Transdiagnostic LGBTQ-Affirmative Cognitive-Behavioral Therapy: Therapist Guide 0197643302, 9780197643303

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Transdiagnostic LGBTQ-​Affirmative Cognitive-​Behavioral Therapy

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T R E AT M E N T S T H AT W O R K

E D I T O R -​I N -​C H I E F David H. Barlow, PhD

SCIENTIFIC ADVISORY BOARD Anne Marie Albano, PhD Gillian Butler, PhD David M. Clark, PhD Edna B. Foa, PhD Paul J. Frick, PhD Jack M. Gorman, MD Kirk Heilbrun, PhD Robert J. McMahon, PhD Peter E. Nathan, PhD Christine Maguth Nezu, PhD Matthew K. Nock, PhD Paul Salkovskis, PhD Bonnie Spring, PhD Gail Steketee, PhD John R. Weisz, PhD G. Terence Wilson, PhD

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TR E ATM E NT S T H AT W O R K

Transdiagnostic LGBTQ-​Affirmative Cognitive-​Behavioral Therapy

THERAPIST GUIDE

J O H N E . PA C H A N K I S AUDREY R. HARKNESS SKYLER D. JACKSON STEVEN A. SAFREN

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Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford is a registered trade mark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016, United States of America. © Oxford University Press 2022 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Names: Pachankis, John E., author. | Harkness, Audrey R., author. | Jackson, Skyler D., author. | Safren, Steven A., author. Title: Transdiagnostic LGBTQ-affirmative cognitive-behavioral therapy : therapist guide / John E. Pachankis, Audrey R. Harkness, Skyler D. Jackson, Steven A. Safren. Description: New York, NY : Oxford University Press, [2022] | Series: Treatments that work | Includes bibliographical references and index. Identifiers: LCCN 2022018792 (print) | LCCN 2022018793 (ebook) | ISBN 9780197643303 (paperback) | ISBN 9780197643327 (epub) | ISBN 9780197643334 Subjects: LCSH: Sexual minorities—Mental health. | Cognitive therapy. Classification: LCC RC451.4.G39 P332 2022 (print) | LCC RC451.4.G39 (ebook) | DDC 616.89/14250866—dc23/eng/20220510 LC record available at https://lccn.loc.gov/2022018792 LC ebook record available at https://lccn.loc.gov/2022018793 DOI: 10.1093/​med-​psych/​9780197643303.001.0001 9 8 7 6 5 4 3 2 1 Printed by Marquis, Canada

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About

Treatments ThatWork™

Stunning developments in healthcare have taken place over the last several years, but many of our widely accepted interventions and strategies in mental health and behavioral medicine have been brought into question by research evidence as not only lacking benefit, but perhaps, inducing harm (Barlow, 2010). Other strategies have been proven effective using the best current standards of evidence, resulting in broad-​ based recommendations to make these practices more available to the public (McHugh & Barlow, 2010). Several recent developments are behind this revolution. First, we have arrived at a much deeper understanding of pathology, both psychological and physical, which has led to the development of new, more precisely targeted interventions. Second, our research methodologies have improved substantially, such that we have reduced threats to internal and external validity, making the outcomes more directly applicable to clinical situations. Third, governments around the world and health care systems and policymakers have decided that the quality of care should improve, that it should be evidence-​based, and that it is in the public’s interest to ensure that this happens (Barlow, 2004; Institute of Medicine, 2001, 2015; McHugh & Barlow, 2010). Of course, the major stumbling block for clinicians everywhere is the accessibility of newly developed evidence-​based psychological interventions. Workshops and books can go only so far in acquainting responsible and conscientious practitioners with the latest behavioral health care practices and their applicability to individual patients. This series, Treatments ThatWork™, is devoted to communicating these exciting new interventions to clinicians on the frontlines of practice. The manuals and workbooks in this series contain step-​by-​step detailed procedures for assessing and treating specific problems and diagnoses. But this series also goes beyond the books and manuals by providing

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ancillary materials that will approximate the supervisory process in assisting practitioners in the implementation of these procedures in their practice. In our emerging health care system, the growing consensus is that evidence-​based practice offers the most responsible course of action for the mental health professional. All behavioral health care clinicians deeply desire to provide the best possible care for their patients. In this series, our aim is to close the dissemination and information gap and make that possible. This guide addresses the distinct stressors that often lead LGBTQ people to seek mental health care more frequently than the general population with an LGBTQ-​affirmative cognitive-​behavioral therapy (CBT) protocol that can be delivered in individual and group formats in an outpatient mental health setting. It is estimated that the majority of LGBTQ individuals will experience a mental health condition at least once in their lives, with rates of major depressive disorder, generalized anxiety disorder, alcohol use disorder, social anxiety disorder, posttraumatic stress disorder, panic disorder, and dysthymia being significantly elevated among LGBTQ populations compared to heterosexual/​cisgender populations. The guide is intended to be used by clinicians who are familiar with CBT generally and are looking to incorporate an LGBTQ-​affirmative CBT approach for addressing the stressors that contribute to LGBTQ people’s elevated risk of mental health problems. Because the processes and techniques that are presented here build upon a treatment protocol with extensive empirical support accumulated across community consultations and randomized controlled trials for over a decade, Transdiagnostic LGBTQ-​Affirmative Cognitive-​Behavioral Therapy will be an indispensable resource for all practitioners who wish to effectively and efficiently help LGBTQ people reduce distressing symptoms and improve quality of life. David H. Barlow, Editor-​in-​Chief Treatments ThatWork™ Boston, Massachusetts

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Contents

Acknowledgments  ix Part I: Background for Therapists 

Chapter 1 Introduction to LGBTQ-​Affirmative Cognitive-​Behavioral Therapy  3 Chapter 2 History, Basic Principles, and Outline of LGBTQ-​Affirmative Cognitive-​Behavioral Therapy  13 Chapter 3 Additional Information for Therapists  35 Chapter 4 Overview of General Treatment Format and Procedures  41 Part II: Providing the Treatment 

Chapter 5 Session 1: Functional Analysis and Introduction to Treatment  49 Chapter 6 Module 1: Setting Goals and Building Motivation for LGBTQ-​Affirmative Cognitive-​Behavioral Therapy  77 Chapter 7 Module 2: Understanding the Nature and Emotional Impact of LGBTQ-​Related Stress  95 Chapter 8 Module 3: Understanding and Tracking LGBTQ-​Related Stress and Emotional Experiences  111 vii

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Chapter 9 Module 4: Increasing Mindful Awareness of LGBTQ-​Related Stress Reactions  139 Chapter 10

 odule 5: Increasing Cognitive M Flexibility  161

Chapter 11

 odule 6: Countering Emotional M Behaviors  185

Chapter 12

 odule 7: Experimenting with New M Reactions to LGBTQ-​Related Stress  209

Chapter 13

 odule 8: Emotion Exposures for Countering M LGBTQ-​Related Stress  233

Chapter 14

 odule 9: Recognizing Accomplishments and M Looking to the Future  255

Bibliography  273 About the Authors  281

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Acknowledgments

The material contained in the therapist guide and client workbook for Transdiagnostic LGBTQ-​Affirmative Cognitive-​ Behavioral Therapy derives from several sources. Most significantly, the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders—​Therapist Guide and the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders—​ Patient Workbook by David Barlow, PhD, Todd Farchione, PhD, and colleagues served as the basis for the materials contained herein. David Barlow, PhD, Todd Farchione, PhD, and Oxford University Press provided permission to work from the Unified Protocol to prepare the Transdiagnostic LGBTQ-​ Affirmative Cognitive-​ Behavioral Therapy—​ Therapist Guide and Transdiagnostic LGBTQ-​Affirmative Cognitive-​Behavioral Therapy—​Client Workbook. The general outline and much of the text about the nature of emotional disorders, setting goals, increasing cognitive flexibility, emotion exposures, and relapse prevention comes directly from the Unified Protocol therapist guide and patient workbook. John Pachankis, PhD, thoroughly revised and updated the outline and text of the Unified Protocol therapist guide to specifically respond to the needs of LGBTQ clients, including through consultation with LGBTQ community members and expert mental health providers, following an adaptation process described elsewhere1. This adaptation process resulted in the inclusion of LGBTQ-​specific content throughout the therapist guide. Much of this new

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, 21(4), 313–330. 1

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content focuses on the relevance of LGBTQ-​ related stress triggers and maladaptive coping responses as sources of emotional disorders for LGBTQ individuals. Other new content for Transdiagnostic LGBTQ-Affirmative Cognitive-Behavioral Therapy includes the chapter regarding functional analysis, which was influenced by2 Cognitive-behavior therapy: Reflections on the evolution of a therapeutic orientation, and the chapter regarding experimenting with new reactions and assertiveness, which was influenced3 by Lange and Jakubowski’s (1971) Responsible Assertive Behavior: Cognitive/​Behavioral Procedures for Trainers. The LGBTQ-​specific adaptation of that specific approach is described elsewhere4. Mark Hatzenbuehler, PhD, contributed helpful suggestions at the adaptation stage. The client workbook was created from several sources, starting with the therapist guide described above and session summaries of Transdiagnostic LGBTQ-​Affirmative Cognitive-​Behavioral Therapy created by Charles Burton, PhD, Melvin Hampton, PhD, Craig Rodriguez-​Seijas, PhD, Ingrid Solano, PhD, and Katie Wang, PhD. Several individuals initially helped revise the therapist guide and these session summaries to use more easily accessible, client-​centered language, based on their practical experience delivering the therapy in clinical trials. These individuals worked closely with John Pachankis, PhD, to undertake this initial language revision. The team included the following individuals: Charles Burton, PhD (treatment introduction, Chapter 2; goal setting, Chapter 4); Nitzan Cohen, PhD (introduction to LGBTQ-​related stress, Chapter 5; relapse prevention, Chapter 12); Zachary Rawlings, PhD (understanding emotions, Chapter 6; emotional behaviors, Chapter 9; emotion exposures, Chapter 11); Kriti Behari, MA (awareness

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Goldfried’s (2003). Lange, A., & Jakubowski, P. (1976). Responsible assertive behavior: cognitive/behavioral procedures for trainers. Champaign, IL: Research Press. 4 Pachankis, J. E. (2009). The use of cognitive-behavioral therapy to promote authenticity. Pragmatic Case Studies in Psychotherapy, 5(4), 28–38. 2 3

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of LGBTQ-​related stress reactions, Chapter 7); Tenille Taggart, MA (cognitive flexibility, Chapter 8; countering emotional behaviors, Chapter 11); and Alexander Belser, PhD (experimenting with new reactions to LGBTQ-​related stress, Chapter 10). John Pachankis, PhD, subsequently edited these language revisions. Following this client-​centered language revision process, Cal Brisbin, BA, Benjamin Fetzner, BA, Eric Layland, PhD, Erin McConocha, MPH, and Ilana Seager van Dyk, PhD, performed additional revisions to further increase language accessibility and LGBTQ relevance. These materials were then thoroughly edited and revised by John Pachankis, PhD, Skyler Jackson, PhD, Audrey Harkness, PhD, and Steven Safren, PhD, taking into account subsequently published clinical trials results of this treatment5–7, the revisions included in the second edition of the Unified Protocol, and alignment with the content of the therapist guide for Transdiagnostic LGBTQ-​Affirmative Cognitive-​Behavioral Therapy. Benjamin Eisenstadt proofread the therapist guide and client workbook and contributed style and content edits to both texts.







Jackson, S. D., Wagner, L., Yepes, M., Harvey, T., Higginbottom, J., & Pachankis, J. E. (2021). A pilot test of a treatment to address intersectional stigma, mental health, and HIV risk among gay and bisexual men of color. Psychotherapy 6 Pachankis, J. E., Harkness, A., Maciejewski, K.R., Behari, K., Clark, K. A., McConocha, E., Winston, R., Adeyinka, O., Reynolds, J., Bränström, R., Esserman, D. A., Hatzenbuehler, M. L., & Safren, S. A. (in press). LGBQ-affirmative cognitive-behavioral therapy for young gay and bisexual men’s mental and sexual health: A three-arm randomized controlled trial. Journal of Consulting and Clinical Psychology. 7 Pachankis, J. E., McConocha, E. M., Wang, K., Behari, K., Fetzner, B. K., Brisbin, C. D., Scheer, J. R., & Lehavot, K. (2020). A transdiagnostic minority stress intervention for sexual minority women’s depression, anxiety, and unhealthy alcohol use: a randomized controlled trial. Journal of Consulting and Clinical Psychology, 88, 613–630. 5

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PA R T I

Background for Therapists

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CHAPTER 1

Introduction to LGBTQ-​ Affirmative Cognitive-​ Behavioral Therapy

Background of the LGBTQ-​Affirmative Treatment Presented in This Guide The treatment described in this therapist guide employs evidence-​based cognitive-​behavioral principles and techniques shown to significantly improve mood and anxiety disorders in the general treatment-​seeking population. These techniques were adapted to specifically help lesbian, gay, bisexual, transgender, and queer (LGBTQ; sexual and gender minority) people improve their mental health. In the past two decades, several epidemiological studies have shown that LGBTQ people are significantly more likely than heterosexual and cisgender individuals to experience mood and anxiety disorders because of the stress they face as a result of their disadvantaged social status (Bränström et al., 2020; King et al., 2008; Mays & Cochran, 2001; Rodriguez-​Seijas et al., 2019). Accumulating research shows that this unique form of stress, referred to as minority stress, or as we will refer to it in this treatment program LGBTQ-​related stress, largely explains the excess burden of mental health problems borne by LGBTQ populations (Meyer, 2003). Recognizing the central role of LGBTQ-​related stress in the mental health of LGBTQ individuals, this treatment focuses specifically on helping LGBTQ clients understand this stress and the impact it has on their presenting concerns as well as learning to build coping skills and self-​efficacy for managing this impact. Although decades of research support the efficacy of cognitive-​ behavioral therapy (CBT) across mood and anxiety disorders (Hofmann et al., 2012), CBT has received relatively little attention for addressing the unique stressors that LGBTQ individuals experience. This gap is striking given that CBT is well suited to promoting coping self-​efficacy

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in the face of stressors ultimately rooted in the social environment (Balsam et al., 2006). Recognizing the need for guidance in adapting CBT to specifically address the role of LGBTQ-​related stress in LGBTQ individuals’ mental health, our clinical research team developed a CBT treatment that employs CBT principles and techniques in combination with theory and research on LGBTQ-​related stress and its manifestations in LGBTQ people’s lives. This protocol represents the first treatment approach to integrate CBT principles and techniques with minority stress theory (Burton et al., 2019; Pachankis, 2014). The treatment shows promising evidence for reducing depression, anxiety, and other stress-​ related outcomes among LGBTQ people across randomized controlled trials (Pachankis et al., 2015, 2020c). The material in this therapist guide derives from three sources: 1. The Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders by David Barlow and colleagues (2017b), a CBT-​based treatment approach focused on the common roots of mood and anxiety disorders in emotion-​related challenges; 2. Minority stress theory (Meyer, 2003) and clinically useful extensions thereof (Hatzenbuehler, 2009); and 3. The result of interviews conducted with 33 mental health experts with extensive experience treating LGBTQ clients and 40 LGBTQ community members who reported experiencing depression, anxiety, and other problems of emotion regulation (e.g., substance use, suicidality, sexual compulsivity; Pachankis, 2014; Pachankis et al., 2020c; Scheer et al., 2022). Minority stress theory and interview results were merged with the Unified Protocol content in order to create a CBT-​based treatment specifically adapted to help LGBTQ people cope with LGBTQ-​related stress.

A Unified, Transdiagnostic Approach The Unified Protocol (Barlow et al., 2017b), upon which this treatment approach is based, responds to advances in the psychological treatment of mood and anxiety disorders that recognize that these common conditions share more similarities than differences. Specifically, 4

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comorbidity across the anxiety and depressive disorders is the rule rather than exception (with estimates as high as 75%; Kotov et al., 2017), suggesting that clients do not fit neatly into the diagnostic boxes the field has created for them. Finally, there appears to be a broad treatment response when targeting one disorder that often generalizes across other disorders (Barlow et al., 2017a). This evidence suggests that there may be a common set of vulnerabilities contributing to the development of anxiety, depression, and related disorders that can become a more efficient focus of treatment than the diverse symptoms themselves. Based on the above evidence of transdiagnostic vulnerabilities across anxiety, depressive, and related disorders, the Unified Protocol focuses on three core vulnerabilities that put individuals at risk of these common mental health conditions: 1. It draws upon evidence suggesting that anxiety, depressive, and related disorders are characterized by high levels of negative affect. In other words, individuals with these disorders have a temperamental propensity to experience negative emotions frequently and intensely, sometimes referred to as neuroticism (Barlow et al., 2014). 2. The Unified Protocol recognizes that individuals with these common conditions tend to view their emotional experiences negatively (e.g., “it’s weak to feel this way,” “no one else is reacting like this,” “these physical sensations are terrible”). 3. The Unified Protocol draws upon research showing that aversive reactions to emotions when they occur lead to efforts to avoid and suppress these emotions. Individuals with anxiety and depressive disorders often rely on maladaptive regulation strategies that backfire (Purdon, 1999), maintaining high levels of negative affect and contributing to the persistence of symptoms. Given the role of emotional experiences in the development and maintenance of the full range of anxiety, depressive, and related disorders, the Unified Protocol emphasizes the role of emotion and emotion regulation across its treatment approach. For more information on the role of emotions in the “emotional disorders,” see Barlow et al. (2014). Based on these advances in understanding emotions, Barlow and colleagues developed a treatment applicable to all anxiety and unipolar

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depressive disorders, and potentially other disorders with strong emotional components (e.g., eating disorders, borderline personality disorder). The Unified Protocol addresses neuroticism by targeting the aversive, avoidant reactions to emotions that, while providing relief in the short term, increase the likelihood of future negative emotions and maintain disorder symptoms. The Unified Protocol forms the basis of the treatment adapted here for LGBTQ people’s experiences of LGBTQ-​related stress. The clinical strategies of the Unified Protocol are largely based on common principles found across existing empirically supported psychological treatments, primarily CBT. These CBT principles include: ■ ■ ■ ■

Fostering mindful awareness, Re-​evaluating automatic cognitive appraisals, Changing action tendencies associated with maladaptive emotions, and Utilizing exposure procedures.

The Unified Protocol focuses these skills on specifically addressing core negative responses to emotional experiences, and we further focus them to specifically reduce the role of LGBTQ-​related stress in generating these responses.

An LGBTQ-​Related Stress-​Focused Approach for LGBTQ Clients LGBTQ-​ related stress refers to the unique and chronic stress that LGBTQ people experience because of their marginalized social status. Strong empirical evidence suggests that LGBTQ-​related stress plays a key role in the mental health of LGBTQ people. LGBTQ-​related stress can represent the relatively broad influences on mental health that are rooted in anti-​LGBTQ societal attitudes and social policies. LGBTQ-​ related stress also refers to LGBTQ people’s coping reactions to these stressors. LGBTQ-​related stress exerts its most powerful toll on vulnerability to depression and anxiety through the efforts required to cope with it (Meyer, 2003). LGBTQ-​related stress typically begins early in LGBTQ people’s development with consequences across the life course. For

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instance, LGBTQ people express more gender non-​conforming interests and behaviors in their childhoods compared to heterosexual, cisgender people (Lippa, 2008; Rahman & Wilson, 2003; Rieger et al., 2008). Gender non-​conformity has been found to confer risk for parental and peer non-​acceptance across formative years of development, and this non-​acceptance can consequently lead to depression, anxiety, and related emotional problems (Pachankis et al., 2020a). Sexual orientation concealment, chronic expectations of rejection, and internalized stigma represent additional LGBTQ-​related stressors that are also associated with depression, anxiety, and related emotional problems, such as substance use and behaviors that might place one at risk for HIV or sexually transmitted infections (Newcomb & Mustanski, 2010; Pachankis et al., 2020b; Wang & Pachankis, 2016). Concealing or downplaying one’s sexual orientation on a day-​to-​day basis can serve as a strategy to avoid being the target of stigma. While concealment may represent a functional adaptation to a hostile social climate (Pachankis & Goldfried, 2006), it has also been shown to be associated with contingent self-​worth, compartmentalization between one’s public and private self, shame, and symptoms of depression and anxiety among LGBTQ people (Pachankis et al., 2020b). Similarly, early relationships in which one is rejected because of one’s sexual orientation or gender identity by important others, such as one’s parents, may instill chronic anxious expectations of interpersonal rejection throughout life (Pachankis et al., 2008). While expectations of rejection may operate as an adaptive coping strategy to early rejection, similar to concealment such expectations have also been shown to predict interpersonal unassertiveness (Pachankis et al., 2008), symptoms of depression and social anxiety disorder (Feinstein et al., 2012), and condomless sex (Wang & Pachankis, 2016). The act of internalizing anti-​LGBTQ messages and bias represents another strategy for coping with sexual orientation stigma with strong associations with depression and anxiety (Feinstein et al., 2012; Newcomb & Mustanski, 2010). Insidiously, internalized stigma often occurs outside of awareness and manifests in automatic beliefs about oneself and other LGBTQ people as inferior, deviant, or universally “bad” (Millar et al., 2016). Internalized stigma is also associated with

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perceiving the LGBTQ community to be a source of stress rather than support (Pachankis et al., 2020a). Over the past decade, research has shown that the LGBTQ-​related stressors described above ultimately generate excess depression, anxiety, and related emotional problems because they compromise LGBTQ people’s emotion regulation skills. In fact, in response to LGBTQ-​related stress, LGBTQ individuals often respond with rumination, social isolation, hopelessness, and maladaptive self-​ schemas (Hatzenbuehler et al., 2008, 2009, 2010). Over time, uses of these emotion regulation strategies accumulate to predict depressive symptoms and anxiety. Therefore, LGBTQ-​affirmative CBT leverages the strong efficacy of the Unified Protocol for addressing emotional problems in the general population and applies its focus on building healthy emotion regulation to the unique sources of stress in LGBTQ people’s lives. As described in the chapters that follow, the resulting treatment recognizes the ultimate source of LGBTQ-​related stress in unjust societal stigma while also promoting coping self-​efficacy as a way to reduce the impact of LGBTQ-​related stress on mental health. Like the Unified Protocol, the coping skills taught in LGBTQ-​affirmative CBT focus on strong, intense negative emotions, maladaptive reactions to them, and efforts to suppress or avoid negative emotions. LGBTQ-​ affirmative CBT takes a social justice approach by recognizing that for many LGBTQ people these experiences of emotions occur against a societal backdrop that teaches LGBTQ people that their experiences are invalid. Rather than perpetuating the belief that LGBTQ people’s emotional experiences are invalid, LGBTQ-​affirmative CBT takes the opposite approach by teaching LGBTQ clients that their emotional responses are often quite valid reactions to LGBTQ-​ related stress. LGBTQ-​affirmative CBT recognizes that some reactions to LGBTQ-​ related stress are indeed still adaptive, whereas others were adaptive in their original context but are no longer so, and still others serve to further perpetuate stress through habitual avoidance tendencies. This LGBTQ-​related stress focus occurs throughout the adapted Unified Protocol modules, including its adapted techniques and skills, therapeutic examples and vignettes, and suggestions for therapist competence and style. The feedback gained from developmental interviews infuses the entire protocol. 8

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Efficacy of LGBTQ-​Affirmative CBT The Unified Protocol, upon which this treatment is based, has garnered strong empirical support for its use with a range of emotional disorders. For instance, in a randomized controlled trial of 223 treatment-​seeking individuals, the Unified Protocol demonstrated similar improvement in mental health symptoms as gold-​standard single-​disorder protocols for generalized anxiety disorder, social anxiety disorder, obsessive-​ compulsive disorder, and panic disorder (Barlow et al., 2017a). With regard to comorbid conditions, 62% of clients treated with the Unified Protocol no longer met diagnostic criteria for any emotional disorder, and these improvements were largely maintained 1 year later. Overall, these results suggest that the transdiagnostic Unified Protocol approach is just as good at addressing the primary disorder as the targeted protocol designed explicitly for that disorder. Given the practical advantages of the Unified Protocol, such as eliminating the need for training in multiple single-​disorder protocols, these results lend support for the widespread dissemination of the Unified Protocol. Preliminary data also suggest that the Unified Protocol can be successfully applied to other diagnoses that are characterized by the emotional disorder vulnerabilities described earlier. Specifically, there is evidence to support the use of the Unified Protocol for those with co-​occurring alcohol abuse or dependence diagnosis (Ciraulo et al., 2013), bipolar disorder (Ellard et al., 2012), borderline personality disorder (Sauer-​Zavala et al., 2016), and posttraumatic stress disorder (Gallagher, 2017). Finally, the Unified Protocol delivered in a group format shows moderate to strong effects on anxiety and depressive symptoms, functional impairment, quality of life, and emotion regulation skills; clients receiving the group format report comparable satisfaction to those receiving the individual format of the Unified Protocol (Bullis et al., 2014). Based on the promising efficacy of the Unified Protocol described above, we have since tested the efficacy of the LGBTQ-​affirmative CBT in several trials. The first randomized controlled trial of LGBTQ-​affirmative CBT with 63 young gay and bisexual men (Pachankis et al., 2015) showed that LGBTQ-​affirmative CBT produced moderate to large reductions in depressive symptoms, alcohol use problems, sexual compulsivity, and sex without condoms. These reductions were significantly greater

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than those experienced by men in the waitlist condition and persisted at the 3-​month follow-​up. Reductions in anxiety and associated impairment were moderate. Young gay and bisexual men who received this treatment also reported significant reductions in rejection sensitivity and internalized homonegativity and increases in emotion regulation skills, social support, and assertiveness from pre-​to post-​treatment. Reductions in these LGBTQ-​related stress processes support the theoretical premise of this minority-​stress–​informed CBT intervention. This treatment was shown to have significantly stronger impact for young gay and bisexual men who exhibited greater internalized stigma at the start of treatment (Millar et al., 2016). The treatment has recently been tested in a larger randomized controlled trial with 254 sexual minority young men against community treatment as usual and HIV testing and counseling. Results from that trial suggest that LGBTQ-​affirmative CBT was associated with significant reductions across several outcomes, including HIV transmission risk behavior, depression, anxiety, and substance use problems. Compared to the two control conditions, LGBTQ-affirmative CBT was associated with small-to-moderate relatively greater benefit and was particularly efficacious in reducing substance use problems and comorbidity across the above conditions (Pachankis et al., 2022). Following the initial successful impact of LGBTQ-​affirmative CBT when applied to men, our team then adapted the treatment to focus on the specific LGBTQ-​related stressors faced by sexual minority women, most of whom also identified outside of the gender binary (Pachankis et al., 2020c; Scheer et al., 2022). In a waitlist-​controlled trial with 60 gender-​diverse sexual minority female clients, LGBTQ-​affirmative CBT was associated with strong reductions in depressive and anxiety symptoms and small reductions in alcohol use problems, significantly greater than the waitlist control condition. LGBTQ-​affirmative CBT was also associated with small to moderate reductions in rejection sensitivity and increases in emotion regulation skills from pre-​to post-​ treatment, suggesting that the treatment might have exerted benefit through the theoretical premise of the Unified Protocol as adapted to specifically address LGBTQ-​related stress reactions. While the above trials of LGBTQ-​affirmative CBT utilized individual delivery modalities, its effect has also been tested in a group-​based treatment. Specifically, LGBTQ-​affirmative CBT was delivered to two group cohorts of Black and Latinx gay and bisexual young men (n =​21) in a 10

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community-​based clinic (Jackson et al., 2021). The treatment was associated with reductions in depression and anxiety, as well as LGBTQ-​ related stressors related to both sexual identity and racial/​ethnic identity, preliminarily supporting its suitability for addressing intersectional stressors in a group-​based format. Preliminary trials also support the preliminary effect of this approach in non-​Westernized cultural settings, such as China (Pan et al., 2020).

Purpose of This Therapist Guide This guide was developed to provide mental health providers with guidance on administering LGBTQ-​affirmative CBT. This guide is based on research related to the development of the Unified Protocol and the adaptation of the Unified Protocol to specifically address LGBTQ-​related stress as the source of LGBTQ people’s disproportionate mental health burden. This guide is also based on the clinical experience and feedback we have received across our experience developing, delivering, and training other practitioners in LGBTQ-​affirmative CBT. The first four chapters of this guide provide introductory and background information about the treatment program. Subsequent chapters provide step-​ by-​step instructions for conducting the treatment sessions.

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CHAPTER 2

History, Basic Principles, and Outline of LGBTQ-​ Affirmative Cognitive-​ Behavioral Therapy

Basic Principles of Cognitive-​Behavioral Treatment for Emotional Disorders The main premise of the Unified Protocol is that individuals experiencing depression, anxiety, or other stress-​related symptoms use maladaptive emotion regulation strategies—​namely attempts to avoid or dampen the intensity of uncomfortable emotions—​that ultimately backfire and contribute to the maintenance of their symptoms and risk behaviors. Thus, like many forms of cognitive-​behavioral therapy (CBT), the Unified Protocol teaches clients to confront and experience stress and respond to their emotions in more adaptive ways. By modifying clients’ emotion regulation habits, this treatment aims to reduce the intensity and incidence of interfering and overwhelming emotional experiences and improve functioning. It is important, however, to understand that the Unified Protocol does not attempt to eliminate uncomfortable emotions. On the contrary, the emphasis is on bringing emotions back to a functional level, so that even uncomfortable emotions can be appreciated as adaptive and helpful. Below are four basic principles that guide the successful delivery of the original Unified Protocol, the cognitive-​ behavioral treatment upon which we base our LGBTQ-​affirmative adaptations described next.

Unified Protocol Principle 1: Fostering Mindful Awareness of Emotions In early modules of the Unified Protocol, clients are presented with a model of emotions that helps them develop a greater understanding of the interaction of thoughts, physical sensations, and behaviors in generating internal emotional experiences, including stress. Clients

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are taught to track their emotional experiences in accordance with this model. This process assists clients with gaining a greater awareness of their emotional experience (including the triggers and consequences of behavior) and helps them take a more objective view of their emotions rather than simply getting caught up in their emotional response. This principle emphasizes the adaptive, functional nature of emotions and facilitates greater tolerance of emotions. Increased understanding and awareness of emotion transitions to the first core skill of the treatment, mindful emotion awareness, which involves the practice of nonjudgmental, present-​focused attention towards emotional experiences. This mindful awareness building is seen as a fundamental skill serving to enhance acquisition of subsequent treatment concepts.

Unified Protocol Principle 2: Re-​evaluating Automatic Interpretations of Threats and Increasing Cognitive Flexibility Unlike other cognitive therapies, the focus is not on eliminating or suppressing negative thoughts and replacing them with more adaptive or realistic appraisals, but rather on increasing cognitive flexibility as an adaptive emotion regulation strategy. Clients are encouraged to use reappraisal strategies not only before but also during and after emotionally laden, stressful situations. The Unified Protocol emphasizes the dynamic interaction between cognitions and both physical sensations and behaviors as an important component of emerging emotional experiences. This cognitive reappraisal is particularly important for assisting clients later in the treatment as they change behaviors and face challenging, emotionally provoking situations.

Unified Protocol Principle 3: Changing Action Tendencies Associated with Maladaptive Emotions All clients, regardless of their specific mental health symptoms, are asked to engage in a series of exercises designed to evoke experiences analogous to those typically associated with stressful challenges. Inclusion of this strategy is consistent with theories and evidence from emotion science

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that indicate that focusing on and modifying these actions can be an effective means of emotion regulation. The idea of reducing patterns of avoidance is introduced early in treatment, during the initial discussion on the nature of emotions, and is then discussed in greater detail in the second half of the program.

