Contextual Behavior Therapy for Sexual and Gender Minority Clients

A Practical Guide to Treatment

Matthew D. Skinta

• Publisher: Routledge
• Year: 2020
• ISBN:
  9780429638534
• Edition: 1
• Topic: Psychology
• Subtopic: Clinical Psychology
• Index: Psychology

Combining theory, research, and case studies, this book shows clinicians how to apply transdiagnostic contextual behavioral approaches when working with sexual and gender minority (SGM) clients.

The text first examines minority stress theory through the lens of contextual behavior analysis. Subsequent chapters illustrate the application of therapeutic techniques drawn from acceptance and commitment therapy, functional analytic psychotherapy, and compassion-focused therapy. The book concludes with a close look at special areas of consideration, including pre-surgical evaluation, the impact of HIV on SGM communities, ethical considerations, and future directions in therapy with SGM clients. Every chapter provides a series of diverse vignettes that illustrate how each aspect of treatment might build upon the last along with a list of recommended books for further exploration of that topic.

This book offers a unique, integrated approach that can be used for case conceptualization and followed as a treatment manual for professionals or graduate students with a foundation in SGM psychology.

1

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A CONTEXTUAL BEHAVIORAL ANALYSIS OF MINORITY STRESS

Introduction

Minority stress theory has become one of the central lenses used to research psychological experiences of SGM populations (e.g., Graham et al., 2011). Minority stress theory began with the premise that anti-LGBTQ+ animus in society is ubiquitous and affects the well-being of SGM people in a variety of ways. No single measure, such as direct discrimination or internalized stigma (i.e., internalized homophobia, internalized biphobia, internalized transphobia), can capture the full impact of living in a biased society (Meyer, 1995). These factors are generally described as proximal to distal, and the list includes internalized stigma, rejection sensitivity, or the expectation of rejection, outness or concealment, discrimination or violence, and specific to gender minority individuals, being misgendered (e.g., referred to by an incorrect name or with incorrect pronouns; Hendricks & Testa, 2012; Meyer, 2003). More recent formulations include resilience factors, as well, such as community connectedness and, for gender minority individuals, pride (Hendricks & Testa, 2012; Meyer, 2015). Minority stress theory provides a starting point for case conceptualization and transdiagnostic assessment, and this chapter will explore how developing a minority stress informed treatment plan can be supported through a consideration of process-based therapy and a functional contextual approach.

The path to minority stress theory

In the first decades after the declassification of homosexuality from the DSM, most publications describing the sexual minority experience emphasized internalized stigma (i.e., internalized homophobia; e.g., Malyon, 1982). While a useful starting point as the field began to acknowledge the deleterious effects of pervasive anti-SGM bias in society, there were a number of shortcomings to this approach. First, the interpersonal and societal challenges facing SGM people were not contingent on resolving negative beliefs one was exposed to earlier in life. Familial rejection, social exclusion, and workplace discrimination all had harmful impacts, and it has been less than 20 years since the U.S. Supreme Court overturned the last sodomy laws that criminalized same-sex sexuality (for a broader discussion, see Eskridge, 2008).

This changed with the popularity of minority stress theory (Meyer, 1995). First described in Minority Stress and Lesbian Women in 1981 (Brooks, 1981), it was not widely adopted until subsequent promotion in the works of Ilan Meyer (1995; 2003). Based upon Brooks’s grounding in systems theory, Brooks considered minority stress to be the biopsychosocial outcome of culturally sanctioned bias against SGM individuals, conveyed through both systemic bias as well as interpersonal interactions informed by anti-SGM animus (Rich et al., 2020). SGM individuals respond to the stress of living in a biased society in a number of ways, and minority stress theory offered enough flexibility to begin making sense of responses that ranged from anxiety to depression, substance use to sexual compulsivity (e.g., Lipson et al., 2019; Kerridge et al., 2017). Though initially minority stress research centered the experiences of and primarily included sexual minority individuals, the model was extended and refined to be inclusive of gender minority experiences (e.g., Testa et al., 2017).

The component parts of minority stress are internalized stigma, rejection sensitivity (or the expectation of stigma), concealment, discrimination, and violence, and in the case of gender minority stress, misgendering (Hendricks & Testa, 2012; Meyer, 2003). As noted in the introduction, it cannot be emphasized enough that minority stress is the response of SGM individuals to societal bias, and not a shortcoming of individuals (Meyer, 2019). In some cases, these may be adaptive responses to hostile environments. For example, concealment acts as a stressor, though may be an accurate response to a local context high in discrimination (Pachankis et al., 2015). Rejection sensitivity, which includes both interpersonal guardedness as well as a cognitive bias toward perceiving ambiguous responses as rejection or interpersonal submissiveness, may reduce unwanted attention in an environment in which safety is unclear (Pachankis et al., 2008). It must not be forgotten that targeting minority stress factors in psychotherapy is a means of healing individuals in societies that have not yet wholly embraced SGM people, and is not intended to supplant continued efforts to change society in ways that would allow SGM individuals to thrive (Meyer, 2019).

Research over the past decade has highlighted two major expansions of minority stress theory. First, most recent work incorporates a recognition of SGM-specific resilience factors into the model, as they mitigate the impact of bias in society (Meyer, 2015). Second, a series of studies has led to an emphasis on mediating psychological processes, with emotion dysregulation receiving the greatest attention (Hatzenbuehler, 2009). That is, the cumulative impact of minority stressors appears to diminish one’s capacity for emotion regulation, which in turn increases the likelihood, varying by context, that an individual will experience adverse psychological and medical outcomes. This expanded model includes some elements not commonly listed though supported in the literature, such as experiential avoidance and shame as additional mediators, and self-compassion as a possible resilience factor (Figure 1.1; Gold et al., 2011; Leleux-Labarge et al., 2015; Mereish & Poteat, 2015; Vigna et al., 2018).

