors related to your identity are related to why you are seeking care, therapy can be a place for you to really explore that. Maybe you’re just figuring it out, so you want a place that’s nonjudgmental and affirming where you can talk about all parts of you and how it’s impacting you.”
And if a person is seeking care unrelated to their sexual and gender identity, they may want to know that their provider will be respectful and understand that their challenges aren’t tied to these aspects of who they are. “It’s important to feel you can walk into therapy and know that your provider will respect your boundaries around what you want to disclose and share, and not make assumptions about what issues may or may not be related to your sexuality, gender identity, or other important aspects of your identity,” said Lehavot.
LGBTQIA+ therapists typically indicate this in their profiles, websites, or bios. They may note that they work with LGBTQIA+ people or that they practice affirmative therapy.
There are also implicit ways of recognizing LGBTQIA+-affirming therapists. Do they use LGBTQIA+-affirming terminology? Do they put pronouns after their names as a way of showing allyship with the LGBTQIA+ community? Do they provide evidence-based therapy (EBTs)? All evidence-based therapies should take an affirmative therapy approach. While providing EBTs doesn’t always mean they practice LGBTQIA+ affirmative therapy, it should indicate this as a strong possibility.
“I would also absolutely encourage people to ask a potential provider if they are LGBTQIA+ affirming or what their approach is to working with LGBTQIA+ clients during their screening call,” said Lehavot. “Let your provider know if you have any concerns or if you’re hoping to work with someone with a specific background or expertise. As a therapist, I’ve had several prospective clients ask me about my experience working with the LGBTQIA+ community. They’re often looking to hear my affirmative stance.”
In addition to the American Psychological Association’s practice guidelines for working with lesbian, gay, and bisexual clients as well as transgender and gender-nonconforming people, these 10 practices can help providers promote an affirming, safe space for LGBTQIA+ clients.
LGBTQIA+ clients may experience minority stressors in ways that have a significant impact on their physical and mental health. These stressors can include individual and larger circumstantial factors that affect health like bullying, homophobic or transphobic attitudes, legal discrimination as it relates to health insurance, employment, and marriage, and a lack of access to health care or providers who are knowledgeable about LGBTQIA+ mental health. LGBTQIA+ clients may also be at higher risk for suicide. It’s crucial that providers understand these health concerns and validate their impact on clients as part of providing LGBTQIA+ affirmative therapy.
“Minority stress that’s unique to someone’s identity is a very real stressor in many people’s lives, and it can have an impact on depression, anxiety, and other mental health outcomes,” said Lehavot. “Simply telling an LGBTQIA+ individual that their depression is due to unhelpful thinking doesn’t acknowledge that their stressors are often embedded in an oppressive external environment.”
Providing affirmative psychotherapy also means ensuring screening and intake forms are inclusive and allow for the full gender and sexual expression of LGBTQIA+ clients. “Part of normalizing the experience from the get-go is actually seeing places to mark if you’re transgender, LGBTQIA+, or in a relationship with a same-sex partner,” said Lehavot. “Include a space for clients to share what pronouns they use. Be sure that any behavioral health screeners you use incorporate inclusive language around gender and sexual identity.”
We all have many cultural identities that overlap and intersect. These identities can be influenced by race, ethnicity, gender, age, religion, spirituality, physical attributes, political beliefs, personal values, and life experiences. A sole focus on one identity can rob a person of their full story.
Similarly, it’s best to avoid assuming that a client has specific religious or political beliefs based on their LGBTQIA+ identity. Honor the multiple influences on your clients’ lives. The client’s LGBTQIA+ identity may not be the most salient aspect of their identity or something they want to focus on in therapy.
“Part of culturally responsive care is to invite clients to share with you what aspects of their identity are most important to them and to your work together,” said Lehavot. “Pose questions to clients about what you hear. Be curious, nonjudgmental, affirming, and respectful. A way to build trust is to reflect and validate.”
Therapists can wear or include symbols or indicators in their office that represent or promote a safe space for LGBTQIA+ clients. This might include a rainbow health care pin or buttons and signs that say LGBTQIA+ “ally,” “equality,” pride,” or “safe zone.” Books, posters, brochures, and other materials in the office should include representation of LGBTQIA+ people and communities. Gender-neutral bathroom signs are also helpful.
An affirmative approach doesn’t assume that a client’s sexual or gender identity equates to specific sexual practices. Providers should ask permission or invite clients to discuss their sexual health. Don’t assume that LGBTQIA+ clients are engaging in riskier sexual practices. If risky behaviors are present, the therapist should dialogue and discuss without judgment.
Knowing and internalizing the reality that LGBTQIA+ clients are strong, powerful, and whole is an important foundation that helps therapists provide an affirming space for them. Providers should focus on their strengths, honor their resilience, and join them in celebrating their pride. It’s important to avoid assuming that LGBTQIA+ clients are struggling to manage the stressors they experience. Therapists would do well to recognize the positive impact of LGBTQIA+-affirming communities and support networks on their clients.
“Be aware of unique issues, stressors, or strengths that may come up in the LGBTQIA+ community so it’s relevant to the care you’re providing,” said Lehavot. “Learn about minority stress, bias, discrimination, and internalized versions of shame as well as unique strengths and pride they may have from the community support and social support they’ve built in their identity, like overcoming adversity and developing resilience.”
Learning about moments in history that impacted the fight for LGBTQIA+ rights provides context for the struggles and oppression that some clients may have experienced. This knowledge is important regardless of clients’ age. For example, typically referred to as Compton’s Cafeteria Riot, in August 1966, a group of mostly trans women of color stood up against persistent police harassment and abuse. This historic event is considered one of the first acts of resistance for queer liberation and occurred three years before the Stonewall Riots. However, the riot at Compton’s is not as well-known and the trans women are given much less credit for sparking the ensuing fight for LGBTQIA+ rights. Another example is the Don’t Ask, Don’t Tell military ban that prevented LGBTQIA+ members from serving in the military, which wasn’t officially repealed until September 2011.
Some clients may not want to feel as though they have to share their experiences of being LGBTQIA+ to yet another person. Conversely, some clients may never have had spaces where they could freely share their story and identities. LGBTQIA+ affirmative therapy seeks to collaboratively create a space for both, and lets the client be the guide on what feels most useful to them.
Therapists should proactively work to identify and understand how their own biases, experiences, and perspectives influence the way they navigate the world and interact with clients. Recognizing their own privileges and biases can be uncomfortable, but providers can use this discomfort to become a better ally and advocate for their clients and LGBTQIA+ mental health.
“It’s also about taking time to reflect upon your own identity around sexuality and gender and how it relates to this community,” said Lehavot. “Are there things you need to be mindful of yourself and how you work with clients, and what are ways you can further build your competence?”
Providers should develop the mindset that working with clients, regardless of background, involves continuous openness, self-awareness, and self-reflection. That means seeking guidance, training, and continuous consultation in LGBTQIA+-affirming care. This helps enable ongoing learning, growing, and cultivating a safe space for LGBTQIA+ clients.
“It’s OK not to know it all and to be honest about your ongoing learning,” said Lehavot. “Openly acknowledge mistakes if you make them. All therapists are fallible and make errors. If you used the wrong pronoun or said something that could be perceived as a microaggression, apologize and do the repair work.”
Therapy should be a space where people feel free to express and explore all aspects of themselves. Affirmative therapy ensures that such a safe, affirming space is accessible to LGBTQIA+ clients. We’re proud that our Lyra therapists practice affirmative psychotherapy and culturally responsive care and receive ongoing training to improve their skills.