Unified Protocol Principle 4: Promoting Corrective Experiences Through Internal and Situational Exposure Procedures Patterns of avoidance and other maladaptive action tendencies stemming from mood and anxiety symptoms are explored and changed. This is consistent with theories and evidence from emotion science indicating that focusing on and modifying these actions can be a fundamental method of emotion control. First, clients, regardless of their diagnosis, are helped to engage in a series of interoceptive exercises designed to evoke physical sensations analogous to those typically associated with the emotions they find uncomfortable. These interoceptive exposures are applied across diagnoses, whether or not physical sensations represent a specific trigger for the client’s emotional response. This serves not only to increase the client’s awareness of physical sensations as a core component of emotional experiences but also to increase tolerance of these sensations, which in turn reduces the contribution of physical sensations to emotion aversion and avoidance. Through interoceptive exposure exercises, clients begin to recognize the role of physical sensations in emotional experiences, identifying ways in which these somatic sensations might influence thoughts and behaviors, as well as how thoughts and behaviors can serve to intensify these somatic sensations—​all while challenging expectations about their ability to cope when experiencing strong physical symptoms. Clients also get help confronting situations they have previously avoided due to fear or maladaptive stress responding. The crucial function of this type of situational exposure is to prevent the action tendencies previously associated with the emotion and facilitate alternative behaviors. The focus is on confronting the situation fully, so that patterns of avoidance and other safety behaviors are identified. Consistent with

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other cognitive-​behavioral therapies utilizing exposure, these exposure exercises occur in a graduated “step-​wise” fashion, so that clients confront less difficult (and less emotionally provoking) situations before systematically moving on to situations that elicit more intense emotions. However, it is important to communicate that there is no necessary reason for conducting exposures in this way. More difficult situations may produce higher-​intensity emotions that may be more difficult for clients to tolerate, but it does not make the emotions dangerous. With all exposures, the focus is on confronting the situation fully, so patterns of avoidance and other safety behaviors are identified and then efforts are made to reduce or eliminate these behaviors during the exposure exercises to best facilitate new learning and the creation of new memories. In this way, the tendency to engage in avoidance behaviors or emotional suppression is replaced with a more flexible approach that is adaptive given the situation at hand.

Using Expert Feedback to Adapt the Unified Protocol to Create LGBTQ-​Affirmative CBT Thirty-​three expert mental health providers and 40 LGBTQ community members who were experiencing depression, anxiety, and related behavioral problems (e.g., substance use, suicidality, HIV transmission risk behavior) provided extensive input into the LGBTQ-​affirmative adaptation of the Unified Protocol. The community mental health experts were specifically asked to describe effective approaches that they have used to support LGBTQ people in successfully managing LGBTQ-​ related stress and to provide input on how the Unified Protocol could be effectively adapted to help LGBTQ people who experience symptoms of mood and anxiety disorders and related behavioral risks function better. Additionally, community members were interviewed about their stress experiences and asked to discuss how the proposed treatment might support them in coping with that stress. The responses of these experts and community members yielded the following six basic principles that inform LGBTQ-​affirmative CBT (Burton et al., 2019; Pachankis, 2014; Rodriguez-​Seijas et al., 2019; Scheer et al., 2022). As will be discussed in greater detail below, these principles align seamlessly with the CBT principles of the Unified Protocol.

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Basic Principles of LGBTQ-​Affirmative CBT The above four basic principles of CBT for emotional disorders can be integrated with the following six basic principles uncovered through deep LGBTQ expert and community consultation to enhance the relevance of CBT for LGBTQ people. The following six principles specifically identify ways that CBT can be enhanced to address the impact of LGBTQ-​ related stress on LGBTQ people’s mental and behavioral health.

Principle 1: Normalizing Mood and Anxiety Disorders as a Common Response to LGBTQ-​Related Stress In Chapter 1 of the client workbook, Principle 1 is presented as: “Uncomfortable emotional experiences like depression and anxiety are normal responses to LGBTQ-​related stressors.” While at least part of the vulnerability to mood and anxiety disorders comes from genetic predispositions, those predispositions are activated under conditions of stress. Research has shown that, for LGBTQ people, LGBTQ-​related stress is added on top of typical everyday stress and therefore makes LGBTQ people more likely to experience stress-​sensitive mental health problems, such as mood and anxiety disorders (e.g., Meyer et al., 2008). LGBTQ-​ affirmative CBT helps LGBTQ people recognize that the source of and/​or contributor to many mental health problems lies in a stigmatizing society, not in their personal deficiencies. In fact, LGBTQ people might be particularly likely to blame themselves rather than stigma for their presenting concerns. In LGBTQ-​affirmative CBT, therapists outline for clients the scientific explanation of how stigma jeopardizes LGBTQ people’s mental health to help clients shift away from their internalization of blame for their current problems. The treatment explains how early experiences of LGBTQ-​related stress can manifest as mental health challenges in adulthood. For instance, unlike many ethnic and racial minorities, many sexual and gender minority (LGBTQ) people develop their identities in isolation without the support of similar peers, role models, or family members who share their minority status. For some, peer and family rejection can compound this isolation by producing ingrained core beliefs of oneself as inferior or unlovable, contingent self-​ worth, or common emotional tendencies such as shame (Jackson et al., 2021). Although LGBTQ-​related stress is not a central experience in all 17

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LGBTQ people’s development, it is our belief that most LGBTQ clients are at least somewhat influenced by past and current encounters with LGBTQ-​related stress. Therefore, starting at the beginning of treatment, LGBTQ-​affirmative CBT creates explicit space to discuss the influence of LGBTQ-​related stress on the client’s presenting problems.

Principle 2: Challenging Inflexible, Internalized Cognitions Stemming from LGBTQ-Related Stress In Chapter 1 of the client workbook, Principle 2 is presented as: “Early and ongoing experiences with LGBTQ-​related stress can teach LGBTQ people powerful and negative, yet faulty, lessons about themselves.” Stigmatizing contexts, both in early development and in one’s current life, communicate that LGBTQ people are inferior, weak, abnormal, or even immoral. These messages can become internalized by LGBTQ people, even in deep ways that are processed outside of the person’s awareness. Upon close scrutiny, some LGBTQ people may come to realize that their negative thoughts about themselves as flawed or inferior are inaccurate formulations derived from LGBTQ-​ related stress experiences. These thoughts, although incorrect, can become ingrained ways of thinking about oneself across one’s life if they are never held up to critical scrutiny. LGBTQ-​affirmative CBT helps LGBTQ people adopt a curious, flexible perspective on the lessons that they might have encountered about themselves while growing up and on an ongoing basis. The treatment adopts an affirmative lens to challenge persistent, inflexible LGBTQ-​ related stress cognitions by suggesting that current cognitive patterns might have previously served adaptive functions. For instance, early fears of rejection or even violence can instill ongoing expectations of rejection. However, if these expectations persist inflexibly across many or most contexts in the person’s life, especially in safe contexts, they can lead to maladaptive action tendencies (e.g., avoidance) and keep the person away from disconfirming evidence. LGBTQ-​ affirmative CBT adapts the Unified Protocol’s reappraisal strategies to specifically focus on these types of LGBTQ-​related stress cognitions. Importantly, this principle in no way implies that LGBTQ people’s experiences are invalid and, accordingly, this principle does not promote questioning the veracity of LGBTQ people’s experiences. To the contrary, this principle solely focuses attention on the ways that 18

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negative messages about LGBTQ people become internalized to lead LGBTQ people to think that they themselves are invalid, problematic, unlovable, deviant, or shameful, without recognizing the source of these beliefs in anti-LGBTQ societal ideologies.

Principle 3: Encouraging Assertive Behavior and Open Self-​Expression to Effectively Cope with the Consequences of LGBTQ-​Related Stress In Chapter 1 of the client workbook, Principle 3 is presented as: “LGBTQ people can effectively cope with the unfair results of LGBTQ-​related stress.” One of the most harmful consequences of LGBTQ-​related stress is that it can shape LGBTQ people’s perception that they are disempowered or weak. When the social environment communicates that a person is inferior, abnormal, or unlovable because of their LGBTQ identity, then the social environment, not the person, sets the rules of the game. These rules include that LGBTQ people’s voices and perspectives are less valuable than those of others, which can drive unassertive behaviors, such as self-​ silencing; denying one’s needs and wants; and covering, downplaying, or outright concealing one’s identity from important others in one’s life. These unassertive behaviors interfere with relationships and contribute to depression, anxiety, and related mood and behavioral problems. LGBTQ-​ affirmative CBT seeks to empower LGBTQ people by teaching assertive communication skills. In line with Principle 1 above, unassertiveness is normalized as a potentially adaptive response to LGBTQ-​related stress while the possibility is also suggested that unassertiveness across all contexts might be counterproductive. Invoking Principle 2, unassertiveness is presented as driven by LGBTQ-​related stress-​induced cognitive patterns (e.g., of inferiority, weakness, fear of rejection). LGBTQ-​affirmative CBT helps clients identify areas of their lives in which their unassertiveness is contributing to mental and behavioral health problems, articulate discrepancies between their desires and outcomes of their current behavioral patterns, and learn and practice assertive behavior in everyday contexts. In this way, LGBTQ-​affirmative CBT returns a sense of empowerment back to the individual. LGBTQ-​ affirmative CBT also recognizes that assertiveness is shaped by culture and that assertive expressions are not universal, or even altogether appropriate, across cultural contexts (Pan et al., 2020). 19

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Principle 4: Validating LGBTQ Clients’ Unique Strengths In Chapter 1 of the client workbook, Principle 4 is presented as: “LGBTQ people have unique strengths.” Often from an early age, young LGBTQ people face tremendous challenges and crises because of LGBTQ-​related stress. Nonetheless, the majority of LGBTQ people show tremendous resilience in coping with this stress, providing the building blocks for the creative and successful approaches to managing future challenges across the lifespan, including challenges faced in mental health treatment. Unlike many other stigmatized populations (e.g., racial/​ethnic minorities, religious minorities), LGBTQ people often do not share the same identity as their parents. Combined with a lack of inclusive historical education in schools or in the media, this lack of LGBTQ socialization available at home can lead LGBTQ people to lack awareness of the rich culture and history that characterizes LGBTQ communities. LGBTQ-​ affirmative CBT draws upon LGBTQ people’s unique strengths to facilitate optimism and creative coping in the face of ongoing LGBTQ-​related stress. This treatment educates LGBTQ clients about the remarkable resilience of LGBTQ individuals and communities and encourages clients to also draw upon their own personal resilience (e.g., coming out) as a source of strength and optimism for navigating current challenges. LGBTQ-​ affirmative CBT highlights the relational (e.g., building families of choice, navigating consensual non-​monogamy) creativity demonstrated by LGBTQ communities as relevant to flexible problem-​solving orientations. Finally, the treatment recognizes that the development of LGBTQ people is often characterized by a unique identity formation process whereby individuals learn empowering, unique perspectives on themselves and others. These perspectives can be drawn upon throughout all of the treatment modules to empower clients to also address their presenting concerns.

Principle 5: Building Authentic Relationships as an Essential Resource for LGBTQ People’s Mental Health In Chapter 1 of the client workbook, Principle 5 is presented as: “Sex is healthy!” LGBTQ people’s challenges can start early with peer teasing and family rejection, leading to anxious, insecure, and 20

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avoidant relational schemas. Healthy relationship formation might also be currently impeded by family members, coworkers, or religious communities—​places where many other ethnic or racial minority individuals can find comfort and support. Many LGBTQ people also report that they encounter relational stress within the queer community and perceive it to be inaccessible or inhospitable. Given stigmatizing and false messages of LGBTQ people as sexually shameful or incapable of forming true authentic loving relationships, together with a normative lack of role models for sexual and relational health, LGBTQ people might also face challenges to forming healthy sexual and romantic relationships. As a result of the above LGBTQ-​related stressors, LGBTQ people may have difficulties developing romantic, community, and sexual relationships to support their mental and behavioral health. In fact, LGBTQ individuals experience more social isolation and fewer social supports than the general population, which is, in turn, associated with poorer mental health. LGBTQ-​affirmative CBT helps LGBTQ people build genuine, supportive relationships in order to support their well-​being and their ability to confront LGBTQ-​related stress. Throughout the treatment, this might take the form of assessing one’s relational schemas (consistent with Principle 2); building assertiveness skills to improve relational challenges with family, friends, or sexual partners (consistent with Principle 3); and considering and expressing creative ways of relating both socially and sexually to solve ongoing relational challenges (consistent with Principle 4).

Principle 6: Recognizing Intersectional Identities as a Source of Stress and Resilience In Chapter 1 of the client workbook, Principle 6 is presented as: “Genuine, real relationships are essential for LGBTQ people’s mental health.” For many LGBTQ people, experiences of LGBTQ-​ related stress are inextricably tied to stressors related to identities based on race/​ethnicity, socioeconomic status, immigration status, age, ability, gender identity, and other social positions. In fact, no LGBTQ client presents to treatment with an LGBTQ identity only. LGBTQ people exist across society and, as a result, reflect the diversity of society. For 21

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instance, research suggests that Black LGBTQ individuals encounter both positive and negative intersectional experiences with implications for mental health (Jackson et al., 2020). Intersectional experiences include those experiences that are related to two or more of a person’s marginalized identities that are intertwined and inseparable from each other and shape how the person experiences the world and often how others interact with the person. Although when providing LGBTQ-​ affirmative CBT the therapist highlights the experience of LGBTQ-​related stress, as an identity-​focused treatment LGBTQ-​affirmative CBT can also incorporate the ways that this stress intersects with stressors related to any other stigmatized identity (e.g., racism, sexism, classism). The above treatment principles and all modules can be adapted to address these intersectional stressors. For example, LGBTQ-​affirmative CBT can: ■ normalize the depleting mental health impact of intersectional manifestations of stigma (Principle 1); explore ways that cognitive styles are shaped by intersectional stress ■ (Principle 2); help clients develop new, assertive ways of thinking and behaving that ■ overcome disempowering societal lessons directed towards individuals facing intersectional stressors (Principle 3); validate the unique strengths of the diverse individuals, subcommunities, ■ and intersectional experiences that make up LGBTQ communities (Principle 4 and Principle 6); and build supportive relationships that affirm LGBTQ individuals who ■ possess other salient identities (Principle 5). Table 2.1 provides a summary of these principles and their possible applications in the context of delivering LGBTQ-​affirmative CBT.

Description of Treatment Modules Based upon the principles just discussed, LGBTQ-​affirmative CBT consists of nine core treatment modules that target key aspects of problematic emotional processing, specifically aversive reactions to emotions that lead to avoidant coping strategies (see Box 2.1.).

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Table 2.1.  Basic Principles of LGBTQ-​Affirming CBT Principle

Possible Applications

1. Normalizing mood and anxiety disorders as a common response to LGBTQ-​related stress

■  Your client might feel like something is “wrong” with them because they are depressed, anxious, or otherwise experiencing mental health symptoms.   You can highlight that depression and anxiety are entirely ■ normal responses to LGBTQ-​related stress, which can have a significant impact on mental health.

2. Challenging inflexible, internalized cognitions stemming from LGBTQrelated stress

■  Growing up or living in a culture that devalues, stigmatizes, and/​or stereotypes LGBTQ people can lead to internalizing these negative messages, even without realizing it.   Internalizing these messages might have led your client to ■ believe that they don’t matter as much as others, they don’t deserve love, or that they are a bad person.   The lessons of LGBTQ-​related stress can be so profound and ■ widespread that they can often affect your client in ways they may not consciously realize.   You can identify the ways in which LGBTQ-​related stress ■ has shaped your client’s thinking and explore whether your client’s thinking can become more self-​empowering.

3. E  ncouraging assertive behavior and open self-​expression to effectively cope with the consequences of LGBTQ-​related stress

■  Your client might silence their authentic voice, cover their LGBTQ identity, or otherwise take a passive stance towards current challenges.   You can help your client learn the ways that LGBTQ-​related ■ stress leads to unassertive thoughts and behaviors so that your client can learn and practice assertive responding in everyday life.

4. Validating LGBTQ clients’ unique strengths

■  The fact that your client is presenting for treatment with you means that they have overcome some significant challenges in their life, which is worth conveying to them.   The very act of exploring one’s sexuality and/​or gender ■ identity is something that most people never have to do, and speaks to your client’s courage.   You can also point out that members of the LGBTQ ■ community have included important thinkers, artists, and athletes, noting that resilience and growth are often forged in the fires of adversity.   You and your client can use treatment as an opportunity to ■ capitalize on your client’s strengths and work towards their goals. (continued)

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Table 2.1.  Continued Principle

Possible Applications

5. B  uilding authentic   Your client may have been isolated, shunned, or devalued ■ relationships as an essential in their early relationships because of their LGBTQ identity resource for LGBTQ or development, which can influence the way their current people’s mental health relationships take shape.   Your client might have received the message from an early ■ age that same-​sex sexual expression is wrong and shameful.   Your client might experience stress from within the LGBTQ ■ community.   You can help your client identify the ways that LGBTQ-​related ■ stress may be making their relationships less healthy and support them in forming relationships that are affirming and supportive.   You can help your client recognize that sex is a normal and ■ pleasurable drive.   You can help your client build supportive connections with ■ other LGBTQ people. 6. Recognizing intersectional ■   Your client might have other salient identities besides being identities as a source of LGBTQ that shape their experiences of stress and support. stress and resilience ■  Explore with your client those intersectional experiences that are sources of stress and support in their lives.   Help your client pinpoint identity-​affirming experiences in ■ their daily lives as a source of resilience against intersectional stressors.

Box 2.1. LGBTQ-​Affirmative CBT Modules

Module 1: Setting Goals and Building Motivation for LGBTQ-​Affirmative Cognitive-​ Behavioral Therapy Module 2: Understanding the Nature and Emotional Impact of LGBTQ-​Related Stress Module 3: Understanding and Tracking LGBTQ-​Related Stress and Emotional Experiences Module 4: Increasing Mindful Awareness of LGBTQ-​Related Stress Reactions Module 5: Increasing Cognitive Flexibility Module 6: Countering Emotional Behaviors Module 7: Experimenting with New Reactions to LGBTQ-​Related Stress Module 8: Emotion Exposures for Countering LGBTQ-​Related Stress Module 9: Recognizing Accomplishments and Looking to the Future

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Based upon traditional CBT approaches, these modules are anchored within the three-​ component model of emotion (thoughts, physical sensations, and behaviors), with an emphasis on the function of emotions and behaviors within both the present moment and a context of early and ongoing LGBTQ-​related stress experiences. Placing unfolding emotional experiences within the context of present-​moment awareness allows the client to identify patterns of emotion regulation strategies being employed that are inconsistent or incompatible with ongoing situational or motivational demands. Placing unfolding emotional experiences within the context of past or ongoing LGBTQ-​related stress helps the client understand the original utility of these responses as reactions to stigma and builds motivation for developing more empowering reactions. The five core modules (Modules 4 through 8) are preceded by three introductory modules (Modules 1 through 3) that include treatment exercises for enhancing motivation and identifying the ways that LGBTQ-​related stress has affected the client’s emotional experience now and in the past. A final module (Module 9) consists of reviewing progress over treatment and developing relapse prevention strategies. As the treatment proceeds, thoughts, physical feelings, and behaviors are each explored in detail, focusing specifically on elucidating maladaptive emotion regulation strategies that the client has developed over time within each of these domains as a function of LGBTQ-​related stress and teaching more empowering emotion regulation skills.

Treatment Time and Pacing All the treatment modules can be completed in as few as 10 sessions, but typically one or more of the modules will require more than one session, extending the total length of treatment to between 12 and 18 sessions. Sessions are approximately 50 to 60 minutes in duration and are typically conducted weekly. In our trials, we implemented this treatment across 10 sessions (one session per module, and two sessions for Module 6, which was originally written as two modules in the Unified Protocol from which the current treatment was adapted). Therefore, therapists with as few as 10 sessions available to implement their full course of treatment can adopt

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this treatment approach. At the same time, our clinical experiences with CBT in general and LGBTQ-​affirmative CBT in particular suggest that spending multiple sessions on some modules can be beneficial. As noted above, this can extend the length of treatment to between 12 and 18 sessions. In addition, we strongly recommend an introductory session (described in Chapter 5 of this guide) in which therapists can review the components of the treatment with clients and formulate a case conceptualization and functional analysis. This session is valuable for multiple reasons. First, an introduction can build initial rapport with clients and ensure their understanding of the principles and content of the treatment they will undergo. Further, it allows therapists to perform a structured functional analysis to identify with clients areas of particular emphasis for them during treatment and lay the groundwork for goal planning. Finally, review of intake assessments and development of a case conceptualization provide guidance for therapists to assess the client’s presenting concerns within an LGBTQ-​affirmative CBT framework and to tailor components of the treatment to specific client needs. As such, you may wish to allow for extra time to be devoted to certain modules in accordance with individual client presentations. For example, individuals with excessive, uncontrollable worry might benefit from an extended focus on mindful emotion awareness (Module 4), whereas individuals with repetitive compulsive behaviors might benefit from prolonged practice and attention to emotional behaviors (Module 6). Further, a common use of additional time is to extend Module 7 (Experimenting with New Reactions to LGBTQ-​ Related Stress) as needed, as this module provides an opportunity to practice all treatment skills simultaneously. Empirical evidence, therefore, suggests that this entire treatment program can be delivered in as few as 10 sessions, but we encourage you to consider the larger number of sessions suggested below for each module if you have the freedom to deliver this treatment across more than 10 sessions. The following is a basic description of the treatment modules. We recommend that each client complete all the treatment modules, if possible, even if the module may not initially appear to be directly relevant to the presenting problem. For instance, some clients do not report experiencing significant sensitivity to physical sensations, and so, on the surface, interoceptive exposures may not appear indicated. However, it

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has been our experience that many of these clients still report some benefit from engaging in these procedures, giving them the opportunity to recognize physical sensations as an important component of emotional experiences. For each module, we provide a recommended duration. Again, flexibility in the number of sessions dedicated to each module provides you with some freedom in how much the treatment procedures are emphasized for a particular client.

Session 1: Functional Analysis and Introduction to Treatment Duration: One or two sessions ■ Corresponding therapist guide chapter: 5 ■ Corresponding client workbook chapter: 2 ■ The treatment begins with a session that introduces the client to LGBTQ-​affirmative CBT, including its focus on empowering clients to cope with LGBTQ-​related stress in effective ways in order to improve their mental and behavioral health. The importance of ongoing symptom tracking is introduced as a means to inform treatment targets and maintain motivation. Much of the session is devoted to gathering the client’s understanding of the most pressing mental health concerns in their life and how these concerns might relate to past and present experiences with LGBTQ-​related stress. As the therapist, you discuss intake assessment information with the client to gauge their understanding of their emotions and behaviors. You are then able to formulate a CBT case conceptualization and functional analysis to guide treatment. This case conceptualization is rooted in CBT models and directs you to assess the maintaining factors of the client’s presenting concerns, including the ways in which LGBTQ-​related stress shapes the client’s cognitive, affective, motivational, behavioral, and self-​evaluative experiences.

Module 1: Setting Goals and Building Motivation for LGBTQ-​Affirmative Cognitive-​Behavioral Therapy Duration: One or two sessions ■ Corresponding therapist guide chapter: 6 ■ Corresponding client workbook chapter: 4 ■ 27

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Module 1 focuses on the client’s readiness and motivation for change and on fostering self-​efficacy for engaging in LGBTQ-​affirmative CBT. As the therapist, you use motivational interviewing techniques in order to facilitate motivation for changing the patterns that maintain the client’s mood and anxiety disorders. You will devote particular attention to building the client’s self-​efficacy for change by exploring the unique strengths that the client might possess as a result of navigating LGBTQ-​ related stress throughout their life, including the coming-​out process. The module concludes with a focus on goal-​setting for future modules, particularly in relation to reducing the impact of LGBTQ-​related stress.

Module 2: Understanding the Nature and Emotional Impact of LGBTQ-​Related Stress Duration: One or two sessions ■ Corresponding therapist guide chapter: 7 ■ Corresponding client workbook chapter: 5 ■ Module 2 raises awareness about the potential bearing of LGBTQ-​related stress on the client’s experience of depression and anxiety as well as related emotions. Intake assessment information is provided to the client to generate a discussion about the client’s unique experiences being LGBTQ. You will also provide information regarding the prevalence of depression and anxiety and its relationship to LGBTQ-​related stress to normalize some of the client’s experiences. The concept of tracking ongoing LGBTQ-​related stressors is introduced so that ongoing LGBTQ-​related stress can be linked to current symptoms of depression and anxiety in subsequent modules.

Module 3: Understanding and Tracking LGBTQ-​Related Stress and Emotional Experiences Duration: One or two sessions ■ Corresponding therapist guide chapter: 8 ■ Corresponding client workbook chapter: 6 ■ Module 3 educates the client about the main components of emotional experience and the possibility that their emotional experience

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is shaped by LGBTQ-​related stress. The module provides clients with psychoeducation on the nature and function of emotions and the concept of learned responses. Clients should begin to understand that their emotions serve a functional and adaptive role in providing information about the environment that informs and motivates behavior. During this module, the client is expected to develop greater awareness of their own patterns of emotional responding, including potential maintaining factors such as LGBTQ-​related stressors, by beginning to monitor and track these experiences alongside their environmental contingencies. This module helps the client identify the specific forms that LGBTQ-​related stress takes in their life (e.g., concealment, internalized stigma, rejection sensitivity) and the ways in which it emerges from early and ongoing stigmatizing social contexts. In this way, this module helps the client to develop an understanding of the possibility that early and ongoing LGBTQ-​ related stress contributes to their experience of anxiety and depression as well as maladaptive behaviors that are sometimes associated with these mental health problems among LGBTQ individuals, including substance use, suicidality, and condomless sex.

Module 4: Increasing Mindful Awareness of LGBTQ-​Related Stress Reactions Duration: Two or three sessions ■ Corresponding therapist guide chapter: 9 ■ Corresponding client workbook chapter: 7 ■ The goal of Module 4 is for clients to learn and begin to apply present-​ focused, nonjudgmental attention to their emotional experiences. Specifically, this module serves to cultivate an attitude of curious and willing observation, facilitating the ability to “watch” the interaction between their thoughts, feelings, and behaviors during an emotional experience. Teaching these concepts occurs in the context of three in-​session exercises. First, clients are led in a guided meditation that prompts them to apply mindful attention to each component of an emotional experience; clients are then encouraged to practice this meditation between sessions as a way to gain an understanding of what this type of attention feels like. Next, clients are asked to identify an emotion-​eliciting 29

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LGBTQ-​related stress experience in order to practice applying nonjudgmental, present-​focused awareness in the context of a strong emotion. Finally, clients are taught a “real-​life” application of these formal meditation exercises called “anchoring in the present.” Here, they are encouraged to observe the three components of an emotional response and ask themselves whether their reaction is relevant to the demands of the present moment. After this module, clients’ understanding of their emotions should be sufficient to utilize strategies covered in subsequent modules.

Module 5: Increasing Cognitive Flexibility Duration: Two or three sessions ■ Corresponding therapist guide chapter: 10 ■ Corresponding client workbook chapter: 8 ■ Module 5 allows the client an opportunity to connect their growing awareness of the impact of LGBTQ-​related stress to their automatic thinking patterns and thinking traps. Due to a history of LGBTQ-​ related stress experiences, LGBTQ people may come to believe that they are inferior, shameful, immoral, abnormal, or unlovable, self-​schemas that can shape maladaptive coping tendencies such as behavioral unassertiveness or self-​silencing. The exercises in this module encourage the explicit articulation of cognitions driven by LGBTQ-​related stress and instill more flexible, empowering thought processes so that the client can begin to correct outdated cognitive biases and therefore reduce maladaptive, unhealthy coping tendencies.

Module 6: Countering Emotional Behaviors Duration: Two or three sessions ■ Corresponding therapist guide chapter: 11 ■ Corresponding client workbook chapter: 9 ■ Module 6 focuses on identifying the behavioral outcomes of LGBTQ-​ related stress, such as avoidance, that are driven by emotions such as shame and fear. After discussing how engaging in these behaviors

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maintains distress, you and your client will work to change current patterns of emotional responding. LGBTQ individuals might cope with the emotional experience of LGBTQ-​related stress in several maladaptive ways, including avoiding intimacy; using substances, for example, during sex; and not asserting one’s needs and preferences to others. This module helps the client understand the situations, activities, and people that they currently avoid with the goal of fostering healthy behavior, for example healthy relationships, that can serve to protect them against the negative mental and behavioral outcomes of LGBTQ-​related stress. Here, the consequences of these behaviors (i.e., reduction of distress in the short term but maintenance of it in the long term) are highlighted. After the client identifies their patterns of emotional behaviors, the therapist encourages the use of alternative actions in which emotions (and the situations that provoke them) are approached, rather than avoided.

Module 7: Experimenting with New Reactions to LGBTQ-​Related Stress Duration: One to three sessions ■ Corresponding therapist guide chapter: 12 ■ Corresponding client workbook chapter: 10 ■ Module 7 continues to impart the cognitive and behavioral skills necessary for managing LGBTQ-​related stress and countering emotional behaviors, like avoidance. The primary skill of this module involves assertiveness training for countering LGBTQ-​related stress reactions. As many LGBTQ people may learn, even from an early age, that they do not have the right to stand up to stigma or to articulate their needs or preferences, this module will help the client recognize the ways in which they may silence themselves in certain interactions with others because of expectations of stigma and rejection. Exercises in this module will first help the client review their personal rights in challenging circumstances and revisit the cognitive styles that might interfere with assertive self-​expression. The client is encouraged to consider the accuracy of their expectations of rejection in relevant situations. This module places utmost emphasis on the fact that problems in these situations lie in stigmatizing social contexts, not within the client. By working 31

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on effective communication skills in this module, the client develops empowering stances for countering the negative mental and behavioral health impacts of LGBTQ-​related stress.

Module 8: Emotion Exposures for Countering LGBTQ-​Related Stress ■ Duration: Three sessions ideally. Many therapists find it beneficial to devote several sessions to practicing emotion exposures, if possible. This intervention provides an opportunity to consolidate learning from previous modules and is where many clients see the most progress. Corresponding therapist guide chapter: 13 ■ Corresponding client workbook chapter: 11 ■ Module 8 focuses on increasing awareness of and confronting internal (including physical sensations) and external (including LGBTQ-​ related stress) emotional triggers, which provides the client with opportunities to increase their tolerance of emotions and allows for new contextual learning to occur. The behavioral experiments focus on the emotional experience that arises in certain situations and can take the form of in-​session, imaginal, and in vivo exposures. By approaching painful emotional experiences of early or ongoing LGBTQ-​related stress, the emotions underlying these experiences will no longer drive the client’s behavior in maladaptive ways. The behavioral experiments introduced in this module will help the client to identify the thoughts and behaviors associated with LGBTQ-​related stress situations so that these thoughts and behaviors can be gradually challenged and changed in the safe, supportive context of the therapeutic environment. You will help your client design an Emotion Exposure Hierarchy that contains a range of situations so that exposures can proceed in a graded fashion for the remainder of treatment. Gradual extinction of the unpleasant emotions associated with LGBTQ-​related stress can allow new adaptive responses to LGBTQ-​related stress, including engagement in health-​promoting relationships and activities. This module ends with a self-​affirmation exercise to help consolidate the client’s treatment gains and reinforce their self-​efficacy regarding their ability to respond to LGBTQ-​related stress.

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Module 9: Recognizing Accomplishments and Looking to the Future Duration: One or two sessions ■ Corresponding therapist guide chapter: 14 ■ Corresponding client workbook chapter: 12 ■ Treatment concludes with a general review of treatment concepts and a discussion of the client’s progress. You will help the client to identify ways to maintain treatment gains and anticipate future experiences with LGBTQ-​related stress alongside encouraging them to remember specific skills from the treatment to meet the challenges of these experiences. Module 9 highlights the client’s agency to manage LGBTQ-​related stress over time.