Figure 1.1 Minority stress model with proposed resilience factors and mechanism of action. Gender minority-specific factors are shaded.

This model is incomplete, however. For SGM individuals with intersectional identities, one’s lived experience is not simply minority stress plus racism, sexism, or xenophobia (Bowleg, 2008). While there have been fledgling attempts to measure intersectional stressors, such as the presence of racism within SGM community spaces and anti-SGM bias with a community of color, it has been more challenging to identify ways to measure or assess responses to an individual as a whole person (e.g., Balsam et al., 2011). One example can be found in the growing literature on sexual racism, which appears to be an expression of covert racism (Callander et al., 2015). Sexual racism encapsulates those attitudes and expressions of attraction that either exclude or fetishize a person of color in SGM spaces, and serve as their own unique stressor (Han & Choi, 2018). Sexual racism among sexual minority men has been associated with higher body dissatisfaction (Bhambhani et al., 2019) and psychological distress (Bhambhani et al., 2020). For a consideration of factors missing from Figure 1.1, Figure 1.2 proposes some additional considerations for work with SGM people of color.

Figure 1.2 Emphasizing just the left side of the model, these proposed factors highlight intersectional interpretations of the minority stress model.

Finally, access to SGM communities may serve as stressors of their own. This can occur through pressure to identify with a particular label in the presence of identity confusion (Gandhi et al., 2016), anti-plurisexual sentiment, and bisexual erasure (e.g., Hertlein et al., 2016), and stress to conform to particular body standards (Frederick & Essayli, 2016). Finally, the term intraminority stress has been adopted to refer to those stressors that arise as a result of competition and status anxiety within communities of gay men (Pachankis et al., 2020). The minority stress model, as I hope these adaptations and addendum clarify, is still undergoing revisions and refinements as additional work is completed. While the minority stress model serves as a helpful signpost in developing interventions, there is an array of individual factors that may arise in treatment that should be considered in determining the course of responding therapeutically.

Process-based therapy

In light of the recognition of common symptoms that do not correspond to specific diagnoses, and the recognition of transdiagnostic drivers of psychological diagnoses, many cognitive behavior therapists have shifted their attention toward process-based therapies (Hofmann & Hayes, 2019). Process-based CBT asks what core biopsychosocial processes presented by the client should be targeted, given their goals in their current context, and how might those be most efficiently and effectively changed (Hayes & Hofmann, 2018). In the case of minority stress, some early attempts have targeted emotion dysregulation as the underlying mechanism that may have the greatest impact, with some success in early trials with modifications of the Unified Protocol and Dialectical Behavior Therapy (e.g., Pachankis et al., 2015; Sloan et al., 2017). While such a direction appears promising, there are additional ways to consider crafting interventions that are both mindful of minority stress theory as well as tools at the well-trained clinician’s disposal. This has led to calls to develop and research interventions that emphasize SGM-specific treatment targets, such as internalized stigma, rejection sensitivity, and identity concealment (Cohen & Feinstein, 2020; Feinstein, 2019).

In exploring a contextual behavioral approach to treating minority stress, this volume sides with the latter argument. While a number of the skills and techniques that follow may be expected to also bolster emotion regulation skills, the emphasis is on dismantling some of the behaviors that developed as a function of internalized stigma, rejection sensitivity, and identity concealment. It is also worth recognizing that these are operationalizations that make these phenomena amenable to research, though they are not wholly discrete. For instance, cognitions about the world and other’s responses to an SGM person found within internalized stigma may lead to some of the anticipated stigma that drives rejection sensitivity. Rejection sensitivity contains within the construct a number of behaviors intended to mitigate interpersonal rejection, that may be expressed through overly submissive behaviors, conflict avoidance, or interpersonal guardedness. Identity concealment, and the subsequent lack of interpersonal feedback that may undermine rejection sensitivity, are also deeply interconnected.

In this way, as the therapeutic interventions unfold in the following chapters, you may note that there are overlapping targets that are described. A mindful awareness of one’s present environment may serve as a precursor to identity disclosure for some (Chapter 3), which may facilitate other vulnerable interpersonal disclosure that undermine rejection sensitivity (Chapter 6). Practicing self-compassion skills that soften the impact of situational shame may in turn lead to deeper relationships within the community (Chapter 7).

Developing a treatment that emphasizes transdiagnostic targets frees the evidence-based clinician from reliance on manualized therapies for contexts in which no clear manual exists without straying too far into the unknown. This is perhaps more important in working with SGM clients, as SGM individuals seek therapy at disproportionally high rates compared to the general population, and therapy seeking is not specifically tied to meeting criteria for a specific disorder (Cochran et al., 2003). Minority stress theory has proposed a number of specific targets that merit further attention during the course of treatment.

Philosophy of treatment

The general approach of this book is informed by the philosophy of functional conte...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Contents
• Author Biography
• Introduction
• 1 A Contextual Behavioral Analysis of Minority Stress
• 2 The Therapeutic Relationship and Clinician Self-Work
• 3 Mindfulness and Perspective Taking
• 4 Acceptance and Defusion
• 5 Values and Committed Action
• 6 Vulnerability and Intimacy
• 7 Compassion and Community
• 8 Complex Trauma and Post-Traumatic Stress among SGM Clients
• 9 Health Considerations among SGM Clients
• 10 Special Ethical Considerations for SGM Therapists
• 11 Future Directions in SGM Therapy
• Index