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CHAPTER 3

Additional Information for Therapists

Assessment In order to inform an initial case formulation, we recommend screening all clients for emotional disorders and LGBTQ-​related stress experiences. You may wish to screen clients for emotional disorders using the Mini-​ International Neuropsychiatric Interview (MINI; Sheehan et al., 1998), which was designed to screen for DSM-​5 disorders. The information derived from the interview allows therapists to determine differential diagnoses and gain a clear understanding of the nature and severity of each diagnosis. A medical evaluation is often recommended to rule out medical conditions that may account for or exacerbate presenting symptomatology. A number of standardized self-​report inventories of emotional disorders and cross-​cutting symptoms can also provide useful information for case formulation at baseline. We recommend the Beck Depression Inventory-​II (Beck et al., 1996) and the Beck Anxiety Inventory (Beck et al., 1988; Steer et al., 1993) as general measures of depressive and anxious symptoms, respectively. Additionally, we recommend using the two non–​diagnosis-​specific measures of anxiety and depression provided in the Unified Protocol workbook before each session over the course of treatment to track progress. These measures, the Overall Anxiety Severity and Impairment Scale (OASIS; Norman et al., 2006) and the Overall Depression Severity and Impairment Scale (ODSIS; Bentley et al., 2014), were developed as continuous measures of anxiety-​and depression-​related symptom severity and impairment that can be used across disorders and in clients with multiple disorders. To monitor change in specific emotional symptoms, you might also wish to follow up these screens with disorder-​specific measures. These might

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include the self-​report version of the Yale–​Brown Obsessive Compulsive Scale (Goodman et al., 1989) for obsessive compulsive disorder, the self-​report version of the Panic Disorder Severity Scale (adapted from Shear et al., 1997) for panic disorder with and without agoraphobia, the Penn State Worry Questionnaire (Meyer et al., 1990) for generalized anxiety disorder, and the Social Interaction Anxiety Scale (Mattick & Clarke, 1998) for social anxiety disorder. For clients with co-​occurring maladaptive behavioral patterns, such as alcohol or recreational drug abuse or sexual compulsivity, we recommend administering the Alcohol Use Disorders Identification Test (Saunders et al., 1993), the Drug Use Disorders Identification Test (Berman et al., 2005), and the Sexual Compulsivity Scale (Kalichman & Rompa, 1995), respectively. We recommend administering these scales as relevant periodically across the course of treatment to monitor progress. To inform an LGBTQ-​related-​stress case formulation, we recommend assessing LGBTQ-​related stress reactions, with a focus on identity concealment, hypervigilance, and internalized stigma. The Lesbian, Gay, and Bisexual Identity Scale (Mohr & Kendra, 2011) includes subscales that assess these constructs as well as positive and negative identity-​specific processes related to LGBTQ-​related stress and resilience: difficulty with the identity development process, identity superiority, identity affirmation, and identity centrality. This scale can be adapted for LGBTQ-​related stress experiences specific to transgender individuals, or we recommend the Gender Minority Stress and Resilience Measure (Testa et al., 2015), which assesses nondisclosure, negative expectations for future events, internalized transphobia, gender-​ related discrimination, gender-​ related rejection, gender-​related victimization, non-​affirmation of gender identity, community connectedness, and pride specific to the transgender experience. As described in later chapters, we recommend providing feedback to clients about their summary responses to these measures to build awareness of LGBTQ-​related stress reactions and their impact on mental health.

Medication Many clients presenting to treatment for emotional difficulties will already be on psychotropic medications, including anxiolytics and/​ or antidepressants. We do not recommend that clients discontinue 36

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medications before initiating this treatment. Rather, we suggest that they continue on a stable dose of their current medications while going through the program. However, when clients begin new medication regimens during treatment, it can be difficult to determine whether changes in treatment (either positive or negative) should be attributed to the medication (or side effects of the medication), the treatment, or a combination of the two. This can become confusing for the therapist and frustrating for the client and may ultimately lead to poorer treatment outcome. In addition, certain medications, such as benzodiazepines, when taken regularly, may have a number of negative effects. They may lessen motivation to practice the skills learned in treatment and can dampen the intensity of emotions, making it difficult for clients to reap the full benefit of the exposures at the end of this program. If used to attempt to reduce emotional intensity (such as at the height of a panic attack), medications can also serve to reinforce maladaptive emotional responding (i.e., avoidance or escape of unwanted emotions) through negative reinforcement (i.e., short-​term distress reduction). For some clients, medications can become safety signals that may interfere with their ability to correct misappraisals of danger. Also, consistent with the concept of state-​ dependent learning, skills learned under the influence of the drug may not generalize to times when the drug is not present. Most of these problems are associated with high-​potency benzodiazepines and do not seem to occur with antidepressant medications. In turn, this may limit client ability to reduce or discontinue medications once treatment has been completed.

Who Will Benefit from LGBTQ-​Affirmative CBT? As noted, this treatment was created to help any LGBTQ person suffering from a full range of emotional disorders. This treatment can also address co-​occurring behavioral health issues, including sexual health and substance use. As all modules of the treatment recognize that many of LGBTQ people’s mental health concerns are embedded in the context of LGBTQ-​related stress, LGBTQ-​affirmative cognitive-​behavioral therapy (CBT) is also suitable for LGBTQ people whose primary concern is reducing the impact of this stress on their lives, whether stemming 37

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from family, friends, and romantic relationships; their workplace; their religious communities; or any other social context.

Who Should Administer the Program? Based on the results of interviews with LGBTQ people and mental health experts who work with this population, as well as a review of the literature on therapist competence in working with LGBTQ people and our experience with the treatment and the population, we believe that LGBTQ-​affirmative CBT can be delivered by any mental health professional with CBT experience and an emerging or developed cultural competence in working with LGBTQ clients. Cultural competence in this case refers to both adherence to guidelines for professional practice with sexual and gender minority clients, such as those laid out by the American Psychological Association (2009, 2021), and a deep understanding of the lives of LGBTQ individuals—​including LGBTQ subgroups—​ and their experiences with LGBTQ-​ related stress. For therapists who wish to build cultural competence, we recommend familiarization with the unique aspects of the LGBTQ experience explored in several handbooks (e.g., Bieschke et al., 2007; Nakamura & Logie, 2020; Pachankis & Safren, 2019; Ritter & Terndrup, 2002). Therapists who deliver LGBTQ-​ affirmative CBT should be prepared to explicitly center the unique experiences of the client as an LGBTQ person. In this treatment program, client behavior is understood as a functional adaptation to current or past contexts, including common developmental contexts experienced by LGBTQ people and environments characterized by the presence of LGBTQ-​related stress. When certain behaviors do not appear functional on the surface, you should be prepared to work with the client to understand all aspects of the past or current context on client behavior, including directly exploring the role of LGBTQ-​related stress on thoughts, feelings, and behavior. Therapists who deliver LGBTQ-​affirmative CBT should also be prepared to communicate a deep understanding of common developmental experiences of LGBTQ people; supports and stressors within the LGBTQ community; and the ways that LGBTQ-​related stress can influence thoughts, feelings, and behaviors. We recommend

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that therapists demonstrate openness when discussing sexuality and gender expression so as to not perpetuate stigma towards these aspects of the LGBTQ experience. While some clients will prefer to be treated by a member of the LGBTQ community, and examples of therapists’ shared personal experiences can be helpful in creating an affirming therapeutic environment, we believe that any therapist who adheres to guidelines for professional practice and possesses deep knowledge of LGBTQ individuals and LGBTQ communities can deliver LGBTQ-​affirmative CBT appropriately and compassionately. Members of the LGBTQ community who deliver LGBTQ-​affirmative CBT must take care to recognize the impact of LGBTQ-​related stress on their own lives and its ability to impact treatment. Therapists who deliver LGBTQ-​affirmative CBT must be comfortable using the therapeutic relationship as a model for healthy relationships and possess a general therapeutic style marked by patience, flexibility, confidence, self-​awareness, and humor. Therapists should possess the tact necessary to maintain professional boundaries, while simultaneously using judicious self-​disclosure when indicated for alliance repair or behavioral modeling.

Benefits of Using a Workbook A client workbook accompanies this therapist guide. This workbook can be directly distributed to clients or ordered by them. The client workbook strives to be a scientifically sound guide written at the client’s level, which can be a valuable supplement to programs delivered by professionals from a number of disciplines. There are several advantages to this workbook. First, the workbook provides an opportunity for review of treatment concepts, explanations, and instructions between sessions. Further, it provides an immediate reference for clients when they are experiencing strong emotions. This can be important for the learning process, since going back to the information and using the skills “in the moment” can facilitate a greater understanding of the treatment concepts and a better appreciation for how these procedures can effectively be applied.

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Second, the workbook can help clients to deal effectively with emotional difficulties after treatment is over. As most clients will re-​experience their symptoms at some point following treatment, usually under times of increased stress, they may find it helpful to refer back to the workbook for information on managing their symptoms and hopefully prevent their symptoms from escalating into a full-​blown relapse. The final chapter of the workbook specifically outlines ways for clients to maintain progress and prevent relapse. For many clients, the workbook may also assist them in making further gains once treatment has ended. As they move forward with new challenges and continue to work on meeting their goals for treatment, they may very well find continued meaning in the workbook material and ultimately develop a greater understanding of the treatment concepts. Third, this workbook can aid therapists who prefer that clients read the relevant workbook chapter before the session, so that the therapist can elaborate on issues and treatment activities, as well as answer questions. Other therapists prefer that clients read each chapter after the session is over, to review and consolidate the points covered in session.

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CHAPTER 4

Overview of General Treatment Format and Procedures

Role of the Therapist Following a style that combines cognitive-​behavioral therapy (CBT) with motivational interviewing, therapists should work with clients as close collaborators rather than adopting the role of an “authority.” Both you and your client must work together throughout treatment to design the most effective treatment plan possible. Changing patterns of behavior is difficult and clients will need to give feedback on what is helpful and what is not. As the therapist, you should strive to gain a thorough understanding of the issues the client brings to treatment and work to establish good rapport—​both are crucial pieces of providing a strong foundation from which to introduce treatment concepts and successfully carry out some of the more challenging treatment exercises in future sessions. Although this therapist guide does not provide explicit guidance on how to develop and maintain a strong therapeutic relationship and repair therapeutic ruptures as they occur, the success of this treatment hinges on a strong relationship and we encourage you to consultant relevant guidance as needed (e.g., Eubanks-​Carter et al., 2010; Norcross, 2010).

Session Sequence The treatment program is organized in terms of modules. Each module contains a recommended number of sessions, as indicated at the start of each chapter. That is, each module can be covered across a number of sessions.

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The sequence of the modules is grounded in a logical progression of change strategies. For example, assessment and motivational enhancement occur before insight-​enhancing discussions and self-​monitoring exercises, which occur before cognitive and behavioral practice. While this sequence represents a logical approach for most clients’ presenting concerns, we encourage you to approach the session sequence flexibly, especially given that all modules contain overlapping components, such as a focus on the client’s emotional experience. For example, motivational enhancement can be revisited at any point at which the client’s motivation for progress or session engagement wanes. Further, for clients who experience severe symptoms of depression, including avoidance of essential daily activities, you may wish to implement behavioral experiments sooner in the treatment than currently suggested in order to foster motivation. Other clients may need to spend extra time on building cognitive flexibility before moving on to behavioral experiments. Regardless of the order in which modules are delivered, be sure to implement the primary components of all modules at some point in the course of treatment, given that all modules were created as part of an overall package targeting the multifaceted experiences of minority stress, depression, and anxiety.

Session Structure Sessions refer to meetings with clients typically lasting about 50 minutes. Consistent with most CBT protocols, sessions in this treatment program typically begin with a review of the home practice assigned in the previous session. Notice that we call these “home practice” and not “homework” because we want the home practice to be a natural extension of the conversation that happens during the treatment session versus something seemingly arbitrarily “assigned” by the therapist. Rather, home practice is something that the therapist and client agree upon. The home practice review also provides the therapist with the opportunity to briefly revisit some of the content of the previous session and link that content to what occurred over the week. You can also discuss the client’s weekly brief anxiety and depression inventories (i.e., Overall Anxiety Severity and Impairment Scale [OASIS] and Overall Depression Severity and Impairment Scale

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[ODSIS]) in light of the home practice (e.g., to determine whether any of the home practice exercises led to increases, or decreases, in symptoms). Following the home practice review, the therapist presents key concepts and conducts in-​ session exercises to assist the client with understanding the treatment skills. This didactic instruction and interactive skill-​building forms the main work for the session. At the end of each treatment session, you will help the client consolidate what they have learned. You will ask the client to summarize the main take-​home points or messages from the session and ask if they have any remaining questions about or reactions to the session. Finally, you and your client will discuss the specific home practice that the client will complete before the next session.

Home Practice and Between-​Session Practice Home practice exercises are agreed upon at the end of each module to reinforce the concepts learned during the session and to practice new skills. Research has found that completion of home practice facilitates the practicing of skills learned in treatment and is necessary to maximize the benefits of treatment (Hoet et al., 2018). Thus, it is important to convey to clients that: 1. Attending sessions and learning the concepts will set the stage for change. 2. Application and practice of the concepts in “real life” is what will make noticeable, lasting changes. 3. Every week, clients will use the workbook (or be given weekly worksheets) to record their experiences, and these should be brought to the following session to facilitate discussion about problems, setbacks, or obstacles. 4. Charting the OASIS and ODSIS on the Progress Record will help the client to chart their progress through treatment, which can serve as both a powerful motivator and an important source of discussion during session, such as normalizing when a client feels they have “backtracked” by reminding them that progress doesn’t occur in a straight line.

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Following each session, we recommend that clients read the workbook materials relevant to next visit. If preferred, you may suggest that clients only read the relevant material after that material has been discussed in session. That said, we encourage you to be mindful of clients’ reading levels; it may be more useful to focus on worksheets than reading full chapters. Further, as you work through the treatment modules, you can have the client continue with home practice from previous modules, if the additional practice is warranted. For instance, once the client is introduced to the concept of present-​focused awareness, they can continue to practice this skill for the remainder of the treatment, if clinically indicated.

Home Practice Review Beginning with the second session (or following the initial assignment of monitoring home practice), it is a good idea to begin each session with a review of the client’s home practice. Beginning each session this way serves three important functions: 1. Routinely starting the session with home practice review reinforces the important role home practice plays in the ultimate success of this program. If the client is having difficulty completing home practice, you can address this right away, helping the client identify obstacles to home practice completion and designing a plan the client can stick to. 2. Reviewing home practice allows you to correct any misconceptions or misunderstandings about the previous session’s concepts and provides an opportunity for the client to ask any questions or voice any concerns. 3. Reviewing home practice provides you with a rich source of information about the client’s ongoing experiences from which you can draw when illustrating subsequent concepts.

Client Commitment In order for this treatment to be effective, it is expected that clients will commit to and make time for the sessions each week. Urge clients to

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make the treatment sessions and home practice a high priority. Remind clients that treatment lasts for a relatively short period of time and making it a priority will allow them to reap the full benefits of the treatment and give them the opportunity to achieve their treatment goals.

Working with Ambivalence and Resistance One of the most common difficulties that arises when working with clients is ambivalence about engaging in treatment procedures, including the completion of between-​session home practice. When clients do not readily engage with treatment procedures, therapists may assume that the clients lack motivation for change. However, it is important to appreciate that in treatment we are asking clients to engage in the very tasks that they have had difficulty engaging with in the past, and to confront physical sensations and other emotional experiences that are likely to produce intense, uncomfortable emotions. This can be challenging. Resolving ambivalence and fostering a greater commitment to change is addressed in Module 1 and can be returned to across treatment.

Outline of the Therapist Guide A module-​by-​module description of the LGBTQ-affirmative CBT protocol is provided in the remainder of this guide. Each chapter is arranged as follows: ■ ■ ■ ■

Module goals A list of materials or forms that correspond to the module A summary of the key concepts of the module A description of the principles underlying the particular treatment procedures included in the module ■ Case vignettes that illustrate commonly asked questions arising in each chapter and examples of therapist responses A description of corresponding home practice ■ ■ Suggestions for managing atypical or problematic client responses We strongly recommend that you read all client materials before that week’s session, in addition to reading the pertinent information in this 45

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guide. Some therapists prefer that clients read the relevant material before the session so that the therapist can elaborate on issues and tasks, as well as answer questions. Other therapists prefer that clients read the materials after the session is over to review and consolidate the points covered in session. We hope that these initial chapters have provided you with an overview of the treatment and its contents, and the style in which it can be delivered. As with the original Unified Protocol for emotional disorders, there is a lot of material to cover in the sessions. We have strived to break it down so that you can follow this therapist guide and attain optimal outcomes with your clients.

Additional Readings on Motivation Enhancement Arkowitz, H., Westra, H. A., Miller, W. R., & Rollnick, S. (2017). Motivational interviewing in the treatment of psychological problems (2nd ed.). Guilford Press. Miller, W. R., & Rollnick, S. (2012). Motivational interviewing: Helping people change. Guilford Press. Naar, S., & Safren, S.A. (2017). Motivational interviewing and CBT: Combining strategies for maximum effectiveness. Guilford Press. Rosengren, D. B. (2009). Building motivational interviewing skills: A practitioner workbook. Guilford Press.

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PA R T I I

Providing the Treatment

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CHAPTER 5

Session 1: Functional Analysis and Introduction to Treatment

(Corresponds to Chapters 1–​3 of the client workbook) This initial treatment session is designed to provide a review of your client’s presenting problems and diagnoses, if assigned, within the context of the LGBTQ-​related stress cognitive-​behavioral case formulation. Accordingly, you will: ■ Begin this session with a description of LGBTQ-​affirmative cognitive-​ behavioral treatment (CBT). Assess your client’s understanding of the most pressing mental health ■ issues in their life and identify how your client’s experience fits into a transdiagnostic LGBTQ-​related stress model. Explore the role of LGBTQ-​related stress in your client’s cogni■ tive patterns, frequent strong emotional experiences, and avoidance responses to those experiences. Present intake assessment information to your client, eliciting their ■ understanding of how LGBTQ-​related stress impacts their emotions and behaviors.

Session Agenda Introduce progress monitoring ■ Review client’s presenting concerns ■ Introduce concept of LGBTQ-​related stress and rationale behind ■ LGBTQ-​affirmative CBT Provide your client feedback on LGBTQ-​related stress and mental ■ health intake assessments Conduct the functional analysis ■

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Recommended Number of Sessions This module is intended to be delivered across one or two sessions. If you choose to complete this module in two sessions, you might divide the module content as follows: ■ Session 1: Focus on psychoeducation about LGBTQ-​related stress and the rationale behind this treatment. If you have time, you can also introduce the functional analysis and the LGBTQ-​Affirmative CBT Case Conceptualization (STAIRCaSE) model. Session 2: Conduct the functional analysis by assessing each of the ■ components of the STAIRCaSE model.

Materials Needed ■ Progress monitoring assessments (i.e., Overall Depression Severity & Impairment Scale [ODSIS; Bentley et al., 2014] and Overall Anxiety Severity & Impairment Scale [OASIS; Norman et al., 2006]); these are located at the end of every chapter in the client workbook, starting with Chapter 3 Progress Record, located in the client workbook at the end of ■ Chapter 3 Worksheet 2.1: The STAIRCaSE Model ■

Introduce Progress Monitoring Track Symptoms Throughout Treatment Using Progress Monitoring We recommend using a short assessment of your client’s symptoms (e.g., anxiety, depression) to track changes over time and build motivation throughout treatment. Have the client complete the ODSIS and the OASIS before each session and review them at the beginning of each session. The ODSIS and the OASIS are short assessments of anxious

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and depressive symptoms over the prior week, but you can also use other assessments that may be more relevant to your clients’ presenting concerns (e.g., substance use, body image concerns). Copies of these forms are located at the end of the client workbook chapters starting with Chapter 3 and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. During the first session, explain that the client will complete these assessments before every session and that you’ll start each session by reviewing together how the client’s symptoms are progressing. Keep a graph of your client’s weekly scores on the Progress Record to view changes in symptoms throughout treatment with your client, to highlight positive change, or to facilitate the redirection of treatment goals if symptoms worsen or do not remit.

Review Client’s Presenting Concerns Begin treatment with a brief review of the client’s presenting concerns or diagnoses: ■ In many cases, you will have already identified or assessed your client’s presenting concerns or diagnoses during an intake process; if not, the functional assessment conducted in this introductory session can serve the purpose of gathering details that would otherwise be collected during intake procedures. Although this is typically a continuous process unfolding across early ■ treatment sessions, begin the process in this first session by asking your client to provide a description of their presenting concerns. Your client’s description of their presenting concerns can also be ■ useful in providing a rationale for using LGBTQ-​affirmative CBT, and you may wish to refer back to specific examples when conducting the functional analysis below. In summary: Begin the session by asking your client to describe their presenting concerns.

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Introduce Concept of LGBTQ-​Related Stress and Rationale Behind LGBTQ-​Affirmative CBT

The following are some suggested discussion points for you to go over with your client about what treatment will entail and how the treatment program was developed. Refer to Box 5.1 for overarching principles to incorporate throughout this discussion, as well as future modules.

Therapy Sessions Are a Safe Space to Discuss LGBTQ Issues ■ Some clients may have had experiences, in their lives or even in therapy, where they did not feel comfortable discussing LGBTQ issues. This treatment provides a safe space for LGBTQ clients to discuss ■ important issues in their lives and learn strategies for managing the negative consequences of stigma, including depression and anxiety.

Box 5.1. Reminder: The Core Principles of LGBTQ-​Affirming CBT

There are six core principles that will inform this, and every, session of treatment (for a comprehensive review, see Chapter 2): 1 . Depression and anxiety are normal responses to LGBTQ-​related stress. 2. Early and ongoing exposure to LGBTQ-​related stress can teach LGBTQ people powerful and negative lessons about themselves. 3. LGBTQ people can be empowered to effectively cope with the unfair consequences of LGBTQ-​related stress. 4. LGBTQ people possess unique strengths. 5. Genuine, authentic relationships are essential for LGBTQ people’s mental health. 6. Intersectional identities can be sources of stress and resilience.

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This Treatment Was Made by and for the LGBTQ Community ■ This treatment is not only a safe space to discuss LGBTQ issues, but it was actually developed by and for the LGBTQ community. These aren’t just our ideas of what would be helpful; the makers of this ■ treatment, many of whom themselves identify as LGBTQ, went right to the source as they developed this treatment program. They talked to expert LGBTQ-​affirmative therapists and LGBTQ clients to see what exactly works and doesn’t work and what is needed to make sure that this treatment program meets the unique needs of LGBTQ clients. Although your clients’ experiences are unique, it may be helpful for ■ clients to be aware of the community-​based origins of the LGBTQ-​ affirmative CBT program that they are starting.

CBT Is Skills-​Based ■ This type of treatment is dynamic: Each module introduces new skills and builds on the prior module so that clients can practice and build on all the skills covered in treatment. As part of this LGBTQ-​affirmative CBT treatment, your client will learn ■ strategies for becoming more aware of their emotions and learn how thoughts, behaviors, and bodily feelings all contribute to their experiences. The skills your client will learn in therapy will help them to change ■ less helpful ways of coping and replace these with more helpful ways of managing their experiences.

LGBTQ-​Related Stress Is an Important Part of This Treatment ■ An important part of treatment is talking with your client about the concept of LGBTQ-​related stress. LGBTQ-​related stress refers to the extra stress that LGBTQ people face ■ while growing up and living in a society that stigmatizes LGBTQ people and communities. Some refer to this as LGBTQ-​related stress, but you can use the terms that make the most sense to you and your client. It might be helpful to explain to your client that research shows ■ LGBTQ people face disproportionate rates of depression, anxiety,

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and other emotion-​based disorders compared to their heterosexual and cisgender peers, a difference that is fueled by these extra stressors (i.e., LGBTQ-​related stress). ■ In this discussion, one of the key take-​aways for your client should be that it is entirely normal and expected to feel anxious, depressed, or other types of distress in response to the extra stressors that LGBTQ people have to deal with.

How Has LGBTQ-​Related Stress and Stigma Affected Your Client? See what your client thinks about the treatment model and discuss with them how they see LGBTQ-​related stress and stigma as relevant to their lives. Some clients will immediately see the impact of LGBTQ-​related stress on their lives, and some may not (which will be discussed more later). Either way is OK, as this is just an introductory conversation. Examples from clients with whom we have worked are presented in Box 5.2, which may be useful to explore with your client further. Some questions to guide this conversation may include: How does being an LGBTQ person impact your daily life? ■ How does LGBTQ-​related stress show up in your daily life? (Both ■ obvious and subtle examples are OK.)

Box 5.2. Examples of LGBTQ-​Related Stress Clients Report Experiencing

■ Being constantly on the lookout for rejection from others based on early or ongoing experiences of rejection directed toward one’s sexual orientation Internalizing or enacting stereotypes about LGBTQ people as inferior, weak, or ■ unhealthy Silencing one’s own needs, preferences, or self-​expression out of fear of ridicule ■ or shame Hiding one’s sexual identity or behavior from others, at the cost of close relationships ■ and psychological integrity Not believing in one’s ability to form genuine, intimate relationships outside of a ■ purely sexual context Feeling like the only way to be good enough is to achieve “perfection” at school, at ■ work, in terms of physical appearance, or in other ways

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How have LGBTQ issues affected your depression/​anxiety? ■ How has LGBTQ-​related stress affected your decision to get mental ■ health treatment? Types of LGBTQ-​Related Stressors Differ, as Do Reactions to Them ■ Despite some common LGBTQ-​related stress experiences (examples in Box 5.2), every client will have their own unique experiences with LGBTQ-​ related stress. Their reactions to LGBTQ-​ related stress experiences will also vary. For instance, LGBTQ-​related stress may look different or be expe■ rienced differently depending on a person’s race/​ethnicity, socioeconomic status, ability status, religious identity, sexual orientation, and gender identity. LGBTQ-​ ■ related stress can combine with stress related to other minoritized identities. Although this treatment focuses on LGBTQ-​related stress derived ■ from sexual orientation, it is important to validate all forms of LGBTQ-​related stress and the potential impact of all this extra stress on your client’s mental health.

The Goal of Treatment Is Not to Eliminate Emotions ■ This treatment does not seek to eliminate emotions like fear, anxiety, sadness, anger, and other similar feelings. In fact, eliminating these emotions would not be very helpful because emotions provide us with a lot of important information when they are occurring in a functional, helpful manner. Instead, this treatment focuses on bringing a greater awareness and ■ understanding of the ways in which emotional experiences and responses to these experiences are contributing to symptoms. This treatment will also help clients become aware of the full range ■ of experiences that elicit uncomfortable emotions, which may include both negative and positive events, and help them to learn more helpful ways of responding to situational triggers, including LGBTQ-​related stress. 55

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Provide an Overview of the Treatment Approach It is helpful to explain to clients that changing their responses might be difficult, especially at first, as progress does not happen in a straight line: ■ Symptom fluctuation is natural over the course of the treatment, particularly when clients are asked to engage in more challenging tasks. However, the end result should be substantial improvement in ■ overall functioning and responses to emotions. You should inform clients that in the first few sessions, they will explore their development as an LGBTQ person, their experience of LGBTQ-​related stress, and the impact of these experiences on the various components of an emotional experience. You will also introduce ways in which the client can begin monitoring their own emotional experiences as they unfold, as well as ways in which the client responds to these experiences and their relationship with LGBTQ-​related stress. As the treatment progresses, you and the client will be exploring these experiences and reactions to them in greater detail, focusing on identifying responses that are ultimately not helpful for them, and replacing unhelpful responses with more adaptive (helpful) responses to LGBTQ-​related stress. After providing this overview, you can provide a more detailed description of the treatment components, with an emphasis on how they will help your client to overcome their emotional difficulties discussed so far in the session. Use as many specific examples from your client’s life as possible to help make the skills to be learned in treatment relevant (e.g., “The cognitive exercises will be a chance to start expanding your perspective on talking to your parents, so that these conversations might not always have to feel so stressful”).

Review Logistics Finally, it is helpful to give some information about the general format of treatment (e.g., weekly, 50-​to 60-​minute individual sessions) and procedures, including that there will be ongoing assessments and between-​session practice exercises. More on this will be introduced in the next chapter. 56

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In summary: Help your client understand the concept of LGBTQ-​ related stress and how it affects their life and well-​being.

Provide Your Client Feedback on LGBTQ-​Related Stress and Mental Health Intake Assessments Next, talk with your client about the results of their mental health and LGBTQ-​related stress intake assessments. The following are some key points you may want to incorporate into this discussion.

Explore Links Between LGBTQ-​Related Stress and Mental Health Reviewing the intake assessments is helpful for: ■ Illustrating the connection between LGBTQ-​ related stress and mental health. Showing that this treatment, which focuses on LGBTQ-​ ■ related stress, could be helpful. Motivating your client to engage in this treatment to address the ■ LGBTQ-​related stress that drives their mental health concerns. Try asking: ■ What links do you see between the LGBTQ-​related stress experiences you’ve had and the results of your mental health assessments? How do you think that your past and/​or current LGBTQ-​related stress ■ experiences affect your current symptoms?

Share Hypotheses About the Link Between Your Client’s LGBTQ-​Related Stress and Mental Health Although only at the first session, you as the therapist may already have ideas about how the client’s LGBTQ-​related stress experiences may contribute to their mental health concerns. It is ideal for clients to identify these links on their own; however, you as the therapist

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may wish to begin tentatively sharing your hypotheses using guided questions such as: ■ How do you think that your experience of feeling rejected by your family might impact the social anxiety you feel today? What do you think the function of drinking heavily in heterosexual so■ cial environments might be for you? How does it serve you to drink heavily at those times? Where do you think you got the message that it’s not safe to express what ■ you want or need from others?

Normalize Emotional Responses to LGBTQ-​Related Stress ■ Reviewing the assessment results will likely lead your client to see that they are experiencing a number of emotional reactions to LGBTQ-​related stress. It is essential to normalize and validate this emotional reaction to ■ LGBTQ-​related stress.

Consider the Role of Avoidant Coping One common response to difficult emotions, including those that naturally arise in response to LGBTQ-​related stress, is to use avoidant coping (Box 5.3). Use the assessment results to collaboratively identify ways that your client may attempt to cope with strong emotions by avoiding them. It is completely understandable that your client would want to avoid their difficult emotions, especially those rooted in LGBTQ-​ related stress experiences, because these emotions can feel very

Box 5.3. What Is Avoidant Coping?

Avoidant coping is attempting to avoid, escape from, or control emotions instead of tolerating, accepting, and learning from them.

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uncomfortable. Yet, avoiding emotions can have some long-​term downsides. For example: ■ If your client experienced anti-​gay bullying throughout their school years, it could easily start to feel like the safest thing is to just avoid social interactions altogether. In the long term, though, this can lead to social isolation, depression, ■ and increased anxiety in social situations that might actually be affirming and safe. Future modules will go into greater depth about avoidant coping. For this session, just introduce the concept, identify examples in your client’s life, and invite your client to share any pros and cons about their avoidant coping.

Sometimes the LGBTQ-​Related Stress Model Won’t Fit Perfectly ■ Some clients will immediately see links between their LGBTQ-​related stress experiences and their mental health concerns; others may not initially see these links. In our experience with this treatment, LGBTQ clients usually come ■ to appreciate some impact of LGBTQ-​related stress on their lives over the course of treatment. We recommend patience and not forcing an LGBTQ-​ ■ related stress conceptualization with clients who do not identify with the LGBTQ-​related stress model. However, you also do not need to disregard LGBTQ-​related stress as a strong determinant of mental health in these situations. When you, as the therapist, openly explore the possible connec■ tion between LGBTQ-​related stress and current mental health, you are setting the stage for the safe consideration of this possibility across the course of treatment if, and when, it becomes relevant. Box 5.4 provides examples and detailed guidance on working with ■ clients for whom the relevance of the LGBTQ-​related stress model is not immediately clear.

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Box 5.4. What Can I Do if the LGBTQ-​Related Stress Model Doesn’t Resonate with My Client?

Situation 1: Clients   No LGBTQ person can completely escape the challenges of ■ for whom other developing a minority identity (e.g., most likely growing up factors are the primary with parents who do not share their identity, navigating a contributors to society that is majority heterosexual). their mental health ■  If LGBTQ-​related stress is relevant, even in subtle ways, symptoms this therapist guide and the corresponding client workbook provide guidance on promoting resilience as an LGBTQ person in order to reduce depression and anxiety.   If, based on the intake LGBTQ-​related stress assessments ■ and your clinical judgment, other factors are stronger contributing factors than LGBTQ-​related stress, you might modify how strongly to present the LGBTQ-​related stress model as an explanation for your client’s mental health concerns, while maintaining the LGBTQ-​affirming framework and skills presented in this treatment program. Situation 2: Clients who see LGBTQ-​ related stress as a problem of the past

■  Some clients may indicate that LGBTQ-​related stress was a problem for them in the past but that it no longer contributes to their mental health concerns.   These clients may have already learned skills for managing ■ LGBTQ-​related stress.   As a therapist, you can capitalize on this resilience and re■ inforce these clients’ autonomy, agency, and self-​efficacy for managing LGBTQ-​related stress.   It is also common for these clients to identify ways that past ■ experiences of LGBTQ-​related stress contribute to their current mental health after a few modules. For example, your client might later: –​ See that they are still using maladaptive coping strategies (e.g., avoidance) that they developed to cope with LGBTQ-​related stress. –​ Learn that they are still anticipating stigma or rejection before it occurs, based on earlier LGBTQ-​related stress experiences. –​ Identify deep-​seated negative views of themselves that they learned from hearing anti-​LGBTQ messages earlier in life.

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Situation 3: Clients who feel shame or guilt about experiencing LGBTQ-​related stress

■  LGBTQ-​related stress can teach LGBTQ people that they should be able to manage all their stressors on their own, leading to shame or guilt and, relatedly, denial about experiencing LGBTQ-​related stress.   Sexual minority men are often taught to be “real men” by not ■ showing any weakness or vulnerability, which can make it difficult to acknowledge the emotional toll of LGBTQ-​related stress. Validate their experiences while keeping in mind that LGBTQ-​ related stress can take its toll even outside people’s awareness.   Continue to conceptualize the potential role of LGBTQ-​ ■ related stress on your client’s mental health, as future modules may permit further exploration with your client of this conceptualization.

Situation 4: Clients who deny their own LGBTQ-​related stress in the context of perceiving that other LGBTQ people have it worse

■  Some clients may feel that other LGBTQ people have had even more stressful and difficult experiences than they themselves and deny that their own LGBTQ-​related stress is significant by comparison.   For example, knowing that some LGBTQ youth are kicked ■ out of their home, a client whose family was “tolerant” and not explicitly rejecting might deny the impact of their own experiences of LGBTQ-​related stress.   With clients who express this view, it may be especially ■ important to validate their experiences of LGBTQ-​related stress to encourage them to fully express their experiences.

Situation 5: Clients whose stress related to other minority identities more greatly impacts their mental health

■  LGBTQ clients with multiple marginalized identities (e.g., with respect to race/​ethnicity, gender, ability) may feel that these other marginalized identities are more stigmatized and, in turn, have a greater impact on their mental health.   For example, a Latinx gay cisgender man who recently ■ immigrated to the United States may find it challenging to see the relative importance of his gay identity given other more pressing stressors such as finding work and stable housing or overt discrimination based on being Latinx or Spanish-​speaking.   We have found it helpful to validate and explore the multiple ■ forms of LGBTQ-​related stress that clients may be facing, while also leaving the door open to understanding how sexual LGBTQ-​related stress may intersect with and/​or add on to other identity-​based forms of LGBTQ-​related stress.

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In summary: Review the LGBTQ-​related stress and mental health intake assessments collaboratively with your client to begin building links between the two and setting the stage for the rest of treatment.

Conduct the Functional Analysis With all the information you have reviewed with your client up to this point, you can now transition into a formal functional analysis. Box 5.5 provides some background information on completing a functional analysis. Following this, we provide key discussion points to facilitate the functional analysis in session.

Box 5.5. Completing a Functional Analysis Following the STAIRCaSE Approach

While conducting a functional analysis, we recommend using a CBT case conceptualization informed by LGBTQ-​ related stress theory. An LGBTQ-​ related stress CBT case conceptualization centers the role of early and ongoing LGBTQ-​related stress experiences in shaping LGBTQ clients’ cognitive, emotional, and behavioral experience. A useful heuristic for conducting this functional analysis is the acronym STAIRCaSE (Goldfried, 2003; Jose & Goldfried, 2008; Pachankis et al., 2002). Here, we define each component of the STAIRCaSE Model. Key components of the STAIRCaSE approach to case conceptualization include: 1. The Situations, or contexts, that trigger your client’s maladaptive cognitive patterns, strong emotional experiences, and behavioral reactions, including avoidance. For many LGBTQ clients, challenging situations might include experiences with LGBTQ-​related stress or those that remind the client of past encounters with LGBTQ-​related stress. 2. The Thoughts that arise in challenging situations. Thoughts can refer to cognitive content (e.g., of hopelessness, contingent self-​worth, internalized stigma) or cognitive processes (e.g., rumination, obsessions). LGBTQ-​related stress shapes the thought content and processes of many LGBTQ clients. 3. Affect refers to the principal emotional experiences that clients regularly feel in response to challenging situations (e.g., fear, anxiety, sadness, anger, guilt, shame, embarrassment). Frequent, intense emotions occur across depression and anxiety

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4.

5.

6.

7.

disorders and often drive avoidance behaviors used to escape uncomfortable affect. Affect also includes the physical component of uncomfortable emotions (e.g., fatigue, sleep problems, upset stomach). Intention refers to the client’s needs, wants, or desires in challenging situations. For instance, the client might have the need to express themselves authentically, to be heard and respected, and to engage in other valued behavior. Clients often have an intention to not feel strong uncomfortable emotions. Intentions can also refer to the client’s long-​term goals and values in life. The Response refers to the client’s behavior, or what they do to cope with challenging situations. Clients with depression and anxiety often seek to avoid, escape from, or control uncomfortable emotions or the situations that give rise to them. These avoidance patterns can become habitual ways of coping with LGBTQ-​ related stress. Consequences refer to the outcome of the client’s responses. Consequences can include short-​term reductions in uncomfortable emotions. However, over time, avoidance behaviors lead to maladaptive consequences such as keeping the client away from their long-​term goals and values and eroding their self-​evaluation. Self-​evaluation refers to how the client sees themselves and their performance in challenging situations. Self-​evaluation can be thought of as coping self-​efficacy—​how the client views their ability to cope with challenging situations, including LGBTQ-​related stress, and their accompanying cognitive, emotional, and behavioral experiences. LGBTQ-​related stress can lead to negative self-​evaluations if it keeps the client away from their intention and valued action. Keep in Mind the Role of Learning Theory to Inform Your Functional Analysis Learning theory provides the theoretical basis of CBT. Learning theory proposes that all behavior is functional. That is, all behaviors function to elicit rewards or protections from emotional pain in the large variety of contexts that humans experience on a daily basis. Behavior change starts when the therapist works with the client to understand the function of the behaviors that they want to change. Once the function of the problematic behavior is understood, the therapist and client can identify a new behavior that serves the same function—​that

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brings the same comfort, safety, belonging, protection—​but with a more adaptive, empowering impact on the client.

Review Each Component of the STAIRCaSE Model to Carry Out the Functional Analysis The prior components of this session have allowed you and your client to begin understanding the role of LGBTQ-​related stress in their lives and how it has impacted their presenting concerns. Now, you can formalize your functional analysis following the STAIRCaSE Model. You may find it helpful to fill out the LGBTQ-​Affirmative CBT Case Conceptualization Worksheet (referred to as Worksheet 2.1: The STAIRCaSE Model in the workbook) either during or after your conversation with your client, during which you will identify the function of your client’s presenting challenges. This worksheet and a completed example are available in Chapter 2 of the client workbook (Worksheet 2.1 and Figure 2.2). The worksheet can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Review LGBTQ-​Related Stress Situations ■ Knowing the function of a behavior starts when we understand its surrounding context. This context can be thought of as the situational triggers of behaviors ■ that the client would like to change. These situational triggers can be current experiences of LGBTQ-​ ■ related stress or reminders of earlier LGBTQ-​related stress experiences in the client’s life that continue to influence their emotional experience and their thinking and behavioral patterns today. Alternately, encounters with positive situations, such as identity-​ ■ affirming situations, have the opposite effect—​they cause the client to have thoughts and feelings of contentment and joy. Explore with your client what situations make them feel strong, un■ comfortable emotions. Feel free to draw upon the client’s identified problems to illustrate the points being made.

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Box 5.6. Reviewing LGBTQ-​Related Stress Situations: Example Language

When we talk about challenging situations, we mean the actual physical context that causes you to feel uncomfortable emotions—​the who, what, when, and where surrounding your behavior. These situations include broad societal contexts, which for many LGBTQ people include lack of legal protections and community anti-​LGBTQ bias, and daily situations, including navigating the world as a stigmatized member of society. These situations can also serve as reminders of past painful experiences of devaluation and stigma or past times when you were made to feel inferior. We call these experiences “LGBTQ-​related stress,” which research shows explains LGBTQ people’s greater risk of depression and anxiety disorders. Repeatedly encountering situations that elicit LGBTQ-​related stress can lead to feelings of hopelessness and overall patterns of avoidance. Past encounters with harmful or painful situations can also trigger a renewal of those tendencies when you are faced with similar situations in the future. ■ What situations cause you to feel strong, uncomfortable emotions today? Who is there? What is taking place in those situations? When and where does the situation occur? What is your current experience of LGBTQ-​related stress? What has it been in the past? ■ How might your current challenging situations be influenced by past or current experiences ■ of LGBTQ-​related stress?

■ Refer to Box 5.6 for example language of how to discuss LGBTQ-​ related stress as a situational trigger with your client.

Review LGBTQ-​Related Stress and Thoughts Humans appraise all situations using thoughts. ■ A lifetime of LGBTQ-​related stress can skew one’s thoughts toward ■ internalized hatred of oneself, views of oneself as inferior, chronic hypervigilance, or contingent self-​worth (the belief that one is only as valuable as their accomplishments). These cognitive styles often occur subtly or outside of awareness. ■ These thoughts underlie the experience of depression and anxiety and include thoughts of oneself as blameworthy and one’s own and others’ failures as persistent and pervasive. These thoughts drive depressed and anxious emotions.

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■ While the above refers to thought content, LGBTQ-​related stress can also shape thought processes, such as rumination or obsessions. Rumination refers to the tendency to repetitively focus on one’s uncomfortable feelings and the causes and consequences of that distress. Similar to rumination, obsessions refer to repetitive thoughts about negative circumstances that drive people to try to remove or control the thoughts and deal with the circumstances that the thoughts refer to. Like negative thought content, thought processes of rumination and obsessions also cause uncomfortable emotions and distress. You can explore your client’s thought content and processes using ■ language like that presented in Box 5.7. Box 5.7. Reviewing LGBTQ-​Related Stress and Thoughts: Example Language

We have thoughts all the time; they occur in all situations and guide all behaviors. Thoughts include expectations, anticipations, hopes, opinions, and beliefs. Many LGBTQ people’s thoughts are shaped by LGBTQ-​related stress. For instance, you might have heard of internalized stigma—​ or the tendency to think of oneself or other LGBTQ people as inferior to heterosexual, cisgender people. Internalized stigma is an example of an LGBTQ-​related stress thought. LGBTQ-​related stress can also shape people’s thinking towards anxiously expecting rejection and believing that they are only as good as their accomplishments. LGBTQ-​related stress can also cause certain thought processes associated with uncomfortable emotions, such as rumination and obsessions. These thought processes involve judging our experience of emotions or trying to control our experience through repetitive thoughts. These processes make the ebbs and flows of our emotional life seem even more distressing; when we are hard on ourselves for feeling the way we feel or when we try to control our experience, we generally feel even worse. What part of this resonates with you? Do you ever think of yourself as inferior, maybe because you’re LGBTQ? ■ Are you hypervigilant? That is, are you always on the lookout for rejection or for things ■ going wrong, even in safe situations or situations where this is unlikely? Is your self-​worth dependent on how well you perform in certain areas of your life, like your ■ appearance, your job, or being the best at various tasks? Do you frequently blame yourself for problems that go wrong in your life? ■ Do you beat yourself up for feeling certain ways, like giving yourself a hard time for getting ■ upset about something? When you start to feel nervous, do you often worry that it’s going to escalate into even more ■ anxiety? When you start to feel down, do you feel like it’s going to ruin your whole day? ■

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Review LGBTQ-​Related Stress and Affect ■ At this point, you will most likely begin constructing an idiographic case conceptualization by identifying the specific emotions that are arising for your client in the context of challenging situations. Endeavor to assess not only the emotions consistent with the ■ presenting disorders (e.g., anxiety for someone presenting with an anxiety disorder) but also the full range of negative emotional experiences: anxiety, sadness, anger, fear, guilt, embarrassment, and shame. Ask about the frequency of these emotions, how intense the ■ client finds them, how long the emotions last, and how often the client believes their emotions are stronger than the context of the particular situation may call for (e.g., getting very sad upon experiencing a small setback or disappointment). Also acknowledge the role of LGBTQ-​related stress in LGBTQ people’s emotional experience. The language in Box 5.8 provides an example of how you might ■ explore the client’s experience of their emotions and the role of LGBTQ-​related stress in that emotional experience.

Reviewing Intentions ■ An LGBTQ-​related stress CBT case conceptualization realizes the essential role of the client’s intentions—​what they want or need in a challenging situation, or more broadly, what makes life meaningful for them—​their values, in other words. LGBTQ-​related stress can often interfere with one’s intentions. For example, LGBTQ-​related stress can make LGBTQ people ■ less assertive and more likely to cover or silence their authentic expressions of needs and wants. Your role is to help your clients get in touch with their values and understand the ways that LGBTQ-​related stress can interfere with living them out, and maybe just as importantly, believing that they can live them out. In your LGBTQ-​related stress CBT case conceptualization, you can explore with the client what intentions they have in the face of challenging situations.

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Box 5.8. Reviewing LGBTQ-​Related Stress and Affect: Example Language

How we feel in a situation is ultimately determined by how we interpret a situation. Like thoughts, feelings are always with us, although they vary in intensity. We cannot turn them off. But we can learn how to react to them. Many LGBTQ people grow up in early invalidating environments that tell them that their emotions are wrong or that their desires and interests are wrong. This might be especially true for LGBTQ people who are not cisgender. LGBTQ people can learn that their bodies and the feelings and emotions they produce cannot be trusted. This can lead to feeling out of control of one’s emotional experience, which is a core symptom of depression, anxiety, and related problems. In fact, people at risk for emotional disorders experience emotions more strongly, intensely, and frequently than other people. The good news is that we know that learning the emotion regulation skills taught in this treatment can improve people’s ability to face stress, even if they can’t prevent or avoid the stressors altogether. How does this match your experience of your emotions? ■ ■ ■ ■ ■ ■ ■ ■ ■

Does it seem like you feel sad/​anxious/​frustrated more than other people? Is it hard for you to stop thinking about things that upset, anger, or embarrass you? Do you consider yourself a worrier? Do you have trouble controlling your temper? Have other people observed that your emotions seem more intense than those of others in response to situations? Does it take you longer than other people to calm down when you get upset? Does it seem like you feel things more intensely than other people? How do you feel when you think of yourself and other LGBTQ people as inferior or negative? How do you feel when you have identity-​affirming thoughts of yourself as a proud, competent LGBTQ person?

■ This conversation can also start to build motivation for engaging in the treatment, as the client starts to see a discrepancy between how they are currently thinking or behaving and how they might want to start thinking and behaving. Motivation is further built by helping the client see how LGBTQ-​ ■ related stress is standing in the way of living in accordance with their values. Example language for exploring client intentions is provided in ■ Box 5.9.

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Box 5.9. Reviewing Intentions: Example Language

■ Research finds that LGBTQ people are less optimistic than heterosexual, cisgender people that they will be able to live out their life dreams, hopes, and goals. Research also finds that LGBTQ people have a harder time on average asking for what they want or need in challenging situations. Is this true for you in the situations that you’ve identified as being challenging for you? What do you want in these challenging situations? How do you want to feel, think, and ■ behave? What do you want in these situations that you might currently hold back from saying ■ or doing? What values guide your life? How are you acting out those values? How might you be ■ holding back from living in accordance with those values in challenging situations in your life? Review LGBTQ-​Related Stress Responses ■ Some people with depression or anxiety react to challenging situations and their uncomfortable emotions impulsively or avoidantly. When clients want an uncomfortable emotion to disappear, they ■ might respond in habitual, avoidant ways to make the emotion go away without mindfully listening to their emotion and allowing their emotion to serve as a compass pointing towards valid intentions. That type of mindful emotion awareness and expression is a learned ■ skill, which might be especially missing for those with traumatic LGBTQ-​related stress histories or for those who have learned that their emotions are wrong or invalid due to LGBTQ-​related stress. Example language for exploring your client’s LGBTQ-​related stress ■ responses is provided in Box 5.10.

Review Consequences ■ According to learning theory, all behaviors elicit consequences from the situation in which they occur. Consequences that elicit a positive reward from the environment ■ maintain the behavior over time—​that is, they become habitual.

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Box 5.10. Reviewing LGBTQ-​Related Stress Responses: Example Language

The last major feature of emotional disorders is the one we’ll be focusing our efforts on changing, because it’s what makes the biggest difference in the course of emotions over time, and that’s the tendency to engage in avoidant coping, which means trying hard to dampen or escape emotions rather than tolerating and accepting them. It makes a lot of sense that you’d want to avoid your emotions, since they can feel so bad. But avoidance isn’t an effective strategy in the long term, and we’ll spend a lot of time talking about why that is. For now, though, let’s think about how this applies to you. Some examples of avoidant coping might be refusing to do things that make you anxious, withdrawing from others when you feel sad, avoiding situations that might remind you of unpleasant memories, drinking to calm down, procrastinating on a task that might stress you out, or just not making eye contact during a serious conversation with a person in a position of power. Can you think of some examples of how you avoid strong emotions or how you try to stop feeling strong emotions once they begin? ■ ■ ■ ■ ■ ■

Do you tend to avoid or put off doing things that make you anxious? Do you tend to avoid situations where you think you’ll be uncomfortable? Do you avoid doing things when you’re in a bad mood or feeling down? Do you try not to think about the things that make you upset? Do you sometimes cope with uncomfortable emotions by distracting yourself? Are there things you wish you could do but don’t do because you’re concerned about feeling a strong emotion, like anxiety, sadness, or frustration? ■ Do you try to do things to get rid of your negative emotions? ■ Do you try to do things to prevent yourself from feeling certain emotions?

For people with depression or anxiety, the short-​term removal of a painful emotion can be a highly rewarding consequence. ■ Although avoidance behaviors often elicit the short-​term consequence of avoiding painful emotions, avoidance behaviors can also lead to the long-​term consequence of avoiding one’s intentions and values. Unfortunately, avoidant behaviors get reinforced because they keep ■ the client feeling safe and secure in the short term. So, according to learning theory, the behavior gets maintained and the client keeps engaging in it. This is how habits—​good and bad—​form and persist. ■ You might explore the consequences of your client’s current behavior using language shown in Box 5.11.

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Box 5.11. Reviewing Consequences: Example Language

So, let’s say you’re in that challenging situation, you have thoughts about the situation (that is, you interpret it), and those interpretations give rise to your emotions. These factors—​the situation and your thoughts and emotions in that situation—​determine how you might act in that situation. And some of those actions are consistent with your ultimate intention and some are not. For many LGBTQ people who seek treatment, their short-​term intentions are avoidance-​oriented—​ primarily avoiding emotions (those perceived to be dangerous or threatening and those that might seem to confirm that one is fundamentally bad, unlovable, a failure, or unworthy). Many LGBTQ people might hold on to these avoidance-​oriented intentions even if their long-​term intentions are approach-​oriented—​moving towards love, joy, relationships, spirituality, health, and any combination of the many values that we all hold. A lifetime of LGBTQ-​related stress generates avoidance even if your best intentions are anything but. Our goal is to help you break those avoidance patterns to move towards valued living and behavior. ■ What do you think are the consequences of your behavior? What happens after it? Do you feel better in the short term? What about in the long term? How has this strategy been working for you? ■ How does this strategy allow you to live as a thriving LGBTQ person? ■

Therapist Note Your client might respond by saying they actually feel OK in the situation because their current behavior allows them to avoid the situation altogether or at least to avoid the uncomfortable emotions associated with it. But they might also say that they remain depressed and anxious in general. At this point, you can validate that this is one of the main goals of this treatment—​ to help the client understand and reduce their avoidance behaviors that might feel good in the short term but ultimately maintain long-​term distress.

Review Self-​Evaluation ■ Over time, accumulating avoidance behaviors can teach the client that they are incapable of achieving their values involving planful, meaningful, fulfilling action.

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■ As your client sees themselves habitually avoid, they can come to see themselves as the type of person who avoids, the type of person who cannot successfully cope, and the type of person who does not have the agency over their actions to live out their intentions. This poor self-​evaluation, or diminished self-​efficacy for valued ■ action, characterizes clients experiencing depression or anxiety and ultimately brings clients to treatment—​to receive help doing something that they do not perceive themselves capable of doing on their own. That is, clients come to treatment when they are at a loss for how to be the person who exerts agency on their lives. LGBTQ-​affirmative CBT helps people build that self-​efficacy, ■ step by step, or in CBT language behavioral experiment by behavioral experiment, until they build a behavioral repertoire that can be flexibly deployed in stressful situations to allow them to feel their emotions, to allow those emotions to guide them towards intentional action rather than avoidance of uncomfortable emotions, and to do so with the empowered ways of thinking that teach them that they have self-​worth and can succeed in behaving with intention. In this way, the habitual cycles of avoidance that came to be ■ self-​harming can be replaced with more empowering thoughts, feelings, and behaviors. Example language for exploring your client’s self-​evaluation is ■ provided in Box 5.12.

Box 5.12. Exploring Self-​Evaluation: Example Language

When clients come to therapy, they often have a negative view of their ability to change, to reach their goals. The goal of this treatment is not only to help you reach your goals but also to realize that you are the type of person who can reach their goals. What is your current evaluation of yourself in challenging situations? ■ How would you like to evaluate yourself in these situations? ■

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Explain That the Modules That Follow Will Cover Each Component of the STAIRCaSE Model At this point, you can motivate your client by sharing with them that the treatment techniques to be covered in future sessions will help them achieve their goals so that they ultimately come to evaluate themselves and their movement towards their intentions and values with pride. Each component of the STAIRCaSE Model maps onto one or more treatment modules as shown in Table 5.1.

Table 5.1.  STAIRCaSE Components Addressed in Treatment Modules Module

STAIRCaSE Component

Module 1: Setting Goals and Building Motivation for LGBTQ-​Affirmative Cognitive-​Behavioral Therapy

Intention

Module 2: Understanding the Nature and Emotional Impact of LGBTQ-​Related Stress

Situation

Module 3: Understanding and Tracking LGBTQ-​Related Stress and Emotional Experiences

Situation and Affect

Module 4: Increasing Mindful Awareness of LGBTQ-​Related Stress Reactions

Affect and Responses

Module 5: Increasing Cognitive Flexibility

Thoughts

Module 6: Countering Emotional Behaviors

Responses

Module 7: Experimenting with New Reactions to LGBTQ-​Related Stress

Situation, Thoughts, Affect, Intention, Responses, Consequences, and Self-​Evaluation

Module 8: Emotion Exposures for Countering LGBTQ-​Related Stress

Situation, Thoughts, Affect, Intention, Responses, Consequences, and Self-​Evaluation

Module 9: Recognizing Accomplishments and Looking to the Future

Intention

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Discuss the Importance of Intersectionality ■ Although LGBTQ-​affirmative CBT centers past and current experience of LGBTQ-​related stress in contributing to LGBTQ clients’ depression and anxiety, this functional assessment can easily incorporate experiences of intersectional LGBTQ-​related stress. Therefore, in reviewing each of the components of the STAIRCaSE ■ Model, invite the client to share challenging situations that involve not only past and current experiences of LGBTQ-​related stress but also all sources of stress related to stigma, discrimination, or oppression directed towards one’s personal identities and intersections thereof. Clients who identify as a person of color, a person with disabilities, ■ an immigrant, or an economically marginalized, marginally housed, or unemployed person, or who occupy any other social position of marginalization, should be encouraged to identify the role of these social positions and their intersections in their presenting challenges. Like LGBTQ-​related stress, stress related to these social positions ■ can inform each of the components of the STAIRCaSE Model.

Looking Ahead: Ongoing Functional Assessment and Transdiagnostic Case Conceptualization ■ Assessment should continue throughout treatment as opportunities for assessing emotional disorder features will only be enriched as treatment continues. Not all clients arrive with the insight required to report on emotional ■ experiences, particularly before coming to understand the function and nature of emotions. Thus, it is important to remain vigilant for other opportunities for case conceptualization and assessment later in treatment. In summary: Formalize your case conceptualization and functional analysis following the STAIRCaSE Model.

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Session 1: Additional Helpful Reference Materials Case Vignette Working with a gay Honduran cisgender man, the therapist is helping him to recognize his resilience in the face of LGBTQ-​related stress while also continuing to explore the relevance of the LGBTQ-​related stress model with the client. Notice that the therapist does not push the LGBTQ-​related stress model, while at the same time, leaving it to the client to see the relevance of the model within his life. Client:  Hmm, I guess in terms of how being gay has affected my life, for me it has been pretty OK lately. Like, I live with my mom and she knows, and she’s pretty tolerant. Therapist:  Yeah, I hear that, so you’ve really been able to navigate coming out and drawing on some support from your mom in the past few years. Client:  Exactly. I can’t really complain. Therapist:  You were also mentioning earlier that growing up in Honduras, there were a lot of times where you were pretty concerned about sharing with your friends and family that you were attracted to boys. What was that like for you emotionally while you were growing up? Client:  Oh, I felt really anxious a lot of the time, like any minute someone could find out. There were a few times where kids wrote things on my books and my mom saw it and I just denied I was gay because I didn’t want her to know. Therapist:  What was that like for you? Client:  It was awful. I just felt really alone. Therapist:  That makes sense. It must have taken a lot for you to come out and build such a supportive environment for yourself today. I wonder to what extent any of those past experiences might have any relation to the anxiety you still feel today? Client:  Well, maybe. I’ve always been anxious and worry about what other people think about me. I don’t think those feelings ever went away completely. Therapist:  That must be a really uncomfortable feeling that you’ve been carrying around. And it’s also a really common reaction to that kind of extra stress that a lot of LGBTQ people face when

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Box 5.13. Basic Illustration of the LGBTQ-​Related Stress Model LGBTQ-Related Stress i.e., past or current stressors that LGBTQ people face

+

General Stress i.e., past or current stressors that anyone may face

Mental Health Symptoms e.g., depression, anxiety, and substance use

they’re growing up and having to worry about how other people are perceiving them. What do you think about continuing to explore those kinds of links as we continue our work together? Client:  I think that could be really helpful.

Navigating Challenges in Session 1 Presenting the LGBTQ-​Related Stress Model As discussed above (and in Box 5.4), it is important to work with your client to determine the relevance of LGBTQ-​related stress in their lives, rather than imposing this conceptualization if your client does not initially see it as relevant. We also show a (simplified) visual illustration of the LGBTQ-​related stress model in Box 5.13, which may be helpful for your own reference, or even for showing to your client. As shown in this illustration, there can be direct links between LGBTQ-​related stress and mental health symptoms, but LGBTQ-​related stress can also more subtly deplete a client’s coping resources, making it harder to cope with general stressors. Be patient as clients connect the dots. Sometimes a client’s ability to link past experiences of LGBTQ-​related stress with their current mental health struggles and maladaptive behaviors takes more time than is available in the first session. We have found it useful to always work with the client to build the relevance of the LGBTQ-​ related stress model, rather than imposing it ourselves, even if this exploration requires multiple sessions or even modules.

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CHAPTER 6

Module 1: Setting Goals and Building Motivation for LGBTQ-​Affirmative Cognitive-​Behavioral Therapy

(Corresponds to Chapter 4 of the client workbook) This module focuses on your client’s readiness and motivation for change and fosters self-​efficacy for engaging in LGBTQ-​affirmative cognitive-​ behavioral therapy (CBT). Accordingly, you will: ■ Build motivation for changing the patterns that maintain your client’s mental health concerns. Help your client to set goals for treatment, further building their ■ motivation. Build your client’s self-​efficacy for change by highlighting their ■ strengths.

Module Agenda ■ ■ ■ ■

Review progress monitoring Discuss motivation and its importance for treatment outcomes Motivation enhancement skills you can use throughout treatment Help your client explore the costs and benefits of changing versus remaining the same ■ Help your client set specific goals regarding reducing the impact of LGBTQ-​related stress Build on LGBTQ people’s strengths and resilience ■ ■ Agree on home practice

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Recommended Number of Sessions This module can be delivered across one or two sessions depending on the extent to which the Treatment Goal Setting Worksheet needs to be reviewed. For example, if delivering across two sessions, the module could be split as follows: ■ Session 1: Review all module content and agree on setting three major treatment goals Session 2: Break down client’s treatment goals using Worksheet 4.3: ■ Treatment Goal Setting Worksheet

Materials Needed Progress monitoring assessments (i.e., ODSIS, OASIS) ■ Progress Record ■ Worksheet 4.1: Decisional Balance Worksheet, located in client ■ workbook Chapter 4 Worksheet 4.2: Treatment Goals and Examples, located in client ■ workbook Chapter 4 Worksheet 4.3: Treatment Goal Setting Worksheet, located in client ■ workbook Chapter 4

Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The Progress Record is located at the end of Chapter 3 in the client ■ workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be accessed by searching for ■ this book’s title on the Oxford Academic platform at academic. oup.com.

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Review Progress Monitoring Track Your Client’s Symptoms Review your client’s scores. Use the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session, based on this week’s assessments. ■ Although early in treatment, you might consider exploring any differences in assessment scores today compared to the first session. Remind your client that progress in therapy is not linear—​ups and ■ downs in symptoms are very normal.

Discuss Motivation and Its Importance for Treatment Outcomes Motivation is key to this treatment. Below are some suggested discussion points and tools to use to increase your client’s motivation to engage in treatment.

Motivation Is Key for Treatment Motivation and commitment are important when starting mental health treatment. In fact, the more motivated a client is, the more likely they are to fully engage with sessions (i.e., coming to all their sessions, being fully present while there) and to practice skills in between sessions (i.e., completing home practice), which yields better treatment outcomes.

Ambivalence Is Normal ■ Ambivalence is also a natural part of the behavior change process. Despite your client’s desire to change, they may also feel (understandably) reluctant to engage in the challenging tasks required to make these changes.

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■ At this point, your client has an idea of what treatment is going to entail, and they might feel overwhelmed as they think about completing treatment, which naturally triggers ambivalence. Motivation will wax and wane throughout the course of treatment for ■ all clients. It is useful to acknowledge this from the outset, using the motivational interviewing (MI) skills described below to help resolve ambivalence.

Emphasize the Role of LGBTQ-​Related Stress to Build Motivation ■ By emphasizing the role of LGBTQ-​related stress in contributing to LGBTQ individuals’ disproportionate mental health burden, you are also offering your client another source of motivation: By standing up for their mental health, they are also standing up to the harmful, painful legacy of LGBTQ-​related stress. By emphasizing that LGBTQ-​related stress can teach LGBTQ people ■ that they are not in control—​of themselves, their relationships, and their psychological experience—​you can shift your client’s view of themselves towards someone who can stand up to the disempowering effects of LGBTQ-​related stress.

Motivation Enhancement Skills You Can Use Throughout Treatment In addition to the discussion points above about motivation, we recommend using MI in all modules to enhance motivation. We describe these skills below.

Using Motivational Interviewing to Resolve Ambivalence ■ MI is a set of therapeutic principles and skills that have been shown to help clients resolve ambivalence about making changes and foster motivation to engage in treatment.

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■ MI and MI-​based therapeutic techniques have been shown to be efficacious with individuals with alcohol and substance use disorders (Miller & Rollnick, 2002) as well as anxiety and mood disorders (Westra, 2004; Westra & Dozois, 2006). Although we summarize the skills involved in MI, it may be useful ■ to read more if you are not already familiar. For example, Naar and Safren (2017) describe how MI and CBT can be integrated, and the third edition of Miller and Rollnick’s writing on MI (2012) provides a contemporary guide to practicing MI. Look at Table 6.1: The Spirit of Motivational Interviewing for more detail about the “spirit” of MI and how to utilize MI to build motivation (Miller & Rollnick, 2012). In addition to offering practical tools, MI has been developed to include an overarching approach or mindset, with four contributing components: 1. 2. 3. 4.

Partnership Acceptance Compassion Autonomy support

Processes of Motivational Interviewing Miller and Rollnick (2012) suggest that there are four central approaches to MI that overlap with one another. Table 6.1 is applicable across all four processes.

Engaging ■ Engaging is the process of building rapport and connection between you and your client. Your client may become engaged quickly (or even instantly), or may ■ take longer to feel connected and engaged. It is essential to have a level of therapeutic engagement in order to ■ deliver any type of therapy.

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Table 6.1.  The Spirit of Motivational Interviewing 1. Partnership

■  Your client is an active partner in the therapy process. As such, MI is collaborative, and your client is an expert on themselves.   A metaphor for this partnership is that MI is like a dance where ■ both the therapist and client must play their part to generate a successful treatment outcome.   As the therapist, you must avoid falling into the expert ■ trap, the idea that you are “right” and therefore your client “should” listen.

2. Acceptance

■  Informed by Carl Rogers’s client-​centered approach, this component refers to fully accepting your client. This does not mean that you approve of your client’s specific behaviors or actions; rather, this includes:   Absolute Worth—​the notion that every human being has ■ inherent worth and value and that this is not conditional on anything a person does or does not do.   Accurate Empathy—​seeking to understand how your client ■ experiences their own life and world, rather than imposing your own perspective or views.   Autonomy Support—​acknowledging that your client has the ■ right and ability to make their own decisions and choices about their life.   Affirmation—​seeing and validating your client’s strengths and ■ efforts towards change.

3. Compassion

■  Actively seek to support and promote your client’s personal well-​being and prioritize their needs over your own needs (e.g., to be liked, to be a “good” therapist).   Practice compassion to ensure that the treatment, overall, is ■ focused on meeting your client’s needs.

4. Autonomy Support

■  Autonomy support is a shift from the deficit model of therapy; it shifts from the idea that clients have a deficit that you, as the therapist, will address to a strengths-​based perspective that recognizes that your client has much of what they need in order to attain their goals.   Consistent with the core principles of LGBTQ-​affirmative ■ treatment, autonomy support requires understanding your client’s particular strengths and resources and facilitating your client’s use of these.

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Focusing ■ Your client becoming engaged in treatment permits focusing, or developing an understanding of your client’s goals or agenda for treatment (why are they coming for treatment?). Focusing refers to the process through which you and your client ■ develop and continue to pursue a focused goal or direction for treatment. Use Worksheet 4.2: Treatment Goals and Examples and Worksheet 4.3: ■ Treatment Goal Setting Worksheet to collaboratively focus the treatment. These worksheets are available near the end of Chapter 4 in the client workbook and can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Evoking ■ Evoking is about eliciting your client’s reasons for wanting to change—​for example, by eliciting your client’s own thoughts and feelings about how and why they may wish to make a change to their life or behavior. Invite your client to describe their own arguments or reasons for ■ change (i.e., “change talk”). It is much more important to know why it is important for your ■ client to change, from their own perspective, than any reasons why you, as the therapist, feel they “should” change. Evoking might involve exploring your client’s important goals/​ ■ values, discrepancy between their current behavior and personal goals/​values, and the costs/​benefits associated with behavior change. Use Worksheet 4.1: Decisional Balance Worksheet to build motiva■ tion for change. This worksheet is available near the end of Chapter 4 in the client workbook and can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. It is recommended to focus more on the “change talk” portion of this worksheet: the pros of change and the cons of staying the same.

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Planning ■ Clients who have reached a point where they are ready to implement behavior change are typically ready for the planning process; however, there is not necessarily one distinct moment at which this transition to planning occurs. Planning includes committing to change and making a specific plan ■ of action to enact this change. Planning is an iterative process: New challenges can emerge that ■ require revisions to original planning processes and renewed commitments to change.

When to Use Motivational Interviewing We encourage using MI from the first session and continuing to use it throughout this treatment. If your client’s motivation wanes in the context of being asked to take on a new, challenging behavior in treatment, you can use MI to rebuild motivation. In summary: Motivation is important for treatment outcomes, yet ambivalence about change is a normal part of the process. MI and emphasizing the role of LGBTQ-​related stress in your client’s mental health concerns may help to build motivation.

Help Your Client Explore the Costs and Benefits of Changing Versus Staying the Same The decisional balance exercise is an MI-​based tool to increase motivation for behavior change. Below are some discussion points and suggestions for using the decisional balance exercise in Module 1.

Introduce the Decisional Balance Worksheet Worksheet 4.1: Decisional Balance Worksheet is meant to be an opportunity to look together with your client at the reasons for staying

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the same versus changing, so that you have a shared understanding of how it would be for them to engage in treatment, while also building their motivation for changing. As a reminder, this worksheet is available near the end of Chapter 4 in the client workbook and can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. We usually introduce this worksheet with a phrasing like this: We have found it to be helpful, before starting treatment, to look at the benefits and downsides of keeping everything the same—​coping in the same ways, feeling the same ways—​versus engaging in this treatment program and changing some of these things that have been difficult for you. How does that sound?

Discuss the Benefits and Costs of Changing Versus Staying the Same ■ Consistent with an MI approach, invite your client to determine on their own what these pros and cons are in the context of their own life, rather than instilling your own view on the pros and cons of each option. Having your client come up with these pros and cons on their own ■ generally contributes to some resolution of ambivalence. Following MI, we suggest reviewing the pros of changing last (in ■ order to “end” on your client’s change talk). Below is some suggested phrasing for starting this conversation: ■ Great, let’s work our way through the benefits and costs together. What, for you, are some of the costs of staying the same? In other words, if you kept things exactly as they are now, and didn’t engage in this treatment at all, what would be some of the downsides to you?

Normalize and Validate Ambivalence ■ As you talk through the pros and cons of changing versus staying the same, your client will likely share ambivalent feelings about changing.

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■ We have found it to be helpful to normalize and validate this ambivalence while going through Worksheet 4.1: Decisional Balance Worksheet, rather than arguing for change. Here is some example language you could use: This exercise is really just an opportunity to think carefully together about the pros and cons of staying the same versus changing. We don’t have to make any decisions yet about what to do about these pros and cons. For now, I just want to understand your perspective. Completing Worksheet 4.1 allows you and your client to directly address the ambivalence your client may feel and address some potential sources of your client’s ambivalence. In summary: Help your client weigh the pros and cons of changing versus remaining the same using the Decisional Balance Worksheet, as this can help to build motivation and reduce ambivalence about changing.

Help Your Client Set Specific Goals Regarding Reducing the Impact of LGBTQ-​Related Stress After initiating the discussion of motivation and commitment to change, you will then help the client set specific treatment goals for reducing the impact of LGBTQ-​related stress. Below are suggested discussion points for the treatment goal setting portion of the module.

Setting Goals Is Important! Talk with your client about the importance of setting treatment goals: ■ Research has consistently shown that one of the most effective ways to achieve successful behavior change is through setting specific, manageable goals. The more concrete the goals are, the more likely it is for your client to ■ engage in behavior change leading to completion of these goals.

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Introduce the Treatment Goal Setting Worksheet ■ Show your client Worksheet 4.2: Treatment Goals and Examples and Worksheet 4.3: Treatment Goal Setting Worksheet, and explain that now is the time to start thinking about what their goals are for treatment. These worksheets are available near the end of Chapter 4 in the client workbook and can be accessed by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Completing Worksheet 4.3 will help your client prepare for sub■ sequent modules by identifying their larger goals over the course of treatment and then coming up with more concrete, manageable steps towards achieving those goals.

Goals Come from the Client ■ It is important that while you will facilitate this goal setting exercise, the goals come from your client. Although you, as the therapist, might have ideas about what your ■ client’s goals should be, it is more beneficial if the goals originate from your client, and are consistent with what they want out of treatment. Some clients will have a clear sense of how their emotional ■ experiences rooted in LGBTQ-​related stress lead to significant problems and how to set goals to address these problems, whereas others may not.

Therapist Note If your client does not have a clear sense of this, you can help them to clarify the top problems that might be addressed in treatment by sharing the assessment results and the concept of LGBTQ-​related stress as it applies to the client’s life. In that way, you are helping to elicit your client’s own treatment goals.

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Guide the Specificity of Goals ■ Clients may have some goals that are specifically relevant to treatment and some that are more relevant to their overarching aspirations in life. Some goals are immediately achievable (e.g., “going to the gym to■ night,” “completing my home practice,” “limiting the number of drinks I have this weekend”), while others might take longer to accomplish (e.g., “finding supportive gay friends,” “having a more honest relationship with my parents,” “finding a career I love and in which I can be myself ”), and some are goals that individuals might always be working towards (e.g., “feeling happier,” “feeling more satisfied with my life”). Validate any goal that your client has, while at the same time help ■ them to set specific, concrete, manageable goals for the purpose of Worksheet 4.3: Treatment Goal Setting Worksheet. The specificity of the goal is linked to the odds of changing the be■ havior. For example, the goal of “apply for the job opening at the LGBTQ student center today” is much more likely to be successful than “find a career I love and in which I can be myself.”

Develop the Steps Towards Each Goal ■ Once a specific and concrete treatment goal is identified, help your client consider specific steps that they can take towards this goal. For longer-​term goals, you might ask questions such as, “What would ■ you be doing that you’re not currently doing if you were to be closer to that goal?” or “What would it look like for you to be living your daily life in a way that is consistent with that goal?” to help clarify these concrete steps. Through completion of the goal setting worksheet, your client’s self-​ ■ efficacy for change is likely to increase. We recommend helping your client to work through one of three goals on the worksheet during the first session, with the client completing the remaining goals for home practice, and together spending the next

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session either briefly reviewing the goals (if completing the first module in one session) or reviewing the goals in greater detail for the rest of the second session (if spending two sessions on the first module). In summary: Help your client increase their self-​efficacy for change by setting specific treatment goals that are related to reducing the impact of LGBTQ-​related stress on their emotional functioning using Worksheet 4.3: Treatment Goal Setting Worksheet.

Build on LGBTQ People’s Strengths and Resilience Module 1 is also an important time to appreciate your client’s and the broader LGBTQ community’s strengths and resilience. The following are some discussion points that you might incorporate into Module 1 and the rest of treatment.

Capitalize on LGBTQ Strengths and Resilience ■ In the first module, as well as throughout treatment, you can capitalize on the resilience shown by the LGBTQ community and the unique strengths of the LGBTQ community as a source of clients’ personal self-​efficacy. Discussing sources of LGBTQ-​related stress should be sure to cap■ ture the reservoirs of resilient responding shown by the LGBTQ community at large, the client’s LGBTQ peer group (e.g., queer women, LGBTQ people of color), and your client themselves in the face of stigma.

Highlight Examples of Community Strengths and Resilience You can draw on examples of resilience that the client has already shared with you during this first module, as well as examples of resilience within the LGBTQ community at large with which the client might be less familiar.

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Therapist Note Because LGBTQ people are typically not born into LGBTQ families and because LGBTQ people are typically not taught LGBTQ history in school, many LGBTQ people have never been given space to acknowledge the remarkable historical strengths of LGBTQ people and the opportunity to accept those strengths as their own cross-​generational inheritance. Taking a strengths-​based approach to this treatment involves sharing information so that your client can learn about the strengths of the LGBTQ community at large. We highlight here a few examples of such strengths that may be explored with clients. You may wish to also explore with your client other examples of community-​level resilience that they have experienced or observed: ■ Coming Out: At some point, all LGBTQ people navigate the coming out process, typically starting at a relatively early age and often occurring in isolation, without peer or parental support or accessible role models. As a result, many LGBTQ people have developed a strong sense of independence and self-​preservation. Even LGBTQ people who are closeted to all others have nonetheless begun the process of acknowledging to themselves their LGBTQ identities and forming those identities in the best way they know how despite formidable challenges to self-​affirmation. Building Families of Choice: Many LGBTQ people show resil■ ience through building affirming, familial social networks of choice. Typically born into heterosexual families and existing as a small numeric minority that is randomly distributed in the population, LGBTQ young people lack the critical mass of similar others naturally surrounding heterosexual, cisgender people. Therefore, LGBTQ people often need to figure out ways to creatively and courageously find each other, build community, and draw upon that community as a chosen family. Advocacy and Activism: LGBTQ people have long histories of ■ standing up against discrimination and fighting for equality. For instance, the LGBTQ community has shown impressive activism in the fight against HIV/​AIDS, starting at the beginning of the epidemic, long before HIV/​AIDS became a relatively mainstream

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public health issue. More recently, the community has successfully advocated for changes in policies such as same-​sex marriage. There has also been substantial community mobilization in response to violence towards and surveillance of the LGBTQ community, such as celebrating the 50th anniversary of the Stonewall Uprising in 2019. In summary: LGBTQ people and communities have a history of collective resilience as well as personal strengths in the face of stigma. You can draw on these strengths throughout treatment.

Agree on Home Practice Home practice is a critical component of LGBTQ-​affirmative CBT. Below are some points to highlight in general about home practice, to set the tone for the rest of treatment, as well as specific points about this week’s home practice.

Role of Home Practice for Treatment Outcomes ■ Talk with your client about the importance of practicing the skills discussed in each module throughout the week. We refer to this as “home practice.” We have found that clients who actively engage in module con■ tent between sessions are most able to implement change towards their goals. Remind your client that you’ll only meet for one hour per week, and ■ that, because this treatment is very focused on building skills, it is critical to practice the skills that are learned during that one hour on their own throughout each intervening week. More practice will lead to greater benefit.

Discuss This Week’s Home Practice and Agree on a Plan ■ This week’s home practice is to complete the rest of Worksheet 4.3: Treatment Goal Setting Worksheet.

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■ To do this, your client will, on their own, identify their remaining treatment goals and the steps towards completing these goals. Depending on time and the number of sessions you plan to spend on ■ this module, we recommend trying to complete at least one goal on the worksheet during the first session so that your client understands how to complete the rest of the worksheet for home practice. You might help your client to problem-​solve barriers to completing ■ home practice. For example, if they anticipate that they will not remember to complete their home practice, you might ask how they manage to complete other tasks, and to ask whether reminder strategies for these other tasks might apply in this situation.

Module 1: Additional Helpful Reference Materials Case Vignette Working with a non-​binary gay client, the therapist is helping the client clarify their overall treatment goal and identify the intermediate steps involved in pursuing that treatment goal. Notice that in this example, the therapist is not lecturing or telling the client the steps, but rather the therapist is eliciting the steps from the client using the MI skill of “ask—​tell—​ask” (ATA). Client:  My goal is just to be happy; I don’t know how to make that more specific. If I knew how to be happy, I would have done that already. Therapist:  It’s been hard to figure out on your own what it would take to feel happy, and instead you’ve felt pretty down and isolated these past couple of years. You’d like to feel differently. Client:  Yeah, exactly, I’m just really lonely. Therapist:  Tell me more about what your life would look like if you were to feel happy and less lonely. Client:  Well, it would be nice to have people to call and hang out with. I just feel like the only people I hang out with I can’t really be myself around. Like I go out, but I just end up feeling more alone. Therapist: You were mentioning earlier that you didn’t really have too many friends who are LGBTQ. How does that fit into your experience feeling like you can’t be yourself, and feeling lonely? 92

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Client:  Exactly, it would just be really nice to have some gay friends. It seems like all other gay people except me have a group of gay friends. They all go to bars and parties all the time, but that’s just not me. I don’t love to drink and I don’t have money to spend on that. Therapist:  That makes sense, so you’re really wanting a space where you can be yourself and meet other gay people without spending too much money or feeling like you have to drink. What would be a first step towards that? Client:  I guess I could go online and see if there are any groups? Is that lame? Therapist:  Actually, that sounds great! So, should we list this as step 1 for this goal? Client:  OK, sure. Therapist:  What’s next after that? Client: Maybe finding a group and actually going to one of their meetings or get-​togethers? Like maybe I could join an LGBTQ sports league or something. Therapist:  OK, got it, so it sounds like you have step 2 for this goal. Client:  Yeah, OK, this makes more sense now.

Navigating Challenges in Module 1 Narrowing Treatment Goals and Intermediate Steps Make sure that the client’s goals are reasonable and achievable. Clients will sometimes have problems identifying concrete steps towards the larger goals they have identified. It is important to make sure that the steps they have listed under the Taking the Necessary Steps section of Worksheet 4.3 are in fact manageable; otherwise, unachievable steps will undermine the goal of this worksheet, which is to build self-​efficacy for behavior change. This is illustrated in the above vignette. The therapist responded to a common difficulty by helping the client to generate intermediate steps that could work towards achieving their ultimate goal of feeling happier and less lonely. In addition to modeling the problem solving and goal setting process for the client, the therapist also helped to enhance the client’s self-​efficacy by reinforcing the client’s problem solving attempts.

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Additional Readings on LGBTQ-​Related Stress Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation framework. Psychological Bulletin, 135(5), 707–​730. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 5(129), 674–​697.

Additional Readings on LGBTQ-​Affirmative CBT 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(4), 313–​330. Pachankis, J. E. (2015). A transdiagnostic minority stress treatment approach for gay and bisexual men’s syndemic health conditions. Archives of Sexual Behavior, 44(7), 1843–​1860. Ritter, K. Y., & Terndrup, A. I. (2002). Handbook of affirmative psychotherapy with lesbians and gay men. Guilford Press.

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CHAPTER 7

Module 2: Understanding the Nature and Emotional Impact of LGBTQ-​Related Stress

(Corresponds to Chapter 5 of the client workbook) This module raises awareness about the potential influence of LGBTQ-​ related stress on the client’s experience of depression and anxiety. Accordingly, you will: ■ Provide feedback on your client’s intake assessment information regarding LGBTQ-​related stress. Use the intake information to generate a discussion about your ■ client’s unique experiences as an LGBTQ individual. Normalize the client’s experiences by sharing information regarding ■ the prevalence of depression and anxiety among LGBTQ people and exploring how LGBTQ-​related stress contributes to their own mental health concerns. Encourage your client to start tracking their ongoing LGBTQ-​ ■ related stress experiences so that they can link these experiences to their current symptoms of depression and anxiety in subsequent sessions.

Module Agenda Review current symptoms on the Progress Record ■ Review home practice from the prior module ■ Provide psychoeducation about the nature and emotional impact of ■ LGBTQ-​related stress Explore how LGBTQ-​related stress contributes to your client’s ■ daily life Agree on home practice ■

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Recommended Number of Sessions This module is intended to be delivered across one or two sessions to provide sufficient time for the client to adequately explore and practice key concepts. For example, you might divide the module content as follows: ■ Session 1: Provide psychoeducation about the nature and emotional impact of LGBTQ-​related stress; begin exploring how LGBTQ-​ related stress contributes to the client’s daily life (focusing on your client’s past and current experiences with LGBTQ-​related stress) Session 2: Finish exploring how LGBTQ-​related stress contributes ■ to the client’s daily life (focusing on how past and current LGBTQ-​ related stress relates to your client’s well-​being)

Materials Needed Progress monitoring assessments (i.e., ODSIS, OASIS) ■ Progress Record ■ Worksheet 5.1: Examples of LGBTQ-​ ■ Related Stress, located in client workbook Chapter 5 Worksheet 5.2: LGBTQ-​Related Stress Experiences and Emotions, ■ located in client workbook Chapter 5 Worksheet 5.3: Monitoring LGBTQ-​Related Stress—​Understanding ■ Emotion-​Driven Behaviors, located in client workbook Chapter 5 Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The Progress Record is located at the end of Chapter 3 in the client ■ workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be downloaded by searching for this ■ book’s title on the Oxford Academic platform at academic.oup.com.

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Review Current Symptoms on the Progress Record Track Your Client’s Symptoms Take a moment to review your client’s scores. Use the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session, based on this week’s assessments. ■ Highlight any positive change and explore your client’s perceptions regarding the source of this change. If you see a bump in symptoms, explore this with your client. ■ Remind your client that progress in therapy is not linear. Use the Progress Record review as an opportunity to see what you ■ might need to focus on in today’s session, to determine if any shifts in treatment focus may be needed, or to generally explore with your client how they feel that treatment is going. If the client did not complete the assessment measures, allow your client a moment to complete them during the session. Acknowledge changes in scores and chart them on the client’s Progress Record.

Review Home Practice from the Prior Module Review Worksheet 4.3: Treatment Goal Setting Worksheet Discuss the rest of the treatment goals that your client identified for home practice. Address any questions your client might have about LGBTQ-​affirmative treatment after having had time to reflect on what the treatment sessions will involve. If your client did not complete the home practice assigned last module, briefly work with them to further develop their Treatment Goal Setting Worksheet in session. Explore any perceived barriers to home practice completion. As needed, engage the client in motivational interviewing to resolve ambivalence about completing between-​ session assignments.

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Provide Psychoeducation About the Nature and Emotional Impact of LGBTQ-​Related Stress This module helps LGBTQ clients consider how early and ongoing LGBTQ-​related stress might contribute to their experiences of anxiety and depression, the nature of their emotional responses to LGBTQ-​ related stress, and unhelpful coping behaviors in the face of LGBTQ-​ related stress. Therapist Note This therapist guide uses the term “LGBTQ-​related stress” in referring to the specific stressors that LGBTQ people face related to their sexual or gender identities. As the therapist, you could also use other terms like “minority stress,” which is more consistent with the scientific literature, although clients may not use or recognize this term. Or you could use even more descriptive terminology, like “stressors that LGBTQ people sometimes face because they are LGBTQ.” Most importantly, we recommend adopting the client’s own terminology to refer to this stress. If the client struggles to identify or understand this stress, refer to Table 7.1 on page 103, below, to help guide this discussion further. To start the discussion of how LGBTQ-​related stress might impact your client, it is important to review the following points.

LGBTQ People Are at a Greater Risk of Mental Health Problems Than Heterosexual and Cisgender People LGBTQ people are more than twice as likely to experience major depression, panic disorder, and social anxiety disorder compared to their heterosexual and cisgender peers (Cochran & Mays, 2000; Cochran et al., 2003; King et al., 2008).

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LGBTQ-​Related Stress Causes This Difference in Rates of Mental Health Problems As discussed in Module 1, LGBTQ-​related stress is the extra stress that LGBTQ people face because of past and ongoing stigma. The difference in mental health problems is not caused by individual deficits among LGBTQ people.

Early Experiences of LGBTQ-​Related Stress Can Lead to Current Emotional Distress and Mental Health Problems For many LGBTQ people, early experiences with LGBTQ-​related stress are related to current depression and anxiety as well as unhealthy coping behaviors, such as substance use and risky sex. Here are a few examples of early LGBTQ-​related stress that you might explore with your client (additional examples are presented in Table 7.1): ■ Getting the message that being LGBTQ is something to be ashamed of. This could include messages that their needs, desires, and behaviors as an LGBTQ person are disgusting, deviant, or abnormal. This message can get deeply processed, even outside of the client’s awareness, and lead to more-​or-​less automatic shame responses to a range of situations. Concealing being LGBTQ. Many LGBTQ people go through a ■ lengthy period of concealing their sexual orientation/​gender identity. Although the average LGBTQ person today realizes that they are LGBTQ around the time of puberty, they may not tell another person about their sexual orientation for months or years. During that time, LGBTQ people may self-​consciously worry about seeming LGBTQ to others, lest others may find out and ridicule or reject them. LGBTQ people may go to great lengths during this period to stave off the threat of discovery and rejection. This can lead to ongoing feelings of self-​consciousness, shame, and contingent self-​worth. Experiencing rejection. Some LGBTQ people might also have faced ■ rejection from family, teachers, their religious organization, and/​or peers. Even if they feel affirmed in their current relationships, chronic experiences of rejection in the past can leave a lasting impact, such

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as ongoing expectations of rejection or difficulty asserting oneself to avoid rejection.

Current Experiences with LGBTQ-​Related Stress Also Impact LGBTQ People’s Emotional Experiences Some LGBTQ clients are also likely to be facing ongoing LGBTQ-​ related stress in their lives, leading to increased depression, anxiety, and other unhealthy coping behaviors (e.g., substance use, risky sex). Some common examples of current LGBTQ-​related stress that may be relevant to your client (more examples are presented in Table 7.1): ■ Being in situations that are openly or subtly anti-​LGBTQ. This might include certain workplaces or public settings. Being in these types of situations is likely to produce an uncomfortable emotional experience. Being exposed to ongoing debates about LGBTQ rights. Living ■ in or being a part of neighborhoods, religious communities, counties, or states in which the legitimacy of equal rights for LGBTQ people is openly debated can serve as a constant reminder that one is seen as inferior or unacceptable to large segments of the population. ■ Chronic experiences of LGBTQ-related stress are draining. The experiences discussed above can leave a person with chronic discomfort, stress, and few coping resources. This increased stress can trigger many different types of emotional disorders, such as generalized anxiety disorder, social anxiety disorder, obsessivecompulsive disorder, panic disorder, and depression.

LGBTQ-​Related Stress Can Come from Within the LGBTQ Community Itself Even the LGBTQ community, which for many is expected to be a safe and affirming space, can contribute to additional LGBTQ-​related stress experiences. Examples of LGBTQ-​ related stress within the

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LGBTQ community include the following (more examples appear in Table 7.1): ■ Internalized stigma within the LGBTQ community. Sometimes, LGBTQ people internalize stigmatizing messages about their identities. This means that sometimes LGBTQ people can start to believe false messages that LGBTQ people are inferior. When these stigmatizing messages get internalized, it can lead some LGBTQ people to go to great lengths to prove their superiority even to other LGBTQ people by, for example, competing with other LGBTQ people for status, money, or sexual desirability. Restrictive gender roles in the LGBTQ community. Some ■ LGBTQ people experience rejection within the LGBTQ community based on their gender expression. For example, rejection of male effeminacy or female masculinity can be a problem within the LGBTQ community. Others may find the adoption of gender-​ normative behavior to be problematic (e.g., “lipstick lesbians” who embrace femininity, gay males who are interested in sports). Bi-​negativity within the LGBTQ community. Many bisexual ■ individuals find that the LGBTQ community treats them with suspicion and distrust, which can further exacerbate feelings of shame, guilt, social isolation, or self-​consciousness. Therapists might help bisexual individuals locate supportive community connections, which will be discussed in more detail in subsequent modules. Marginalization within the LGBTQ community based on other ■ identities. Clients who hold marginalized identities in addition to their sexual minority identity (e.g., racial/​ethnic minorities, transgender/​gender non-​binary individuals) might face discrimination and rejection within the LGBTQ community, which can exacerbate the adverse impact of LGBTQ-​related stress. When working with individuals with multiple marginalized identities, therapists should explore the possibility that stigma-​related stress might arise from multiple sources and should be prepared to help clients process the difficult emotions associated with feeling marginalized by their multiple minority identities.

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In summary: Early and ongoing LGBTQ-​related stress, as well as LGBTQ-​ related stress within the LGBTQ community, accounts for the higher rates of mental health problems that are seen among LGBTQ people.

Explore How LGBTQ-​Related Stress Contributes to Your Client’s Daily Life After some psychoeducation has been provided about the potential impact of LGBTQ-​related stress on LGBTQ people’s mental health, the next part of the module involves clarifying how this applies to your client’s own life. It can be important to discuss the following key points.

Explore Your Client’s Past and Current Experiences with LGBTQ-​Related Stress Building on the first module, explore further with your client what types of experiences they have had in the past and continue to experience with respect to LGBTQ-​related stress. Encourage your client to be as specific as possible in exploring their LGBTQ-​related stress experiences (i.e., identifying who, what, when) to really start building their awareness of LGBTQ-​related stress in their life and how this may impact their daily life. You can share the LGBTQ-​ related stress examples presented in Table 7.1 as a tool for those clients who have difficulty identifying LGBTQ-​ related stressors in their lives. These examples also appear as Worksheet 5.1: Examples of LGBTQ-​Related Stress in the client workbook, which you can ask your client to use to indicate all LGBTQ-​related stressors that affect them. You and your client can review this worksheet together in the session to gain a sense of the relevant LGBTQ-​related stressors that might be generating difficult emotions for them.

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Table 7.1.  Examples of LGBTQ-​Related Stress 1. Stigma/​ Homophobia

  Not having the same legal rights as others ■   Others viewing you as immoral, not virtuous, not religious ■   Fear of hate crimes ■   Unfavorable cultural/​media representations of LGBTQ people ■   Having your sexuality as a lesbian viewed by heterosexual men as erotic, ■ trendy, or a sign that you hate men   Others viewing you as not manly because of your identity as a gay or ■ bisexual man   Self-​consciousness, including feeling as if the spotlight is on you and ■ that people can see right through you and know what you’re up to   Heterosexuals conflating being gay with being HIV-​positive and bisexual ■ with being promiscuous   Fear of rejection ■   Fear of harassment in public spaces due to gender presentation or the ■ presence of a same-​gender partner

2. Interpersonal Stress

  Feeling socially isolated or like an outcast ■   Concealment stress (e.g., feeling like you are hiding who you are, living a ■ double life, putting on a show, straining friendships due to concealment)   Disclosure stress, including planning when and to whom to come out ■   Challenges in remaining close with heterosexual, cisgender friends after ■ coming out   Distrust of new people ■

3. Romantic Relationship Stress

  Avoidance of romantic intimacy or suppressing romantic feelings ■   Fear of ending up alone ■   Pressure to lead a heteronormative, cisnormative life ■   Not having people with whom to discuss relationship turmoil or break-​ ■ ups, due to not being open about one’s sexual orientation   Pressure to be in a relationship ■   Fleeting sexual encounters without lasting intimacy ■   Challenges of being bisexual and feeling pigeonholed to the sexual ■ orientation dictated by the gender identity of your current partner   Difficulties communicating about HIV status; fears of contracting HIV ■   Negotiating sexual agreements with partners ■

4. Family and Developmental Stress

■  Early gender nonconformity (e.g., young girl being viewed as a tomboy, young boy wanting to play with dolls)   Bullying ■   Distance within family relationships due to not being open about one’s ■ sexual orientation or gender identity   Lack of parental acceptance ■   Feelings of letting parents down ■   Holidays bringing up non-​acceptance ■   Family’s misinformed theories about sexual orientation and gender identity ■   Not having a sense of control in adolescence ■   Lack of role models for leading a fulfilling life as an LGBTQ person ■   Lack of models for healthy/​fulfilling same-​gender relationships ■ (continued)

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Table 7.1.  Continued 5. LGBTQ Community Stress

  Pressure to be out and proud as an LGBTQ person ■   Oppressive valuing of female femininity and male masculinity ■   Distrust of masculine men or feminine women ■   Body concerns (e.g., rigid body standards, decisions about chest binding, ■ concerns about penis size)   Stereotypes about sexual roles and preferred sexual positions based on ■ age, race, physical characteristics, and gender expression   Distrust of bisexuals and pressure to not label oneself as bisexual ■   Pressure to attain high financial status ■   Oppression within the LGBTQ community, such as ageism, biphobia, ■ classism, Islamophobia, racism, transphobia, and xenophobia   Bias against individuals living with HIV, mental health diagnoses, ■ obesity, a disability, or other health challenges   Pressure to self-​label and fit into a subgroup, like “bears,” “femmes,” or “jocks” ■   Escapism through substances ■   Easy validation and companionship through sex ■   Being told you are not “gay enough,” “lesbian enough,” or “queer enough” ■

6. Institutional Discrimination

Workplace Discrimination   Being discriminated against in a hiring or firing decision ■   Experiencing tokenism in the workplace (e.g., being a representative of ■ all queer women)   Being worried about bringing a partner to work event ■ Health Care Discrimination   Challenges disclosing one’s sexual orientation to a health care provider ■   Feeling judged or stereotyped by health care providers ■   Reading questions on health care forms that exclude or invalidate your ■ sexual orientation or gender identity   Receiving mental health treatment from providers who view your ■ sexual orientation or gender identity as a pathology, phase, or form of confusion Educational Discrimination   Not having openly LGBTQ teachers ■   Receiving inaccurate, non-​inclusive, or homophobic/biphobic/ ■ transphobic sexual health information   Being prohibited or discouraged from publicly expressing affection or ■ attending school dances   Not learning about significant LGBTQ historical figures and events ■ within the school curriculum Religious Discrimination   Being told your sexual orientation or gender identity is a sin, a sign of ■ evil or spiritual weakness, or worthy of punishment   Being prohibited from holding an LGBTQ wedding ceremony within ■ your place of worship   Your religious/​faith institution donating to anti-​LGBTQ causes ■   People of your sexual orientation/​gender identity being prohibited from ■ becoming religious leaders within your place of worship

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Explore How LGBTQ-​Related Stress Relates to Your Client’s Well-​Being The next step is to link the LGBTQ-​related stress experiences that the client identifies as personally relevant to their current emotional distress (e.g., anxiety, depression) and any unhealthy coping behaviors (e.g., disordered eating, risky sex, substance use). Some tips for making these links include: ■ Validating the emotional difficulty of these LGBTQ-​related stress experiences and normalizing their impact on mental health and unhealthy coping. Helping your client determine the function of their unhealthy ■ coping behavior in the context of LGBTQ-​related stress. For example, if they struggle with perfectionism, explore what the function of this might be in terms of coping with LGBTQ-​related stress. Making hypotheses about these links for your client to consider if ■ they have trouble making these links on their own.

Link Past LGBTQ-​Related Stress and Current Emotional Functioning If clients only identify past forms of LGBTQ-​related stress, pay careful attention to the ways that these past experiences may subtly influence the client’s present life. Early LGBTQ-​related stress can lead to lasting feelings of shame. Even if your client’s current emotional distress is not directly related to LGBTQ-​related stress, it may actually have its roots in earlier LGBTQ-​related stress experiences. Some suggestions for exploring this include: ■ Early experiences of peer teasing, exclusion, or feeling different because of being LGBTQ might lead to present expectations of rejection or exclusion, not just around heterosexual/​cisgender people but even around other LGBTQ people, too. Anti-​LGBTQ messages from family, religious communities, or so■ ciety at large may lead LGBTQ people to continue to believe that they are inferior or to demonstrate subtle feelings of inferiority.

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■ Ask your client to identify ways that past LGBTQ-​related stress experiences continue to affect them. If your client is unsure, reassure them that the effects of LGBTQ-​related stress are not always obvious and that you will explore this together during the coming weeks. In summary: This part of the module is about helping your client fully articulate their experiences of LGBTQ-​related stress and helping them to make links between these experiences and their current emotional distress and coping.

Agree on Home Practice Ask your client to complete Worksheet 5.2: LGBTQ-​Related Stress Experiences and Emotions to indicate the impact that current and past LGBTQ-​related stressful situations have had on them. The worksheet, which is available near the end of Chapter 5 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com, asks clients to indicate both the immediate impact of the situation and the ongoing impact, if any, on them today. This worksheet helps facilitate insight into the emotional impact of LGBTQ-​related stress that might continue to impact your client’s experience of emotional disorders today. Worksheet 5.3: Monitoring LGBTQ-​Related Stress—​Understanding Emotion-​Driven Behaviors helps clients become aware of the types of LGBTQ-​related stress that they face on a regular basis. This worksheet, which is also available near the end of Chapter 5 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com, will help the client and you to gain a better understanding of the LGBTQ-​ related stress situations that elicit and maintain the client’s emotional symptoms. ■ Ask the client to record different types of LGBTQ-​related stress that they face (the “Before” column of the worksheet) and to bring this to the next session.

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■ Sometimes, clients find it easier to start with situations and triggers that are not directly related to LGBTQ-​related stress. For the sake of this exercise and building your client’s engagement ■ in treatment, we recommend encouraging clients to track LGBTQ-​ related stress, as well as any other types of identity-​based stress. If the client lists non–​minority-​stress events, see if any of these other ■ events might have their roots in LGBTQ-​related stress. Clients do not need to fill out any column other than the “Before” column of situations and triggers for this week. The purpose of this exercise is to prepare for the next session in which clients will explore any subsequent thoughts, behaviors, and bodily feelings they have experienced in response to LGBTQ-​related stress.

Module 2: Additional Helpful Reference Materials Case Vignettes Case Vignette #1 Working with a 24-​year-​old cisgender gay male client, the therapist is helping the client identify the current LGBTQ-​related stressors that they face. Notice how the therapist validates the client’s experience of stress within the LGBTQ community, which motivated him to provide specific examples of his experiences of LGBTQ community stress. Therapist:  What do you think are some of the common stressors that LGBTQ people face? Client:  I think that the judgment from other gay men is a really big issue in the gay community. Therapist:  Sometimes stress can come from within a community that is supposed to be a source of support. Client:  Exactly. The focus on body, money, and age makes me really uncomfortable. The racial stuff can be tough too. Therapist:  How do you think that these judgments affect your mental health?

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Client:  I worry how I fit in now and also how I’ll fit in 30 years from now. It’s probably not healthy, but I really only meet other men for sex. Therapist:  It sounds like we could spend some time in these sessions thinking of some creative ways for you to access a supportive community. Client:  Yeah, I would like that.

Case Vignette #2 This vignette illustrates working with a 33-​year-​old cisgender bisexual female client who is initially reluctant to acknowledge the relevance of LGBTQ-​related stress on her current emotional difficulties. Notice how the therapist uses a challenge to nudge the client towards acknowledging the salience of her bisexual identity, while also acknowledging that it is only one aspect of who she is. Therapist:  How about you? What stressors do you face as a result of being a bisexual woman? Client:  Things are just so different now, like with queer women and even bisexual characters on TV, and also being able to get married now. LGBTQ people just don’t face the same issues anymore. Therapist:  Being bisexual isn’t stressful to you in any way. Client:  I mean, I used to really worry about what people thought of me and how my parents would react if they found out that I was bi, but that’s all in the past. Therapist:  It sounds like you have shown lots of resilience to some of those earlier stressors and now being bisexual is just one aspect of who you are. Client:  Yeah. I mean, I’d be lying if I said that it’s not an important aspect of who I am, but it’s not everything. Therapist:  You’re a complex person and can’t be reduced to just your sexual orientation. I’m looking forward to learning about those other aspects that are important to you as we continue looking at ways to manage your depression and anxiety.

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Navigating Challenges in Module 2 Responding to Client Discouragement and Despair The primary purpose of this session is to increase awareness of the role that LGBTQ-​related stress plays in LGBTQ people’s mental health and the possibility that their depression and anxiety may have roots in LGBTQ-​related stress. One risk of this conversation is that clients may develop a sense of despair about the pervasive nature of LGBTQ-​related stress or their inability to successfully cope with it. For these clients, therapists should foster a sense of optimism against LGBTQ-​related stress by drawing on clients’ past resilience in the face of LGBTQ-​related stress (e.g., navigating the coming-​out process, acknowledging to oneself that one is LGBTQ) and their membership in a resilient LGBTQ community. This is likely to help clients recognize these personal strengths.

Clients Who Have Difficulty Identifying the Presence and Impact of LGBTQ-​Related Stress Another potential issue that may emerge in this session is that some clients may not readily acknowledge the relevance of LGBTQ-​related stress in their lives, perceiving that LGBTQ-​related stress is a thing of the past or that they were “lucky” compared to many other LGBTQ people. We have found that for these clients, it can be helpful to present to them the list of different LGBTQ-​related stress experiences from Table 7.1 and invite them to consider whether they have ever experienced any of these stressors. With this, many clients will be able to identify the relevance of LGBTQ-​related stress in their lives, even amidst their own good fortune and recent improvements in LGBTQ rights in some parts of the world. Identifying the enduring effects of past LGBTQ-​related stress can be particularly fruitful when working with such clients. For example, LGBTQ people develop an awareness of their sexual orientation in isolation and must decide to whom and how to disclose this information. Presenting examples can normalize the experience of LGBTQ-​related stress and help clients engage in a discussion of the continued relevance of this stress in their own lives. For those clients

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who still indicate that LGBTQ-​related stress is irrelevant for them, your work might include continuing to create a safe place for exploring the possible relevance of LGBTQ-​related stress in later sessions, continuing to formulate a functional analysis considering the possibility that LGBTQ-​related stress may be operating more insidiously in the client’s life, drawing upon the client’s resilience, or drawing upon those aspects of this LGBTQ-​affirmative treatment that address maintaining factors of depression and anxiety outside of LGBTQ-​related stress.

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CHAPTER 8

Module 3: Understanding and Tracking LGBTQ-​ Related Stress and Emotional Experiences

(Corresponds to Chapter 6 of the client workbook) This module focuses on educating your client about the components of emotional experiences and exploring how these emotional experiences may be shaped by LGBTQ-​related stress. Accordingly, you will: ■ Review your client’s home practice, in which they identified emotional triggers related to LGBTQ-​related stress. Introduce the idea that emotions are functional, adaptive responses ■ to LGBTQ-​related stress. Build your client’s understanding of how their past and ongoing ■ LGBTQ-​related stress experiences may impact their emotions using the three-​component model of emotions. Help your client develop greater awareness of their own patterns ■ of emotional responding and explore maintaining factors, such as LGBTQ-​related stress. Invite your client to continue exploring links between past and ■ current LGBTQ-​related stress experiences as well as present mental health concerns and maladaptive behaviors. Help your client to explore any potential barriers to their full emo■ tional expression, such as stereotypes about LGBTQ people and emotions.

Module Agenda Review current symptoms on the Progress Record ■ Review home practice from the prior module ■ Provide an overview of the adaptive nature of emotional responses to ■ LGBTQ-​related stress

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■ Address possible barriers to LGBTQ people’s emotional awareness and expression Present the three-​component model of emotions ■ Introduce the sequence of emotions model (Before, During, ■ and After) Discuss learned emotional responses ■ Agree on home practice ■

Recommended Number of Sessions We recommend spending one or two sessions on this module. If you divide the module into multiple sessions, each session should begin with reviewing symptoms on the Progress Record and reviewing home practice from the prior session. All sessions end with agreement on home practice. We recommend the following split if this module is delivered across multiple sessions: ■ Session 1: Focus more on the psychoeducational aspects of the module and some initial personal examples. Session 2: Go into more detail reviewing personal examples of the ■ client’s sequence of emotions.

Materials Needed Progress monitoring assessments (i.e., ODSIS, OASIS) ■ Progress Record ■ Worksheet 6.1: Three-​Component Model of Emotions, located in ■ client workbook Chapter 6 Worksheet 6.2: Monitoring LGBTQ-​Related Stress, located in client ■ workbook Chapter 6 Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. 112

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■ The Progress Record is located at the end of Chapter 3 in the client workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be downloaded by searching ■ for this book’s title on the Oxford Academic platform at academic. oup.com.

Review Current Symptoms on the Progress Record Continue using the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session, based on the assessments that they complete before the session (i.e., ODSIS, OASIS). ■ Highlight any positive change and explore your client’s perceptions regarding the source of this change. If you see a bump in symptoms, explore this with your client, ■ reminding them that progress in therapy is not linear. Use the Progress Record review as an opportunity to see what you ■ might need to focus on in today’s session, to determine if any shifts in treatment focus may be needed, or to generally check in with your client about how they feel that treatment is going.

Review Home Practice from the Prior Module For home practice, your client tracked emotional triggers related to LGBTQ-​related stress, using Worksheet 5.3: Monitoring LGBTQ-​Related Stress—​Understanding Emotion-​Driven Behaviors. ■ Explore with your client what types of triggers they may have faced in the past week. Validate your client’s experiences and let them know that you will ■ further explore how these experiences contribute to their emotional responses and patterns during today’s session. Use your client’s examples as much as possible throughout the ses■ sion to highlight the relevance of LGBTQ-​related stress to their emotional experiences. 113

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■ Troubleshoot if your client did not complete the home practice. Examine what got in the way of completing the home practice, using motivational interviewing to resolve ambivalence about engaging in future home practice between sessions. Invite your client to reflect on the week and consider completing the home practice in session together.

Provide an Overview of the Adaptive Nature of Emotional Responses to LGBTQ-​Related Stress A core principle of this treatment is that emotions, even though they can be uncomfortable or hard to deal with, especially when strong, are actually functional and adaptive. This includes emotions that occur in response to LGBTQ-​related stress. The following are some key points to highlight related to this core principle.

All Emotions Are Adaptive and Functional All emotions serve some purpose in our lives. Emotions provide us with information about what is going on around us, enabling us to navigate our world and motivating us to do things that help us survive.

It Is Common, But Unhelpful, to Want to “Stop” Certain Emotions ■ A lot of the time, clients seek out mental health treatment because they feel like their emotions are overwhelming, and they would like their therapist to “take away” their negative emotions or “shut off the switch” for intense emotions. The reality is that emotions are not necessarily bad or dangerous, ■ even though they can sometimes feel that way. There are times when adaptive emotions can become maladaptive, ■ but that will be discussed later in treatment. For now, the main point is that all emotions, no matter how uncomfortable they might be, serve a function.

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Emotions Alert Us to Act Drawing on the examples the client provided in home practice, explain that one important function of emotions is to alert us to external or internal events or situations, and prompt us to do something in response to the alert. This response can become automatic: We feel an emotion and it automatically directs us to respond with a specific action. These automatic responses are hard to resist or change because they are so well learned. Table 8.1 provides discussion prompts and examples to help explore the adaptive function of emotions in your client’s life.

Emotional Responses to LGBTQ-​Related Stress Are Normal, Functional, and Adaptive Explain the function of emotional responses to LGBTQ-​related stress. For example: ■ Just like other kinds of emotional reactions, emotional responses to LGBTQ-​related stress also serve a helpful purpose. For example, if you feel angry about someone making anti-​LGBTQ ■ comments, you might feel motivated to act, by either leaving the situation or getting the energy to stand up against these comments. Or you might be reminded that your values do not align with this person’s, allowing you to privately reject their comments. Table 8.1.  Eliciting the Adaptive Function of Emotions in Your Client’s Life Discussion prompts:

  How has feeling _​_​_​_​_​_​_​_​_​ helped you in your life?

■

  What helpful information could feeling _​_​_​_​_​_​_​_​_​_​ clue you in to?

■

Emotions to explore:

  Positive: joy, happiness, excitement ■   Negative: fear, anxiety, depression, anger ■

Example:

  Trigger: Someone threatens you ■   Emotional response: Fear and anxiety ■   Adaptive response: Leaving the situation so that you can’t be ■ harmed

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Although the many possible responses to a situation can feel overwhelming, later modules continue to help the client differentiate helpful versus unhelpful responses. For now, the goal is to help your client appreciate that all emotions are normal and functional. In summary: Work with your client to explore the ways in which all emotions have a functional and adaptive purpose, even if these emotions might be uncomfortable to experience.

Address Possible Barriers to LGBTQ People’s Emotional Awareness and Expression LGBTQ people face unique barriers to being fully aware of their emotions or expressing their emotions to others. It may be useful to explore these barriers with your client and assess whether these barriers apply to their experiences. The potential barriers in Box 8.1 might be discussed.

Discuss How LGBTQ-​Related Stress Affects the Degree to Which LGBTQ People Experience and Express Their Emotions The following language can help you discuss the material presented in Box 8.1 with your client: ■ Next, we’re going to talk about “experiencing and expressing emotions.” Is it OK if I tell you a little bit about what I mean by that? Experiencing and expressing emotions means fully feeling your emotions, being aware of them when they are happening, and sharing your emotional experiences. Could you tell me about a time when you fully experienced and expressed ■ a strong emotion? (Validate client’s experience.) What about a time when you pushed down or held in your emotions? ■ (Validate client’s experience.) Research has shown that LGBTQ people actually don’t experience or ex■ press their emotions as frequently as their heterosexual/​cisgender peers. Based on what we’ve talked about so far and your own experiences, why do you think that may be? (Explore with your client some of the examples presented in Box 8.1 that may be particularly relevant to their lives.)

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Box 8.1. LGBTQ-​Related Stress and Experiencing/​Expressing Emotions

Starting from an early age, LGBTQ people tend to have more difficulty being aware of or expressing emotions compared to heterosexual/​cisgender people (Hatzenbuehler et al., 2008; Szymanski & Kashubeck-​West, 2008; Timmins et al., 2018). Lack of emotional awareness and expression among LGBTQ people seems to be linked to the higher rates of depression and anxiety. Although research has not fully explained why LGBTQ people might have trouble experiencing and expressing their emotions, there are a few possibilities that may be worth exploring: ■ Early awareness of being attracted to the same gender can be anxiety-​provoking. One strategy that young people might use to deal with this anxiety is to push down or ignore their feelings of being attracted to people of the same gender. This might have short-​term benefits of feeling less anxious and gaining peer acceptance, but in the long run it could lead to a pattern of not fully experiencing or expressing one’s emotions. Chronic intense emotions and stress related to navigating LGBTQ-​related stress could ■ lead to holding in these emotions due to the difficulty of managing this excess stress. This could lead to a broader pattern of not fully experiencing or expressing one’s emotions. Childhood sexual abuse, which sexual minority youth are more likely to experience ■ compared to their heterosexual peers, may also impact emotional awareness and expression. Relatedly, gender non-​conformity in childhood is associated with greater likelihood of being a target of childhood sexual abuse (Roberts et al., 2012). For clients who report childhood sexual abuse, it is possible that this experience could exacerbate feelings of difference and added feelings of confusion and/​or shame to the challenging emotions surrounding early awareness of their sexual orientation and/​or gender identity. Stereotypes of LGBTQ people may also lead to not fully experiencing or expressing ■ one’s emotions. For example, gay and bisexual men are often depicted as overly emotional. Emotions themselves are often portrayed as “feminine” or a sign of weakness, especially for men. Thus, some LGBTQ clients might push down or hold in their emotions to avoid confirming these inaccurate stereotypes.

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What Happens When People Don’t Experience or Express Their Emotions Over a Long Period of Time? Discuss the following points to help your client see what can happen as emotions are held in or pushed down over long periods of time: ■ Holding emotions in and trying to push them down may have been helpful in some early situations, but this avoidance usually backfires if someone does this too much in the long term to cope with their emotions. What’s an example of a time when holding back or pushing emotions ■ down backfired for you? One of the most important things we want to emphasize in this treat■ ment is that those emotions are actually safe to experience. It might even be helpful to experience those emotions in stressful situations. The tricky thing is that in order to find out that your strong emotions ■ are safe and helpful, you have to let yourself feel them fully, instead of pushing them down or holding them in. You’ll learn how to do that during this treatment, starting with the skills ■ that we’re going to focus on today and next week.

An Essential Part of This Treatment Is to Fully Experience Emotions Through the exercises in this treatment, your client will have the opportunity to fully experience their emotions and understand the LGBTQ-​ related stress triggers for these emotions. ■ This might be challenging or uncomfortable at times, but, ultimately, experiencing (instead of avoiding) emotions is the only way to learn one’s own capacity for tolerating strong emotions and discovering that these emotions are not dangerous, wrong, or bad. Fully expressing emotions is helpful because it will allow your client ■ the opportunity to try out new, healthy behaviors for responding to difficult situations. In summary: Explore with your client the unique barriers that LGBTQ people sometimes face in being aware of and expressing emotions, and the potential downsides of holding in or pushing down emotions.

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Present the Three-​Component Model of Emotions Cognitive-​behavioral therapy conceptualizes emotions as being made up of cognitive, behavioral, and physiological (bodily) components. Below are some discussion points to review with your client that will help educate them about the three components of emotions.

Storms of Emotion Clients often feel like their emotions feel unpredictable and overwhelming, like storms of emotions that are hard to define and feel as though they come out of nowhere. It might, understandably, feel like the only way of coping is to push away these emotions. Experiencing emotions in this manner also makes it harder to: 1 . Decipher what information our emotions are trying to give us. 2. Understand the impact of LGBTQ-​related stress and other triggers on mental health. 3. Identify healthier and more adaptive ways of responding to LGBTQ-​ related stress and other triggers.

Emotions Are Made Up of Three Components Introduce the three-​component model of emotions with something like this: ■ In this treatment, we think of emotions as made up of three parts: what we think, what we do, and what we physically feel (the sensations in our bodies). Thinking about emotions in this way and breaking down your emo■ tional experiences into these three parts can help to make emotions feel less overwhelming.

Introduce Worksheet 6.1: Three-​Component Model of Emotions Take out Worksheet 6.1: Three-​Component Model of Emotions to help your client understand how it applies to their life. This worksheet is

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available near the end of Chapter 6 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. We have found it helpful to first provide psychoeducation about each component, and then ask the client for examples from their own life. Box 6.1 in the client workbook contains an example of a completed Three-​Component Model of Emotions worksheet to guide your client in completing this worksheet. As described in the workbook, this completed example accompanies the vignette of a person named Ari who experiences anxiety in most situations in his life. For home practice, your client identified examples of times when they experienced LGBTQ-​related stress triggers. Use these examples to begin this discussion: From your home practice, you identified several examples of LGBTQ-​related stress. Today, we’ll practice exploring different parts of the emotional experience that you felt in response to each LGBTQ-​related stress experience using this worksheet, which we call the “three-​component model of emotions.”

Review Each of the Three Components of Emotions Below are each of the components and recommended exploratory questions (examples are provided in Table 8.2).

1. Cognitive Component ■ This part of emotions is made up of the thoughts that get triggered by an event. This includes thoughts about ourselves, other people, and the world. ■ We tend to have different kinds of thoughts depending on our emo■ tional state. Try asking questions like: ■ In the past week, think of a time when you felt the worst, emotionally. Picture where you were and what you were doing. Now, what was going through your head at that time? What types of thoughts do you notice when you feel [depressed/​low/​anxious]? ■

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Table 8.2.  Examples of the Three-​Component Model Related to Common Emotions Emotion

Thought

Behavior

Bodily Feeling

Depressed

There’s no use; I’m going to fail at this.

Stay home, don’t try, maybe stay in bed.

Fatigue, heavy/​weighed down, moving slower

Anxious

Everyone is going to laugh at me.

Tell a self-​deprecating joke. Avoid a situation or stay home.

Heart racing, sweating, nauseous, muscle tension

Excited

This is going to be fun!

Get ready to go on a date (without overpreparing).

Heart beating faster, moving around more

Happy

I really like hanging out Enjoy social plans with with my friends. friends.

Energized, physically calm, at ease

2. Behavioral Component ■ This part of emotions includes behaviors that you engage in, or feel the urge to engage in, while in a given emotional state. Behaviors that occur automatically in response to emotions, as ■ mentioned earlier, are called “emotional behaviors.” This component can also include behaviors that you do not engage in. ■ Try asking questions like: ■ When you felt especially triggered or upset in the past week, what kinds of behaviors did you do or feel like doing? What about things you didn’t do or feel like doing? What about things you don’t do when you’re feeling _​_​_​_​_​_​_​_​_​_​? ■

3. Physiological (Bodily) Component ■ This part of emotions is about the bodily sensations that you have when you are in different emotional states. You can have similar bodily sensations that happen during dif■ ferent emotions. For example, Table 8.2 shows that there are some overlapping bodily feelings between anxiety and excitement.

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Try asking questions like: In the past week when you felt very upset, what did you feel in your body? ■ What bodily sensations happen when you feel _​_​_​_​_​? ■

The Three Components Interact with One Another Thoughts, behaviors, and bodily feelings do not happen in isolation; they feed into one another and are mutually reinforcing. Elaborating on Table 8.2, we present some examples of this cycle.

Example 1: A Depressed Mood State ■ If your client is already in a depressed mood, seeing themselves as a failure and feeling weighed down and fatigued, they might decide not to get out of bed that day, leading them to miss work and watch TV all day. This can lead to negative consequences, like getting a warning from ■ their boss about too many absences from work. This might reinforce the idea that they are a failure. ■ Feeling like a failure and fearful of getting further proof of this, they ■ might quit their job to avoid being fired. Or, after multiple absences, they may get fired. Now without a job, the person might then have even less energy and ■ feel more depressed due to not engaging in pleasurable or mastery activities.

Example 2: A Happy Mood State ■ In contrast, your client might recall times when they were in a happy mood, and so they had a positive outlook on their day. With their energy and positive outlook for the day, they decided to ■ follow through on their social plans, and then fully enjoyed themselves with friends. This may lead to making further social plans; reinforcing their pos■ itive view of themselves, others, and the future; as well as increasing their energy for other activities. 122

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You can also use Worksheet 6.1: Three-​Component Model of Emotions to have your client explore how their thoughts, behaviors, and bodily feelings interact with one another. This worksheet is available near the end of Chapter 6 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Figures 8.1 and 8.2 at the end of this module in the therapist guide provide completed examples of the Three-​Component Model of Emotions as a guide for helping your client complete Worksheet 6.1. In summary: Explain that emotional experiences are made up of three main parts: thoughts, behaviors, and bodily feelings. Invite your client to share examples from their own life.

Introduce the Sequence of Emotions Model (Before, During, and After) The sequence of emotions has three overarching segments: 1. The Before segment refers to triggering situations or interactions. 2. These events trigger our emotional responses (the thoughts, behaviors, and bodily feelings just discussed), which we refer to as the During segment. 3. Finally, the After segment reminds us that these emotional responses have consequences. We refer to this trajectory (Before/​During/​After) as the sequence of emotions model. We recommend taking out Worksheet 5.3: Monitoring LGBTQ-​Related Stress—​Understanding Emotion-​Driven Behaviors, which the client began to fill out for home practice, as you explain and explore the sequence of emotions. Here are some suggested discussion points.

The Sequence of Emotions If we zoom out, we can see that the three-​component model of emotions fits within a larger sequence of emotions: ■ Before (what triggers the emotional response) 123

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■ During (thoughts, behaviors, and bodily feelings that accompany the emotional response) After (consequences of the particular response) ■ Next, we’re going to go through each part of the sequence of emotions. We’ll use your home practice to identify each part of the sequence of emotions.

Before Emotional responses do not come out of nowhere, though it can feel like they do. There is always a “triggering event” that causes us to have an emotional reaction. It can be hard to figure out what triggers us, but with practice it gets easier. (Different types of triggering events are described in Table 8.3.)

Table 8.3.  Types of Emotion Triggers

Event

Proximal triggers

Event

Distal triggers

Intrusive thought Trauma

Intrusive

thought

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■  Something that just happened and led to an immediate emotional response.   Example: Catching your reflection in the mirror (and ■ immediately responding with self-​criticism and checking behaviors related to appearance). ■  Something that happened earlier in the day, or even earlier than that (last week) that is now triggering an emotional response.   Example: Hearing colleagues joking about LGBTQ people ■ in the morning (which can lead to difficulty concentrating on a work call later in the day) ■  Sometimes traumatic experiences can lead to intrusive thoughts related to the trauma.   Those intrusive thoughts can trigger an emotional ■ response.   Example: Being reminded of a prior sexual assault when ■ in a similar location to where the actual assault occurred (which can produce a strong emotional response to this traumatic memory).

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To explore your client’s triggering situations, try questions like: ■ What stressful situations or “triggers” did you experience this past week? (Review from their home practice.) Which of these triggers led to an immediate emotional response? In other ■ words, when it happened, you immediately felt a strong emotion in response. Which of these triggers impacted you later on, after the event ■ happened?

During The During segment refers to the three-​component model of emotions that we just discussed. It includes the thoughts, behaviors, and bodily feelings that occur after the Before segment (or “trigger”). Explore your client’s responses (i.e., the During segment) to the LGBTQ-​related stress triggers they identified for home practice with questions like: ■ What thoughts were running through your head after that happened? About yourself? The other person? What behaviors happened in response to that event? What about ■ behaviors you felt the urge to engage in? Behaviors that you avoided or felt the urge not to do? What bodily sensations did that experience trigger? ■

After The After segment is what happened as a consequence of the response. Often, there are both short-​and long-​term consequences. We’ll look at both of these today and throughout this treatment. Short-​ term consequences of emotional responses are often negatively reinforcing. Negative reinforcement means taking away the discomfort that was caused by the trigger. When we learn that if we engage in a certain response, it takes away discomfort, we are generally more likely to engage in

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that same response again in the future when we face the same or a similar situation. ■ Example 1: Leaving a party with many heterosexual/​cisgender people early due to a great deal of social anxiety leads to the short-​term consequence of an immediate reduction in anxiety. Example 2: Using substances to facilitate intimacy during sex for ■ someone who feels shame about being sexual with someone of the same gender has the short-​term consequence of reducing the shame and anxiety. The long-​term consequences of the response often differ from the short-​term consequences and, in fact, may be the root of the client’s emotional distress. ■ Example 1: Leaving parties early can lead to a longstanding pattern of leaving any social gathering early (or not going at all) to avoid social anxiety altogether, ultimately leading to feeling isolated, lonely, and depressed. Example 2: Using substances to reduce shame during sex prevents ■ emotional connections and may reinforce the shame associated with sex. Explore the consequences with questions like: What happened next? ■ In the short term, what were the effects of this response? What about in ■ the long run? What would happen/​did happen if/​when this response became chronic or ■ inflexible (e.g., you always did this in response to feeling _​_​_​_​)?

The Sequence of Emotions and LGBTQ-​Related Stress As you introduce the sequence of emotions, it is important to review the impact of LGBTQ-​related stress on the sequence of emotions. Table 8.4 provides examples of several situations relevant to LGBTQ-​related stress that trigger subsequent emotional responses and consequences.

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Table 8.4.  Sequence of Emotions and LGBTQ-​Related Stress Before

During

Situation, Triggers

Thought Response

Not being out to family

Behavioral Response

After Bodily Feeling

What Happened Next?

Anxiety Not related to visiting family finding family out sexual orientation

Physical tension, nausea, jittery

Short term: Temporary reduction of anxiety

Feeling inferior or rejectable as an LGBTQ person

Depressed, lonely, worthless

Seeking sexual validation

Weighed Short term: Temporarily feeling down, empty worthy and validated

Feeling self-​ conscious in LGBTQ spaces

Anxious, expecting rejection

Heavy Jittery, tense, Short term: Temporarily feeling alcohol use sweaty palms relaxed

Long term: Avoidance response is strengthened and more likely in the future; reduced contact with family

Long term: Feeling compelled to seek sex whenever thinking of self as inferior or rejected

Long term: Feeling compelled to drink in all LGBTQ social spaces

Monitor the Sequence of Emotions It is helpful for clients to pay close attention to the sequence of their emotions. Understanding this sequence leads to increased emotional awareness. Becoming aware of the sequence of emotions also lays the groundwork for responding more adaptively when triggered, which will be important in later modules.

Awareness Versus Behavior Change ■ At this point in treatment, the most important thing is that the client is beginning to build awareness about the contexts in which

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their emotions arise, including LGBTQ-​related stress contexts; the nature of their emotional responses; and the consequences of their responses. ■ Later modules will introduce skills for trying out alternative, adaptive responses to LGBTQ-​related stress. Therefore, it is important to build emotional awareness early in treatment. To make this point clear, you might say something like: The goal for now is just to be aware of your triggers, emotional responses, and the consequences of these responses in your life. Awareness is the first step towards being able to make changes, which we will work on in future sessions. In summary: Work with your client to build an understanding of the context, including the LGBTQ-​related stress context, of their emotions, the nature of their emotions, and the short-​and long-​term consequences of their responses.

Discuss Learned Emotional Responses When expanding on the “After” segment of the sequence of emotions, it is also important to consider the concept of “learned emotional responses.” Here, we present some key points regarding learned emotional responses.

What Are Learned Behaviors? Learned behaviors are those behaviors that we repeat again and again because they have worked in the past to manage, suppress, or reduce uncomfortable emotions. Learned behaviors might include: Repeating behaviors that make us feel good ■ Avoiding behaviors or situations that make us feel bad ■ Try asking: What are some of examples of these from your own life? ■

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Adaptive (Helpful) Versus Maladaptive (Unhelpful) Learned Behaviors It is adaptive (helpful) that we are able to learn from our experiences. The problem occurs when learned behavior becomes maladaptive (unhelpful) in the client’s current situation. These behaviors may have been very helpful (adaptive) when they originally developed but have outlived their purpose and may now interfere with the client’s goals or contribute to depression, anxiety, or stressful behavioral patterns. An easy example to relate to is as follows: ■ It is adaptive or helpful that we learn not to touch a hot stove after experiencing pain after touching a hot stove. It would be maladaptive or unhelpful if, because of this prior ex■ perience, we no longer feel comfortable cooking or entering a kitchen because we want to avoid the potential pain of touching a hot stove. The relevance of adaptive versus maladaptive learned behaviors to LGBTQ-​related stress becomes clear in other examples: ■ It is adaptive or helpful to hide your sexual orientation if the threat of family rejection and peer bullying is high, such as when you are young. It would be maladaptive or unhelpful to continue to hide your sexual ■ orientation when the threat of rejection is low or when doing so is more likely to cause negative feelings (e.g., shame, feeling removed from oneself ) than positive ones (e.g., authenticity).

Explore Adaptive Versus Maladaptive Learned Behaviors in Your Client’s Life Try exploring the adaptive versus maladaptive learned behaviors from your client’s life with the following questions: ■ What are some examples of behaviors that you learned to engage in because they assisted you in staying safe or protected you in some way while growing up as an LGBTQ person?

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■ Which of these do you still engage in that may have outlived their purpose or might be unhelpful in the context of your current life as an adult? Are there any examples from Table 8.5 (examples of learned behaviors ■ related to LGBTQ-​related stress) that particularly resonate with you or remind you of other examples from your life?

Table 8.5.  Examples of Learned Behaviors Related to LGBTQ-​Related Stress Learned Behavior

Original Adaptive (Helpful) Function

Current Maladaptive (Unhelpful) Function

Avoiding heterosexual/​ cisgender people, even those who may be affirming and safe

Avoidance protected against discrimination and harm from heterosexual people who were, in fact, harmful.

Avoidance leads to social isolation and missed opportunities to receive support and social connection.

Avoiding committing to LGBTQ friendships after learning from early attachments that expressions of platonic intimacy (e.g., friendships), especially with people of the same gender, lead to rejection

Avoiding peers of the same gender might have protected against experiences of shameful rejection.

Avoidance leads to social isolation and missed opportunities to receive support and build community bonds and personal pride.

Avoiding genuine self-​ expression as an adult to avoid rejection after learning as a child that self-​expression led to bullying from peers or rejection from family

As a child, it might have been Chronic self-​silencing can unsafe to be fully self-​expressive. lead to social isolation, There may have been real risks, anxiety, and unassertiveness. such as social exclusion from peers or being kicked out of the home by one’s parents.

Pushing down unpleasant emotions because the pain of emotional discomfort in the past was overwhelming and intolerable

Before developing healthy coping skills, confronting emotional discomfort might have been overwhelming. In the short term, pushing down emotions was a viable alternative.

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Always pushing down emotions can lead to a variety of negative long-​term outcomes, including physical tension, psychological anxiety, and difficulty expressing one’s needs or feelings to trusted others.

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Avoiding What Might Make Us Feel Bad Sometimes, our behaviors become overlearned. We even avoid things that might make us feel bad, which is often maladaptive (unhelpful). Here are some common examples that often resonate with clients: ■ Large social gatherings of other LGBTQ people make a person anxious, so now they avoid going to these social gatherings altogether. A person does not want to experience rejection on a date, so they ■ stop trying to go on dates with people who they perceive could reject them.

Vicious Cycles of Triggers and Learned Behaviors Engaging in overlearned, inflexible behaviors whenever triggered contributes to a vicious cycle in which the behavior becomes automatic and increasingly counterproductive and insensitive to the current context. This means that there are fewer and fewer opportunities to learn new information about oneself and one’s environment because the learned behavior is so restrictive. Learned behaviors that are overgeneralized can prevent learning things like: ■ There may be heterosexual/​ cisgender people who are safe and affirming. There may be situations where it is safe to be fully self-​expressive as ■ an LGBTQ person. Coming out to family may lead to self-​satisfaction or even affirma■ tion from family. There may be opportunities to form genuine, non-​sexual relationships ■ with other LGBTQ people that could be helpful for navigating feelings of low self-​worth. Even if some of these situations do lead to rejection or judgment from ■ others, engaging in valued behaviors (e.g., genuine self-​expression) despite others’ rejection or judgment may lead to the realization that the person can cope.

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In summary: It is important that in this module, clients leave with a good understanding of the downsides of avoiding uncomfortable emotions. This understanding will help to build motivation to engage in behavior change in future modules.

Agree on Home Practice It is important for your client to track their emotional experiences on their own because this will foster increased awareness and create opportunities in future modules to try out non-​avoidant, more adaptive responses to LGBTQ-​related stress. Use Worksheet 6.2: Monitoring LGBTQ-​ Related Stress to track emotional experiences. This worksheet is available near the end of Chapter 6 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. ■ Worksheet 6.2 builds on the last module’s home practice, in which your client tracked the “Before” segment of their sequences of emotions (i.e., their LGBTQ-​related stress triggers). Your client can use Worksheet 6.2 to continue building their un■ derstanding of how LGBTQ-​related stress situations both elicit and maintain their emotional symptoms. Ask your client to record emotional triggers and the three components ■ of emotion (i.e., the subsequent thoughts, behaviors, and bodily feelings they experience). Clients can also note short-​and long-​term consequences of their ■ responses to emotionally distressing situations or events. Keep tracking with Worksheet 6.2: Monitoring LGBTQ-​Related Stress across multiple sessions. Since this module is recommended to take place over two or more sessions, we suggest continuing to use Worksheet 6.2 for home practice following each session. The more practice the client has with this, the more prepared they will be to fully engage in subsequent sessions.

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Module 3: Additional Helpful Reference Materials Case Vignettes Case Vignette #1 Working with a 35-​year-​old lesbian client, the therapist is helping the client to identify the triggers for their daily anxiety. Notice how the therapist facilitates the client’s own recognition of the way that LGBTQ-​ related stress may be related to their emotional experiences. By the end of this interaction, the client is able to identify a more distal trigger for their anxiety and connect this back to its root in LGBTQ-​related stress. Therapist: So for you, a daily emotional experience that you go through is feeling pretty anxious and worried that other people are judging you, or that you’ll be “caught” doing something wrong. Client:  Exactly, and it’s really unbearable and it just feels like it’s always been there. I get what you’re saying about there being triggers for emotions, but to me it just seems like this is just part of who I am. Therapist:  I hear that. It can be pretty tricky figuring out what the triggering situation was, so let’s try to practice together. Client:  OK, that sounds good. Therapist:  You were telling me last time that when you were growing up, you felt like you were getting an “F” in one area of your life because of being gay, so it felt like you had to get an “A” in all the other areas of your life to even this out. Client:  Right. I mean, I know now that being gay doesn’t mean a failing grade, but still, being gay has always just felt like the one thing that people can judge me on, so I try to always make sure that I can’t be judged for anything else. Therapist: Got it. So what’s that like for you to have to avoiding other people’s judgment every day? Client: Well, it’s incredibly stressful. Like, every time I check my email, I’m afraid that I’m going to get an email saying that I messed something up at work. My friends make fun of me because I’m always asking them if they are mad at me, when there’s no reason for them to be mad.

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Therapist:  That must be really difficult and anxiety-​provoking. Client:  It really is. Therapist:  So, this past week, you woke up feeling really anxious one morning, so much that it was hard to focus on your work. Tell me more about what was going on that morning. Client:  It turned out to be nothing, but I got this super vague text from my mom asking if we could talk. When I saw it, I just panicked, because I felt like she was probably upset with me or I had done something wrong. Therapist:  And then what? Client:  I couldn’t relax until I knew why she said that. Therapist:  So, this was the Before segment, or trigger, for that anxious feeling you had, and this trigger could have been connected in a big way to those constant messages you got growing up that it wasn’t OK to be gay. Client:  That sounds about right. So maybe there are actually some triggers for my anxiety.

Case Vignette #2 Working with a 30-​year-​old queer client with longstanding depression, the therapist is working with the client to explore the sequence of their emotions. Notice how the therapist helps the client identify the Before, During, and After segments, including the short-​and long-​term consequences of the situation. The therapist also validates and explores the client’s emotional experience by asking about the function of their emotions within the situation, highlighting that emotions, while painful, are valid and helpful. Therapist:  Tell me some more about this trigger that you experienced on Saturday night. Client:  Well, I had been feeling pretty depressed all week, but I managed to get the energy to go to a club that I go to with my friends sometimes. I wanted to go because the last time that I went, I met this guy who I danced with all night and I wanted to see him again. Therapist:  How was it once you got there?

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Client:  At first, I felt better, not so depressed, because I was happy to be with my friends, and I was hopeful that I would see this guy again. But then he never showed up, even though he said he goes there every weekend. Therapist:  So that was the trigger? Client:  Right. I just felt awful once I realized he wasn’t going to be there. I felt like a loser for even thinking he would be there, or that he would be interested in someone like me. I ended up drinking way too much and hooking up with a guy who I wasn’t even really attracted to, basically to feel better. Therapist:  Thinking that you’re a loser, that he wouldn’t like someone like you: Those were the thoughts that got triggered from him not being there. And then that led to hooking up with someone who you weren’t interested in to feel better. Client:  Yup, and then of course I felt even worse the next day. Therapist:  Okay, so in the short term, drinking and hooking up with someone made you feel better, but in the long term, it didn’t help that much. Client: Exactly. Therapist:  What do you think might have been the helpful function of feeling sad, down, or disappointed that he didn’t make it out that night? Client:  What do you mean? It was a terrible feeling! I wish it hadn’t happened. Therapist:  Of course, it can be really uncomfortable and painful to go through those emotions. What information do you think your emotions were trying to tell you? Client:  Maybe that I really just want to be in a relationship. Therapist:  OK, so in this situation, you felt triggered by the situation, and that led to thinking some pretty negative things about yourself and engaging in some behaviors to cope that worked in the short term but had some downsides in the long term. But at its very core, feeling sad actually clued you in to some really important information about one of your needs right now: to be close with someone who you like. Client:  That’s true. I hadn’t really thought about it that way.

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Navigating Challenges in Module 3 Exploring the Adaptive Nature of Negative Emotions Some clients may have a hard time seeing how painful, overwhelming, negative emotions could serve an adaptive function. They might also not be able to think of examples of the adaptive nature of negative emotions in their own lives. To the extent possible, try to facilitate this understanding by reflecting back examples of the function of their emotions from Modules 1 and 2.

Difficulty Identifying Emotional Triggers Some clients, especially those who have dealt with chronic depression or anxiety, might feel that there are not clear triggers for their emotional responses. In this case, it is helpful to bring in concrete examples from the client’s own life to illustrate the concept of triggering events (i.e., the Before segment). You can even walk your client through the hours or days leading up to a depressive or anxious experience to try to identify a trigger that may be more distal. Working backward is often a helpful way of determining what the trigger was.

Difficulty Identifying Consequences As with the difficulty identifying triggers, clients may have difficulty fully exploring the consequences in the sequence of emotions. To assess the short-​term consequence, you might say to the client, “OK, so following the module we have been talking about, avoiding the party is the ‘behavioral response.’ What did you feel after you engaged in that behavioral response?” Often, clients will say that they felt relieved or better. This is the short-​term consequence: Engaging in the learned behavior led to the client feeling better in the short term. It makes sense, then, that the client would repeat this behavior again in a similar situation. To assess the long-​term consequence, you might ask the client, “What would happen if you always responded to this kind of trigger in this way?” This often elicits more information about the negative, long-​term consequences, from the client’s own perspective.

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Bodily Feelings (What I’m Feeling in My Body)

Tense, tight in my shoulders; pit in my stomach.

What if she rejects me? I’m not attractive.

Thoughts (What I’m Thinking)

Drink to escape the pain. Drink to feel more comfortable having sex.

Behaviors (What I’m Doing)

Figure 8.1. Three-​Component Model of Emotions Worksheet (Example 1)

1. Cognitive (What I Think): These are the thoughts often triggered by or linked with feeling states. 2. Behavioral (What I Do): These are actions a person engages in or has the urge to engage in as a response to the feeling state. Often, someone will respond to a feeling without thinking about it. This is because it seems like our bodies just “know” the best way to deal with these situations. As noted above, these are learned behaviors. 3. Bodily Feelings (How I Feel in My Body): These are the bodily feelings attached to emotional states.

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Bodily Feelings (What I’m Feeling in My Body)

Pressure all around me. Jaw clenched.

I have to be successful to be accepted or loved.

Thoughts (What I’m Thinking)

Avoid interpersonal relationships. Overly focus on school and work performance.

Behaviors (What I’m Doing)

Figure 8.2. Three-​Component Model of Emotions Worksheet (Example 2)

1. Cognitive (What I Think): These are the thoughts often triggered by or linked with feeling states. 2. Behavioral (What I Do): These are actions a person engages in or has the urge to engage in as a response to the feeling state. Often, someone will respond to a feeling without thinking about it. This is because it seems like our bodies just “know” the best way to deal with these situations. As noted above, these are learned behaviors. 3. Bodily Feelings (How I Feel in My Body): These are the bodily feelings attached to emotional states.

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CHAPTER 9

Module 4: Increasing Mindful Awareness of LGBTQ-​Related Stress Reactions

(Corresponds to Chapter 7 of the client workbook) This module is designed to help your client further understand the ways that LGBTQ-​related stress may shape their emotional experience. Accordingly, you will: ■ Explore your client’s home practice, in which they were asked to break down their emotional experiences into three components and track their experiences of LGBTQ-​related stress. Introduce a new skill to help your client engage with unpleasant ■ emotions generated by LGBTQ-​related stress: present-​focused, nonjudgmental awareness, also called mindfulness. Have the client engage in several in-​session mindfulness exercises. ■ Help the client accurately describe their emotional reaction to ■ LGBTQ-​related stress using mindful, present-​focused terms.

Module Agenda Review current symptoms on the Progress Record ■ Review home practice from the prior module ■ Provide the rationale for mindfulness in the context of LGBTQ-​ ■ related stress Introduce the skill of nonjudgmental emotion awareness ■ Introduce the skill of present-​focused emotion awareness ■ Conduct in-​session emotion awareness exercise ■ Conduct in-​session mood induction exercise ■ Agree on home practice ■

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Recommended Number of Sessions This module is intended to be delivered across two or three sessions to provide sufficient time for the client to adequately explore and practice key concepts. For example, you might divide the module content as follows: ■ Session 1: Provide psychoeducation about judging one’s emotions, present-​ focused emotion awareness, and how these correspond to LGBTQ-​related stress reactions; complete in-​session practice of mindfulness grounded in present-​focused, nonjudgmental emotion awareness Sessions 2 and 3: Explore strategies for anchoring in the present; ■ complete in-​session practice of mindfulness in the context of an emotion-​induction exercise

Materials Needed Progress monitoring assessments (i.e., ODSIS, OASIS) ■ Progress Record ■ Worksheet 7.1: Nonjudgmental, Present-​ ■ Focused Emotion Awareness, located in client workbook Chapter 7 Worksheet 7.2: Anchoring in the Present, located in client work■ book Chapter 7 Worksheet 7.3: Mood Induction Recording, located in client work■ book Chapter 7 Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The Progress Record is located at the end of Chapter 3 in the client ■ workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be downloaded by searching ■ for this book’s title on the Oxford Academic platform at academic. oup.com.

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Review Current Symptoms on the Progress Record Continue using the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session, based on the assessments that they complete before the session (i.e., ODSIS, OASIS). ■ Highlight any positive change and explore your client’s perceptions regarding the source of this change. If you see a bump in symptoms, explore this with your client, ■ reminding them that progress in therapy is not linear. If related to LGBTQ-​related stress, note that you will be exploring that further today. Use the Progress Record review as an opportunity to see what you ■ might need to focus on in today’s session, to determine if any shifts in treatment focus may be needed, or to generally explore with your client how they feel that treatment is going.

Review Home Practice from the Prior Module For home practice, you and your client agreed that they would use Worksheet 6.2: Monitoring LGTBQ-​ Related Stress to track their LGBTQ-​ related emotional triggers and the cascade of thoughts, behaviors, and bodily feelings that follow along with the short-​and long-​term consequences. Review the client’s completed Worksheet 6.2, and assess whether they were able to identify any LGBTQ-​related stress triggers over the last week. If so, explore with your client what types of triggers they faced. ■ If not, probe for other stressors they may have faced, potentially ■ exploring the roots of these triggers in LGBTQ-​related stress. Review the thoughts, behaviors, and bodily feelings the client associated with their identified triggers. Validate their experiences within these situations. ■ Assess and discuss the client’s ability to identify and decipher their thoughts, behaviors, and bodily feelings.

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■ Ensure that the client is able to identify the relationships among these components (e.g., how the client’s thoughts might have influenced their bodily feelings or behaviors, how the client’s behaviors influenced their thoughts or bodily feelings). Discuss the short-​and long-​term consequences of their responses to LGBTQ-​related stress situations or events. Tip: If your client gets stuck identifying the long-​term consequences, try asking: If this was the only response you could use to this kind of trigger, what would eventually happen? Identify any patterns emerging in the client’s home practice and reflect these back to the client. Use the examples your client brought in as much as possible throughout the module to highlight the usefulness of nonjudgmental emotion awareness. Troubleshoot any challenges your client experienced with the home practice: ■ If the client had any difficulty with Worksheet 6.1: Three-​ Component Model of Emotions or Worksheet 6.2: Monitoring LGBTQ-​Related Stress, you may want to review the key concepts from the past module. If your client did not complete one or both home practice worksheets, ■ explore what got in the way of completing it, using motivational interviewing to resolve ambivalence about engaging in future home practice between sessions.

Provide the Rationale for Mindfulness in the Context of LGBTQ-​Related Stress As reviewed in the previous module, past and current encounters with LGBTQ-​related stress can elevate LGBTQ individuals’ vulnerability to experience uncomfortable emotional experiences in the face of life stressors. How one responds to one’s negative emotions can make a big difference in short-​and long-​term well-​being: ■ Some coping strategies reduce negative emotions in the moment but backfire in the long term.

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■ Because of the extra stress LGBTQ people often face, many LGBTQ people learn to rely on coping strategies that are helpful in the short term. These strategies might include cognitive strategies such as rumination ■ (i.e., constantly dwelling on the problem, what went wrong, and how bad the problem seems) or behavioral strategies (e.g., escaping the uncomfortable emotion by seeking sex, using substances, or other behaviors). These strategies may offer temporarily relief but can undermine ■ mental, sexual, and physical health in the long run. Therapist Note Many LGBTQ people report that substance use is a primary way of coping with stress. Thus, you and your clients should explicitly consider the possibility that substance use is a way to cope with the emotional manifestations of LGBTQ-​related stress, such as shame, loneliness, and anxiety. When you work with clients who use substances to cope with unpleasant emotions, as identified in previous modules, you might consider presenting the mindfulness exercises in this module as a way to identify and cope with emotional triggers for using substances. Because these strategies can help decrease negative mood in the short term, they can become ingrained ways of coping with stress and unpleasant emotions. As a result, some LGBTQ people find it hard to tolerate unpleasant emotions, and then they judge themselves for having these emotions. Accepting the emotional experience and allowing the emotions to pass are essential steps to ultimately reducing the negative impact of unpleasant emotions. In summary: Explain that the added layer of stress that many LGBTQ people experience can lead to the development of coping strategies that offer temporary relief but are unhelpful in the long run.

Introduce the Skill of Nonjudgmental Emotion Awareness In this module, you will be introducing the concept of emotion awareness to the client. LGBTQ people often report difficulty with emotion

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awareness and expression. Early invalidating environments, such as those characterized by the social rejection and isolation of early LGBTQ-​ related stress, can lead to difficulty identifying and expressing emotions. Yet, it is important to be able to observe and express emotions: ■ The ability to objectively and nonjudgmentally observe emotions as they are occurring in the moment will allow the client to identify and adjust maladaptive thoughts and behaviors, as well as recognize when and how bodily feelings are triggered by, or serve as triggers for, maladaptive thoughts and behaviors. Such nonjudgmental awareness is an important skill for the client to ■ build early on in treatment, as it will help them learn later treatment concepts. Therapist Note Some clients might feel like they are already keenly aware of their emotions, so much so that their emotions are confusing or overwhelming, or seem to just “happen” automatically as a result of some situation, event, or memory. Thus, it may help to make clear that in this session you will be discussing a specific skill of “emotion awareness,” which can be useful for helping make emotions less confusing or overwhelming. There are two kinds of emotion experiences to be aware of: primary emotions and secondary reactions. During every emotion experience, there is an initial emotion that gets triggered by the event or memory, which is then followed by a reaction to this initial emotion. Primary emotions are the “first” emotion reactions to a situation or memory. These emotions are often functional (they serve a direct purpose in the situation) and are directly related to the cues in the situation or memory (e.g., feeling fear when hearing a sudden noise in a quiet house could help to avoid a potentially dangerous situation). In other words, the “primary” emotion is not in and of itself problematic—​it is usually functional and helpful by letting us know what we need in that moment.

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Secondary reactions are the ways we respond to the primary emotions, and these reactions are what typically lead to problematic emotion experiences, such as being confused or overwhelmed, because the secondary reactions tend to be judgmental. Secondary reactions tend to cause more difficulties than primary emotions, as shown in the following examples: ■ The sudden sound could lead to fear (primary emotion), and then to catastrophic thoughts about what could have made the sound (secondary reaction), which might lead to increased anxiety, cause the heart to beat faster, cause muscles to tense, and drive the person to seek reassurance. Someone feels anxious because they are behind on their work ■ (primary emotion), and then interprets that anxiety as a sign that they cannot cope with the current situation (secondary reaction), leading them to feel overwhelmed and unable to complete any of their work at all. Secondary reactions are often not based on information from the current context; rather, they are typically based on what has happened before or what we think might happen in the future. Secondary reactions can get in the way of taking in corrective information from the current, ongoing context. Therapist Note Consistent with Principle 1 of this treatment, it is important for you to emphasize that problems with mood and anxiety are normal responses to LGBTQ-​related stress. Although at least part of the vulnerability to mood and anxiety problems comes from genetic predispositions, those predispositions are activated when people are stressed. For LGBTQ individuals, LGBTQ-​related stress is added on top of everyday stress, making LGBTQ people more likely to experience mental health problems that are triggered by stressful life circumstances. This treatment helps LGBTQ people recognize that the source of many mental health problems is stigma, not LGBTQ people’s personal deficiencies.

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Judgments About Emotions Among LGBTQ Individuals Secondary reactions often carry an evaluative, critical, or judgmental tone, such as, “this feeling is bad” or “the way I am feeling means I am incompetent in this situation.” This tendency may be especially likely for LGBTQ individuals who associate uncomfortable emotions with painful early experiences of LGBTQ-​related stress. Gender norms, societal stereotypes, and fear of vulnerability may lead LGBTQ individuals to judge their emotional experience and try to shut down their emotions before they get fully expressed. Explore how this may apply to your client’s life; here are some examples: ■ Transgender men may view emotions as “not manly” and suppress their emotions to avoid having their manhood—​which may be often invalidated—​further contested by others. Sexual minority men may feel pressure to conform to narrow notions ■ of masculinity and strive to evade or defy stereotypes of gay men as “weak,” “effeminate,” or “too emotional.” For sexual minority women and trans women, emotions may repre■ sent an unacceptable sign of vulnerability. Create a safe space for your clients to consider the validity of their emotions by pointing out: ■ Internalized stereotypes and social rules about emotions are not accurate or fair. Holding emotions in for a long period of time usually leads to feeling ■ even worse. Everyone has a right to feel whatever feelings they may feel. ■ As always, we suggest maintaining a therapeutic stance that validates the difficulty of being aware of and expressing emotions in the face of a long history of LGBTQ-​related stress. Why Reduce Judgments About Emotions? When we judge our primary emotions, we lose touch of the original purpose of the primary emotion (e.g., experiencing the primary emotion of fear after hearing an unexpected sound should have alerted us to something in the environment). 146

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Secondary reactions can make us think that primary emotions are threatening and unwanted, instead of being nature’s clever way of signaling to us what is going on in our world right now. Many people with anxiety and depressive disorders view any sort of negative emotion (e.g., fear, sadness, anxiety) as inherently threatening and bad, often thinking that such emotions are signals of something catastrophic that is about to happen (generally unlikely) instead of transient experiences that will come and go (more likely). Sometimes, people have judgmental secondary reactions to positive emotions as well (e.g., joy), finding them threatening or anxiety-​ provoking, or viewing them as an indication that they are off their guard or more vulnerable to something bad happening. Developing objective, nonjudgmental awareness of primary emotions and secondary reactions allows the client to identify catastrophic or harmful interpretations of their emotions, as well as problematic behavioral responses to emotions. Try these exercises, building on the home practice from the past week, to illustrate the concepts of primary emotions, secondary reactions, and nonjudgmental emotion awareness: ■ Identify a situation: Encourage your client to identify a situation from their home practice that led to a strong emotional response. Identify the primary emotion: What was your primary emotion when ■ that happened? What was the first emotion you felt? Identify the secondary reaction(s): What was your secondary reaction ■ to that emotion? In other words, what did you think or feel about your feeling of _​_​_​_​_​_​? Identify judgments embedded in secondary reactions: What judgments ■ do you hear yourself saying as you describe your secondary reactions? May I share some evaluations of judgments I am hearing you say? Build nonjudgmental responses: Imagine your friend shared that they ■ were feeling a really uncomfortable emotion. How would you respond? Would you tell your friend they were “wrong” for feeling that way or that their emotions were a sign of something terrible, or would you have some empathy for your friend’s experience or maybe a sense of curiosity about the meaning of their feelings? Explore connections among thoughts, behaviors, and bodily feelings: ■ Ask the client to take out their completed Worksheet 6.1: Three-​ Component Model of Emotions, and try asking, How did your secondary reactions in one area influence other areas? (e.g., the thought “I can’t cope” leading to the bodily response of increased heart rate). 147

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Therapist Note The rationale for an emphasis on present-​focused awareness lies in the fact that many of the reactions clients have to their emotions are based upon memories and associations with past situations or events, such as past experiences with LGBTQ-​related stress and/​or anticipation of potential future consequences or outcomes. Often, clients are not paying attention to the current context in which their emotions are occurring and thus are missing out on valuable corrective information. This process of refocusing awareness and attention to the present moment is called being mindful of our experiences. In summary: Collaborate with your client to ensure they can identify primary emotions versus secondary reactions. Ensure they can understand how judging one’s emotions can lead to being confused or overwhelmed by those emotions as well as other secondary reactions, such as fears of catastrophe. Introduce the Skill of Present-​Focused Emotion Awareness Next, you will introduce your client to the concept of present-​focused, mindful awareness of emotions. When discussing present-​focused awareness with clients, it is important to emphasize three main points, as listed below. Practicing Present-​Focused, Mindful Awareness May Feel Awkward at First Some clients find it difficult to observe their emotions without engaging with them or getting “carried away” by them (or judging them). Remind clients that the goal is not to do the exercises that come next perfectly—​ the goal is to practice observing their emotions as they are happening in the present moment. With practice, present-​focused, mindful awareness gets easier and more comfortable. Introduce Worksheet 7.2: Anchoring in the Present Explain to your client that one way to practice present-​focused, mindful awareness is by “anchoring” oneself in the present moment. Clients can 148

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use these exercises to help develop a habit that can be used to quickly shift their attention to the present moment. Help your client identify some “cue” they can use to “anchor” themselves in the present moment. One very useful (and portable) cue is breath. Try using the following language to introduce this: ■ Try taking a deep breath and at the same time paying attention to something tangible that is happening right now. Do you hear the sound of _​_​_​_​_​(e.g., cars passing by or a bird singing)? Try using your breath to anchor yourself into the here and now. Remember, ■ the purpose is to be fully present, not to distract or relax yourself. Use your breath as a reminder to focus on what is going on in this current ■ moment. Now, try using your breath to shift your attention to the present moment ■ when you experience heightened emotions over the next week. Once the client has identified their cue, encourage them to use it during times of distress to help shift attention to the present moment. Therapist Note The ability to observe and notice one’s emotions in a present-​focused, nonjudgmental way will facilitate the client’s ability to engage in the remaining sessions. As such, you might consider repeating this exercise at the beginning of each subsequent session, especially if the client indicates initial difficulty. You may also use the exercise to help the client work through particularly distressing emotions, thereby reinforcing the value of nonjudgmental emotion awareness throughout treatment.

Teach the Client the “Three-​Point Check” Explain to your client that once they have anchored themselves in the present with the cue they chose (e.g., their breath), they can do a quick “three-​point check.” The goal of a three-​point check is to objectively and nonjudgmentally observe their current, ongoing reactions within each of the three domains of emotion experiences.

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When doing the three-​point check, clients can ask themselves: What are my thoughts right now? ■ What emotions and bodily feelings am I experiencing right now? ■ What am I doing right now? ■ In summary: Review the rationale for taking an objective, nonjudgmental stance on emotions and ensure the client understands how this practice can help safeguard against judging one’s emotions and other unhelpful secondary reactions.

Conduct In-​Session Emotion Awareness Exercise In order for clients to fully understand the concepts presented in this module, it is essential for them to practice them, or learn by doing.

Invite Your Client to Practice Nonjudgmental Emotion Awareness Have the client practice present-​focused, nonjudgmental awareness by conducting a brief mindfulness exercise that involves mindfully noticing their breath (Segal et al., 2002). Inform the client that during this exercise they should: ■ Practice paying attention to what is happening inside and around them at this very moment. Observe their inner experience in an objective way by acknowledging ■ any thoughts, behaviors, and bodily feelings just as they are, and by letting go of the need to critically judge, change, or avoid their inner experience. See Box 9.1 for a sample script to lead your client through the brief mindfulness exercise, which is estimated to take about 5 minutes—​or use your own if you prefer. The audio file for this script (called “Activity 1: Mindfulness Meditation”) can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup. com, so that clients can listen to the meditation on their own.

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Box 9.1. Mindfulness Meditation Script

When you’re ready, settle into your chair—​try sitting comfortably upright, setting both feet on the ground, resting your arms and hands in a comfortable position. As you settle in, begin to notice the rise and fall of your breath. Simply notice your breath as it is. There is no need to count, change, or do anything different with your breathing. Just let it be and observe it as it currently is. Begin to scan your body, noticing the sensations in your muscles, your heartbeat, and your breath. You might also notice the sensations of your feet touching the ground, your body in your chair, or your arms resting on your lap. Just observe these physical sensations, without judgment or evaluation. As you sit and become present to your current physical state, begin to notice what is happening in your mind. Notice what feelings you’re currently experiencing. If you notice a specific feeling, try describing it without evaluation. If you notice sadness, you can imagine the word “sad.” If you notice anxiety, you can imagine the word “anxious.” If you notice happiness, imagine the word “happy.” This lets you notice and describe your current state of being, without judging it. As you sit and tune in to your thoughts, feelings, and physical sensations, remember that there is no need to change, judge, or avoid your current experiences. Right now, all you are asked to do is notice and let it be. Continuing to be present to your current state of being, notice what thoughts your mind is producing at this time. Imagine that you are watching your thoughts being produced as though they’re a movie you are watching. In this way, you can stop yourself from getting “hooked” into the thoughts, and instead just watch them play out as an objective observer. If, as you strive to be present and self-​aware in the here and now, you find yourself getting carried away by thoughts about the past or future, that’s OK. Try using your breath as an anchor to bring yourself back into the present moment. Notice the physical sensation of the breath you are taking right now. In this way, you can always use your breath to anchor you to the present moment. You might also notice judgments or evaluations that you have in response to your emotions. You might have the thought, “This emotion is bad” or “I shouldn’t feel this way.” You could also think, “I like this feeling and I don’t want it to go away.” If you notice any of these reactions, gently bring yourself back to the role of an objective observer. If you notice you are feeling sad, you can think the word “sad” or if you notice you are anxious, you can think of the word “anxious.” Know that there is no right or wrong way to feel. All you are asked to do right now is to notice and describe your current feelings. Bringing your full attention back to your breath, notice a few more breaths, then when you’re ready, you can bring yourself back into the room.

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If the client is finding it difficult to stay focused in the moment or finds their mind wandering with thoughts, encourage the client to practice using their cue (such as their breath) to help bring their attention back to the present and back to objective observation of their experience.

Process the Mindfulness Exercise with Your Client You may want to use Worksheet 6.1: Three-​Component Model of Emotions to help the client identify their reactions and responses to the exercise. Reflect any maladaptive or judgmental responses that the client expresses, without correcting them at this time. Remind the client that over the coming weeks each of the three domains will be explored in greater detail. However, for now the goal is simply to observe and notice their experience. In summary: Lead your client in a mindfulness exercise. Be sure to prepare them before beginning the exercise and take time to process the experience afterward.

Conduct In-​Session Mood Induction Exercise Now that the client has practiced present-​focused, objective awareness using a formal mindfulness exercise, it is useful to practice this same skill in the context of an emotion experience. The purpose is to be able to gain an objective, nonjudgmental perspective during times of distress.

Invite Your Client to Practice Nonjudgmental Emotion Awareness During a State of Emotion Arousal Ask the client to recall an upsetting instance of LGBTQ-​related stress from their past. The client’s home practice might be a useful place to start in identifying an LGBTQ-​related stress trigger to use for this exercise. Using the previously completed Worksheet 6.2: Monitoring LGBTQ-​Related Stress as a guide, prompt the client to remember the situation as vividly as possible (e.g., Think about the situation as if it were happening to you all over again). 152

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Box 9.2. Mood Induction Script

Sitting comfortably in your chair, begin to recall this experience in as much detail as possible. Remember where you were; who was there; and what you saw, heard, or felt in that moment. Try thinking about the situation as though it were happening to you all over again. As you take yourself back to that situation, begin to notice the physical sensations that you are experiencing. What do you notice in your body? Notice your breath, heartbeat, muscles, and any other physical sensation you experience. Remember, there is no need to change how you feel. Simply notice your experiences, without judgment or evaluation. Now begin to notice what feelings you are experiencing. You may notice different types of emotions. Try just naming those emotions that you detect. You might notice feelings of sadness, nervousness, worry, happiness. There is no right or wrong way to feel. Just notice your feelings, letting them be. Notice the thoughts that you are experiencing, having put yourself back in this situation. Our minds are factories of thoughts—​try simply watching those thoughts being produced by your mind, as an independent and objective observer. If you find yourself becoming hooked into ruminating about the past or worrying about the future, try bringing your attention back to your breath as a way of becoming present to the here and now. Try asking yourself, “What am I thinking about right now? “How am I feeling right now? What am I doing right now? Notice a few more breaths, and when you are ready, bring yourself back to the room.

Invite the client to practice observing their experience by noticing thoughts, feelings, and reactions, much in the same way as during the mindfulness exercise. See Box 9.2 for a sample script to lead your client through the brief mood induction exercise, which is estimated to take about 5 minutes—​or use your own if you prefer. The audio file for this script (called “Activity 2: Mood Induction”) can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com, so that clients can listen to the meditation on their own.

Process the Mood Induction Exercise with Your Client Assist the client in eliciting thoughts, feelings, or other reactions, helping them observe these reactions in objective, nonjudgmental ways. If you notice that the client is judging their emotional experience, gently 153

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suggest the possibility that full emotional acceptance may be a new experience for those who have learned to cope with LGBTQ-​related stress through attempts to avoid or suppress emotions. You might also raise the possible role of any relevant stereotypes about LGBTQ people and emotions (discussed above) if the client has difficulties with present, nonjudgmental awareness of emotions. In summary: Lead your client in a mood induction exercise, processing the experience once complete.

Agree on Home Practice To reinforce the concepts from this module, collaboratively discuss the following home practice activities: 1. Encourage clients to set aside time to practice nonjudgmental, present-​ focused awareness as many times as they can over the next week (ideally every day for at least 5 minutes per day), using the mindfulness meditation presented here, in the client workbook, and available for download. Ask clients to record their experiences on Worksheet 7.1: Nonjudgmental, Present-​Focused Emotion Awareness. Be sure to note that even though the client is being asked to set ■ aside time to practice this exercise initially, over time this is a skill meant to be used as needed throughout the day. Let your client know that with increased practice these techniques ■ become more automatic and can eventually become a useful skill for times of distress. After a period of deliberate practice, encourage clients to infor■ mally practice present-​focused awareness several times throughout the day, using their chosen cue such as their breath to help anchor themselves to the present. 2. Ask clients to practice anchoring themselves to the present at least three times over the next week by noticing at least one thing going on around them for at least 60 seconds and recording this on Worksheet 7.2: Anchoring in the Present. This anchor can be a sound they hear, something they see, or ■ something they can physically feel (like a chair, a computer keyboard, a dish sponge). 154

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■ Have clients pair this exercise with their chosen cue (e.g., their breath), so that this cue will become a reminder to shift their attention to the present moment. Remind clients that the goal of this exercise is not to think about the ■ meaning of what they notice, nor is it to try to understand their reaction to it. The purpose of this exercise is simply to practice paying attention to what is going on around them at that moment. 3. Ask clients to choose at least one reminder of LGBTQ-​related stress from their own lives that has strong personal meaning or memories associated with them. The purpose of this exercise is to practice observing their emotions, for at least 5 minutes, in an objective, nonjudgmental way while in an emotional state. Ask clients to note their reactions to the reminders on Worksheet 7.3: Mood Induction Recording, so that these reactions can be discussed in the next module. If clients have trouble selecting a reminder (e.g., photographs, let■ ters, video clips, old emails), you might suggest that they select a song with personal meaning. Encourage clients to use their chosen cue to help anchor them if ■ they find themselves shifting from objective to subjective observation (e.g., getting “carried away” by their thoughts). Clients may want to use a blank copy of Worksheet 6.1: Three-​ ■ Component Model of Emotions to explore their reactions further. Some clients may wish to start their mindfulness exercise more grad■ ually. In this case, you can suggest they choose one relatively simple positive event (e.g., sitting by a beach) and one negative event (e.g., getting minor dental work) before focusing on the emotionally evocative LGBTQ-​related stress situation or feelings described above.

Module 4: Additional Helpful Reference Materials Case Vignettes Case Vignette #1 In this vignette, the therapist is inviting a 35-​year-​old Black transgender woman to observe her experiences in the present moment as a powerful tool for coping with LGBTQ-​related stress. Notice how the therapist

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acknowledges the client’s resistance in a validating manner and reframes the invitation in a way that highlights the tangible potential benefits to the client. Client:  This feels a little “new age-​y.” I’m not really into the spiritual yogi sort of thing. I feel like all that stuff is just for those rich cis White women in the suburbs. Therapist:  It is true, the idea of mindfulness meditation has its roots in practices like Buddhism, and the idea of practicing something not derived from Western medicine can feel uncomfortable to some people. What we are asking you to do here is not to become a Buddhist, or even a formal “meditator,” or someone you are not comfortable being—​although some people do find the practice of meditation so helpful that they begin to practice it in their daily life, and not just wealthy cisgender White women. Instead, we have found that the principal objective of mindfulness meditation—​ shifting your attention from being caught up “in your head” to an objective, curious perspective on your experience—​is incredibly helpful both for understanding your experience during times of stress and for recognizing when and how you might be reacting to your experience in ways that are making things worse. For example, when you feel anxious, and then begin to have a lot of really harsh, critical thoughts about yourself for being anxious, those thoughts are making you feel worse. Taking a nonjudgmental, objective stance will help you begin to separate out your anxiety from your harsh critical reaction to it, giving you the opportunity to stop the cycle before it starts. Doing these formal mindfulness exercises now allows people of any race, gender, or income to practice what it feels like to observe their experience in this way, giving them a powerful tool for coping with uncomfortable emotions during times of stress.

Case Vignette #2 Exploring with a 21-​year-​old client how to separate their anxiety from their harsh critical reaction to it, the therapist is giving the client the opportunity to stop the cycle before it starts. Notice how

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the therapist highlights the importance of practice and makes the task less daunting by stating that this daily practice only needs to last for 1 week. Client:  I don’t like to sit still; it makes me more anxious. Therapist:  Tell me more. What happens when you sit still? Client:  I don’t know; I just feel like I should be doing something. I feel like if I let myself stop thinking about everything I need to do, my whole day will fall apart. I’m also afraid I’ll start thinking about things I’d really rather not think about. Therapist:  So, by sitting still and focusing on the present, you are afraid you will be losing control of things that are supposed to happen during your day, and you might start thinking about things that have happened in the past? Client:  Yeah, and that just makes me even more anxious. Therapist:  Tell me what you are thinking about the things you need to do later today. Client:  Well, I’m worried that I’ll be late for my doctor’s appointment, and that I won’t be home to walk my dog in time for his evening walk, and that he will start barking so loud that he annoys the neighbors, which would be really bad. Therapist:  And where are you right now? Client:  I’m here in this office. Therapist:  Are you running late right now? Client:  No, unless we run over. Therapist:  Are we running over? Client:  Well, not right now. Therapist:  So, you are not late for anything at the moment, but you are focusing on the possibility that you might be late later on. How does focusing on the possibility that you might be late later on make you feel? Client: Anxious! Therapist:  And what about the information that right now, in this moment, you are not running late? Clint:  Well, much less anxious. But I still could run late later! Therapist:  Does thinking about being late later, or noticing that you are not late now, change what is going to happen in 3 hours’ time? Client:  I don’t know; it depends on what happens later.

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Therapist:  Right! So, you really have no way of knowing what will happen later. The bus might be running slow. Your doctor’s appointment might run over. Or, alternatively, you might find the bus shows up right away and your appointment only lasted 15 minutes instead of the scheduled 30 minutes. In other words, you just don’t know. The only thing you do know for sure is that you are in this office right now, and at the moment you are not late for anything. So, the only thing that is different about worrying about the future as opposed to paying attention to the present moment is that one makes you really anxious, and the other makes you less anxious. How does worrying about being late later this afternoon make you feel physically? Client:  Agitated, tense, stressed out! Therapist: And what about the thought that you are not late right now? Client:  Well, I guess a little less tense. Therapist:  So, sitting still and observing your experience in the present moment doesn’t mean trying to pretend you are not worried about what is going to happen later in the day, or trying not to think about memories from the past. Instead, sitting still and observing your experience means noticing in an objective, curious way that your thoughts are focused on potential negative events that may or may not happen in the future, and noticing that these thoughts also make you feel tense and anxious and cause you to feel like fidgeting in your seat. Observing these reactions as they are happening in the present moment allows you to take in other, important information that is happening in the here and now that you might have otherwise missed. Noting to yourself in a curious way, “Huh, that’s interesting. When I stop moving, my thoughts wander towards worries about being late and something bad happening. When I think these thoughts, my muscles tense up. When I shift my focus to the room, my thoughts are that I am here now and not late. When I think these thoughts, my muscles relax a little.” Refocusing your attention from the future to the present allows you to start understanding your reactions better, and to see where your interacting thoughts, behaviors, and bodily feelings might be making the situation worse.

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Navigating Challenges in Module 4 Resistance or Discomfort with Mindfulness Some clients may be resistant to the idea of mindful awareness, finding it difficult, or even “hokey,” as illustrated in Case Vignette #1. Others may feel that by simply observing their experience they are not “doing enough” to address their symptoms, and this may seem inherently unsatisfying to them. It is important in any case for therapists to convey to clients the rationale behind practicing present-​focused awareness, and to be sure clients fully understand this rationale. Practicing present-​ focused, mindful awareness in this treatment program is viewed as an attentional shift that allows clients to step out of their experience, enabling them to identify where specific thoughts, behaviors, and/​or bodily feelings may be leading them astray.

Feeling Stuck in a Cycle of Chaos It can be helpful to use Worksheet 6.1: Three-​ Component Model of Emotions to demonstrate how emotions emerge as a dynamic, interacting cycle of thoughts, behaviors, and bodily feelings, all of which influence and “feed off” of the other. Clients can give examples from a recent experience and draw arrows demonstrating how each domain influenced the others. Explain to your clients that most of the time people exist right in the middle of this chaos, which makes it very difficult to find an adaptive way to cope in response. Practicing present-​ focused awareness enables people to step outside of this chaos, allowing them to adopt a more objective view. You might demonstrate this by drawing a larger circle around all three domains, demonstrating where the client’s focus ought to be: observing this interaction as a whole from a distance, rather than being stuck in the middle of it. From this objective distance, clients will be better able to identify where they might intervene to break the cycle. For example, by stepping back and observing their experience, clients may be able to recognize how a catastrophic thought leads to heightened autonomic arousal, which may fuel further catastrophic thoughts, causing them to engage in escape or avoidance.

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CHAPTER 10

Module 5: Increasing Cognitive Flexibility

(Corresponds to Chapter 8 of the client workbook) This module allows clients an opportunity to connect their growing awareness of their emotional experience of LGBTQ-​related stress to their negative and potentially rigid thinking patterns. Accordingly, you will: ■ Explore your client’s home practice, in which they were to practice nonjudgmental, present-​ focused emotion awareness (i.e., mindfulness). Introduce automatic thinking patterns and thinking traps, ■ discussing how these relate to early and ongoing LGBTQ-​related stress experiences. Help your client identity examples of automatic thinking and ■ thinking traps that they commonly encounter and how these might connect to their experience with LGBTQ-​related stress. Introduce the concept of cognitive flexibility and discuss various ■ ways it can be used to combat harmful automatic thinking and thinking traps.

Module Agenda Review current symptoms on the Progress Record ■ Review home practice from the prior module ■ Explain the impact of LGBTQ-​related stress on LGBTQ people’s ■ automatic thinking patterns Introduce automatic thinking patterns and underlying core beliefs ■ Help the client identify common thinking traps arising from ■ LGBTQ-​related stress and discuss how these thinking traps can impact emotions Introduce and help clients practice cognitive flexibility ■ Agree on home practice ■

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Recommended Number of Sessions This module is intended to be delivered across two or three sessions to provide sufficient time for the client to adequately explore and practice key concepts. For example, you might divide the module content as follows: ■ Session 1: Explain the impact of LGBTQ-​related stress on LGBTQ people’s automatic thinking patterns; introduce automatic thoughts Sessions 2 and 3: Introduce thinking traps; discuss cognitive flexi■ bility as a strategy for coping with LGBTQ-​related stress

Materials Needed Progress monitoring assessments (i.e., ODSIS, OASIS) ■ Progress Record ■ Figure 8.1: Ambiguous Experience Example, located in client work■ book Chapter 8 Box 8.1: The Core Belief Questions, located in client workbook ■ Chapter 8 Worksheet 8.1: Downward Arrow Technique, located in client work■ book Chapter 8 Worksheet 8.2: Identifying and Evaluating Automatic Thoughts, ■ located in client workbook Chapter 8 Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The Progress Record is located at the end of Chapter 3 in the client ■ workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be downloaded by searching ■ for this book’s title on the Oxford Academic platform at academic. oup.com.

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Review Current Symptoms on the Progress Record Continue using the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session, based on the assessments that they complete before the session (i.e., ODSIS, OASIS). ■ Highlight any positive change and explore your client’s perceptions regarding the source of this change. If you see a bump in symptoms, explore this with your client, ■ reminding them that progress in therapy is not linear. Use the Progress Record review as an opportunity to see what you ■ might need to focus on in today’s session, to determine if any shifts in treatment focus may be needed, or to generally explore with your client how they feel that treatment is going.

Review Home Practice from the Prior Module Review the home practice that was agreed upon in the last session. Depending on the sequence in which you delivered Module 4, this review may include the client’s Worksheet 7.1: Nonjudgmental, Present-​ Focused Emotion Awareness; Worksheet 7.2: Anchoring in the Present; and/​or Worksheet 7.3: Mood Induction Recording. Assess whether your client was able to practice present-​focused awareness (without mood induction) using Worksheet 7.1: Nonjudgmental, Present-​Focused Emotion Awareness. If so, explore with your client what types of thoughts, behaviors, and bodily feelings they noticed. Assess how effective they were at not judging their experience. As needed, reinforce the interconnected nature of thoughts, behaviors, and bodily feelings, and the rationale for nonjudgmental emotion awareness. If your client had difficulty completing this practice, normalize that this can be a very difficult skill to develop. You might suggest scheduling a time to practice present-​focused awareness as a way for your client to build a habit of mindfulness. Assess whether your client was able to practice anchoring in the present using Worksheet 7.2: Anchoring in the Present. If so, review their experience, including their worksheet responses.

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If the client had difficulty completing this practice, normalize that this can be a difficult skill to develop. Remind the client that they may consider using their breath to anchor themselves in the present moment. Therapist Note You can help clients to practice this skill by engaging them in an in-​session exercise where the client performs an everyday task (e.g., eating a snack) and focuses on the sensory experience of that task. This can help give the client a better sense of how to complete this home practice exercise. Assess whether your client was able to practice present-​focused awareness (with mood induction) using Worksheet 7.3: Mood Induction Recording. If so, review the responses within the worksheet, including their reminder, the initial emotional response and its intensity, and their reaction to the emotional response. If the client had difficulty completing this practice, normalize that this can be a difficult skill to develop. In this case, you might wish to engage in additional in-​session exercises in which the client practices mindfulness mediation. You can also explore motivational barriers to competing this practice at home, given the importance of applying mindfulness in daily life outside of session. ■ As needed, reinforce the difference between primary and secondary emotions (see Module 4 for a review). Discuss how the client’s experience of present-​focused awareness ■ may have differed when paired with mood induction. Remind the client that practicing this skill will allow them to more ■ easily gain an objective, nonjudgmental perspective during times of distress. Troubleshoot any challenges your client experienced with the home practice: ■ If your client had any difficulty with these worksheets, you may want to review the key concepts from Module 4. If your client did not complete the home practice, explore what ■ got in the way of completing it, using motivational interviewing to

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resolve ambivalence about engaging in future home practice between sessions. ■ Additionally, invite your client to reflect on the week and consider completing the home practice within the session together.

Explain the Impact of LGBTQ-​Related Stress on LGBTQ People’s Automatic Thinking Patterns Begin the module by highlighting the fact that LGBTQ people learn about themselves, their world, and their future possible selves in the context of peers, parents, and a society that often holds negative views of LGBTQ individuals. Early and ongoing anti-​LGBTQ messages shape LGBTQ people’s thoughts about themselves, others, and the future. For example, anti-​LGBTQ social messages may shape one’s self-​worth and future expectations: ■ LGBTQ people often base their self-​worth on their achievements (e.g., academics, appearance, financial status). For instance, research has shown this to be true for sexual minority men, particularly within sexual minority male circles (Pachankis et al., 2020a). This possibly occurs because other sources of self-​ ■ esteem (e.g., God’s love, family approval) are not perceived as readily available to LGBTQ people in the same way that they are to heterosexual and cisgender people, because of societal stigma. Additionally, early and ongoing experiences with LGBTQ-​related ■ stress may lead LGBTQ people to experience low self-​worth and to internalize anti-​LGBTQ messages later in life. Anti-​LGBTQ social messages may also shape whether, when, and to whom LGBTQ people disclose their sexual or gender minority identity: ■ As discussed in earlier modules, LGBTQ people often conceal their sexual orientation or gender identity across most of adolescence and sometimes even into adulthood. This period of early hiding may put LGBTQ people in the long-​term ■ habit of expecting rejection and fearing being “found out.”

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■ Later in life, this tendency to change oneself to fit in and avoid rejection may extend beyond concealing one’s sexual orientation or gender identity. LGBTQ people often develop an identity in relative isolation: ■ During the stage when many LGBTQ people begin recognizing their sexual attractions or gender identities and expressions, they might not have a network of similar others for validation and approval or visible role models of people like themselves. At worst, LGBTQ people might experience explicit condemnation ■ or rejection during the very developmental period in which they need support the most. These developmental predicaments can lead LGBTQ people to ex■ perience themselves as alone or isolated across the lifespan. In summary: Stigmatizing messages about LGBTQ people from an early age can powerfully shape LGBTQ people’s thinking patterns across the lifespan.

Introduce Automatic Thinking Patterns and Underlying Core Beliefs Explain the concept of automatic thinking patterns by addressing the following topics.

In Any Given Situation, There Are a Number of Different Aspects of That Situation That a Person Can Focus On Our brains are designed to deal with and simplify complex human interactions without our awareness, so that we can respond quickly: ■ Automatic thinking is when a person’s brain filters in/​out certain information about a situation so that they can quickly make sense of and respond to that situation. The process of filtering in/​out information about a situation helps ■ us interpret that situation, which in turn informs us of what might happen in the future.

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■ For example, if you are called by your boss for an individual meeting in their office, you might suddenly feel either pleasant anticipation or nervousness/​dread. You could be automatically reminded of either (a) the pleasant conversation that you had with them just before you received the call or (b) the fact that your colleague was given a “warning” about their productivity during an individual meeting with the boss. Focusing on the first would make you think that something positive ■ might happen, whereas focusing on the second would suggest something negative might happen during your meeting. The unique experience of growing up LGBTQ can powerfully shape one’s interpretations of many different kinds of situations, as well as expectations about what will happen next. Try asking your client how their own experiences growing up LGBTQ might have shaped their thinking patterns: ■ How did growing up LGBTQ shape what information you pay attention to in social situations? What kinds of automatic interpretations do you think that you make ■ in social situations that might be rooted in earlier experiences related to being LGBTQ? Explore with your client the possibility that expectations of rejection, fears of wrongdoing or being “found out,” low self-​worth, and self-​ hatred or shame may emerge from early and ongoing experiences with LGBTQ-​related stress: We’ve talked in other sessions about how you often expect that other people are going to reject you. How do you think your early experiences with LGBTQ-​related stress led to that kind of automatic thought?

The Aspect of a Situation That We Focus On Shapes the Emotions We Experience Refer to Figure 8.1: Ambiguous Experience Example, located on page 119 in the client workbook. The Ambiguous Situation Exercise (presented in Box 10.1) can be used to help clients identify how their automatic thinking patterns can influence their emotions.

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Box 10.1. Ambiguous Situation Exercise

The following in-​session exercise may be used to show how many different interpretations of a situation are possible—​and to show how these interpretations are affected by one’s current mood. Present Figure 8.1 from the client workbook: Ambiguous Experience Example. ■ After approximately 30 seconds have elapsed, put the figure away. ■ Then, ask for the client’s initial interpretation of the ambiguous situation and en■ courage them to consider the factors that contributed to their initial interpretation. What information helped you decide what might be happening? ■ Next, help the client generate alternative interpretations about what might be hap■ pening in the picture. Encourage your client to generate as many alternate interpretations as possible, ■ even if some seem less plausible. Some clients have difficulty generating alternate interpretations. Validate that this can ■ be difficult at first, but that with practice it gets easier and can become “second nature.” Emphasize that there is no “correct” interpretation. Rather, the purpose is to illus■ trate that despite our ability to quickly come up with an initial interpretation, other interpretations are possible. Finally, explore how each of the different interpretations (initial and subsequent) ■ would impact one’s mood: If you interpreted it the first way, how do you think you would feel? ■ What other feelings might you have if you interpreted it the second, third, or fourth way? ■ What does this tell you about how your interpretations about the same situation can ■ affect your emotions? In addition to interpretations influencing emotions, the reverse is also true: Emotions ■ can influence the kinds of interpretations that are made in a given situation. Use the Ambiguous Situation Example to illustrate how one’s emotional state can ■ influence interpretations of a situation: How might your mood lead you to interpret this same exact situation differently? If you felt ■ nervous, how do you think you would interpret that situation? What about if you felt confident? Although Filtering Out Unnecessary Information Helps in the Short Term, Over Time, We Can Develop Unhelpful Automatic Thinking Patterns Automatic thinking patterns can become problematic when we repeatedly exclude other possible, more realistic evaluations of a situation. For 168

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example, a person might tend to view ambiguous situations in a manner that suggests they are being rejected, such as thinking their boss is mad at them because the boss’s door is closed, when it could be that they are having a difficult day, are currently busy, or are simply making a private phone call. Research shows that individuals with emotional disorders are more likely to latch onto negative, more pessimistic evaluations. It can be useful to use the client’s initial interpretation of the ambiguous situation to illustrate this point: How do you think that interpreting the picture this first way might lead to feeling [depressed, anxious]? LGBTQ people are more likely than cisgender and heterosexual people to develop negative and unhelpful automatic thinking, such as hopelessness and anxious/​repetitive focus on negative events: ■ This kind of negative and unhelpful automatic thinking can be a cause or effect of depression or anxiety. In other words, negative automatic thoughts can lead to feeling more ■ anxious or depressed; feeling anxious or depressed can also lead to more negative automatic thoughts.

Automatic Thoughts Are Often Driven by Core Beliefs, Which for Many LGBTQ People Involve Beliefs of Wrongdoing, Inferiority, and Loneliness Core beliefs refer to the underlying deep-​down beliefs about ourselves, others, or the world that inform how we perceive ourselves and the situations we find ourselves in on an ongoing basis. For example, the core belief “I’m unlovable” would lead someone to automatically perceive rejection in many situations, even in situations where they are not actually being rejected. Similarly, the core belief “I will be alone forever” would lead someone to act very independently or perhaps have difficulty relying on other people. In the case of depression, anxiety, or other emotional disorders, one’s core beliefs are often biased toward being internally focused, overly global, and stable. 169

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For many LGBTQ people, core beliefs get shaped during developmental periods marked by identity uncertainty, shame, and self-​consciousness without affirmative support. Figure 10.1: Downward Arrow Technique can help clients identify their core beliefs that drive their automatic thinking patterns today (e.g., “I’ll never do anything right,” “I’m worthless”). Note that this figure also appears in Chapter 8 of the client workbook (as Figure 8.2, on p. 140). Identifying core beliefs can lead to impactful change, as it can help your client understand their characteristic schemas for perceiving the world and serve as a heuristic device for catching themselves in those moments when they are relying on their core beliefs rather than looking at objective reality to interpret a stressful situation. To help your client identify their core beliefs, it can be helpful to ask them to scrutinize their automatic thoughts using the downward arrow technique and corresponding Worksheet 8.1: Downward Arrow Technique. This worksheet is available near the end of Chapter 8 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. ■ The downward arrow technique is a form of questioning that can be useful for helping clients identify their core beliefs. Here, clients are asked questions about their automatic thoughts about real or imagined life events, such as “What would happen if this were true?” and “What would it mean about you if this were true (or if this did happen)?” Worksheet 8.1 provides a step-​by-​step visualization that can help ■ clients understand the connection between their automatic thoughts and core beliefs as a logical sequence of thoughts. For instance, if someone described avoiding a social encounter and ■ the automatic thinking pattern related to this was “I won’t have anything to say to people” after completing the worksheet, the client might realize that they have also been thinking, “Because I won’t have anything to say to people, then people will reject me, and therefore I will never have any friends for the rest of my life, and therefore I will be alone forever.” This latter thought is the core belief that has led the person to interpret the situation automatically through a series of anxious and depressive logics.

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Example: Some friends went out last night without inviting me. Automatic Interpretation: I knew they never really liked me

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next?

Underlying Interpretation: They rejected me because I’m awkward and not fun to hang

out with. And I’ve always known I’m not “trans enough”for them

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Underlying Interpretation: If what I wrote were true, it would mean that there’s nothing

to like about me

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next?

Underlying Interpretation: It would mean that I’ll never fit in

If this were true, what would it mean about me? Why does this matter to me? What would happen if this were true? What would happen next? Underlying Interpretation : It would mean that I’m unlovable

Figure 10.1. Downward Arrow Technique—​LGBTQ-​Related Stress Example

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Therapist Note For LGBTQ people, their current context may look quite different than the context in which negative thoughts about one’s self, one’s world, and one’s future possible self originally developed. At this stage of treatment, it is essential that you help your clients attribute their thinking patterns, and the difficulty involved in changing these patterns, to their early and ongoing experiences with LGBTQ-​related stress, rather than to personal deficiencies. Help your client understand that these past lessons could likely outdated if they are no longer useful, relevant guides in their current life.

Some Automatic Thinking Patterns Are Especially Common Among LGBTQ People with Emotional Disorders As you go through the four automatic thinking patterns below, it can be helpful to discuss examples from your client’s life.

Thinking Pattern 1: Expectations of Rejection (or Rejection Sensitivity) Explain to your client that, because of ongoing experiences with rejection, LGBTQ people may begin to expect that they will always be rejected by others, especially in situations in which they assert themselves or their needs, desires, or preferences. Share that this can also involve the fear that the client’s true self (e.g., as an LGBTQ person) will be “found out” and rejected.

Thinking Pattern 2: Internalized Stigma Explain to your client that some LGBTQ people think that they and other LGBTQ people are somehow inferior, bad, lower status, sinful, or diseased. Discuss how this societal stigma can become internalized and explain that when stigma gets internalized, LGBTQ people can start having automatic negative thoughts about themselves or other LGBTQ people.

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Explain how oftentimes this process of internalization is quite subtle and that internalized negative thoughts can be so deeply ingrained that they seem almost unconscious.

Thinking Pattern 3: Contingent Self-​Worth Contingent self-​worth refers to the belief that one has to achieve some accomplishment (e.g., be the best) in order to be valued and loved: ■ Some LGBTQ people end up believing that they must be successful in achievement-​related domains (e.g., academics, appearance, competitions) to have value as a person. Contingent self-​worth among LGBTQ people is often rooted in ■ early and ongoing experiences with sexual LGBTQ-​related stress that denies many LGBTQ people traditional sources of self-​esteem from an early age (e.g., unconditional love from parents). If you are working with clients with strong achievement-​related contingent self-​worth, you can help these clients identify their personal worth outside of achievement-​related domains.

Thinking Pattern 4: Isolation and Loneliness Because of being a numeric minority in society, some LGBTQ people develop a sense of self that is not readily reflected in others. As a result, some LGBTQ people believe that they are alone, deserve to be alone, or will always be alone. Share with such clients that this belief has roots in LGBTQ-​related stress and is common among LGBTQ people.

For Each of These Different Thinking Patterns For each of the thinking patterns discussed above, try asking: Tell me about a time when this thinking pattern applied to your own life. ■ How do you think your early experiences with LGBTQ-​related stress ■ shaped this thinking pattern? 173

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■ In what ways do you think that this thinking pattern may have helped you, at least in the short term? In what ways do you think that this thinking pattern may not have ■ helped you, perhaps in the long run? What about ways that this pattern has gotten in the way of your goals?

Clients Need Not Blame Themselves for Their Automatic Thinking Patterns Ensure that your clients understand that these thinking traps are common—​especially among LGBTQ people with emotional disorders. Building upon the skill of present-​ focused nonjudgmental emotion awareness, invite your client to become aware of their automatic thinking patterns in a curious, nonjudgmental way. In summary: Automatic thinking patterns are common and are often rooted in early and ongoing experiences of LGBTQ-​related stress.

Help the Client Identify Common Thinking Traps Arising from LGBTQ-​Related Stress and Discuss How These Thinking Traps Can Impact Emotions Next, help your client to identify, understand, and consider ways to challenge thinking traps.

What Are Thinking Traps? As illustrated in Figure 10.2, thinking traps are automatic, rigid, and generally unhelpful ways of filtering information that make our emotional experiences in situations worse because they prevent us from considering alternative (and potentially more realistic) interpretations of situations. As shown in Worksheet 8.2: Identifying and Evaluating Automatic Thoughts, two thinking traps are common reactions to early and ongoing LGBTQ-​related stress:

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Ambiguous Event

Thinking Trap(s)

Negative Emotional Reactions

Figure 10.2. Model demonstrating how ambiguous events can trigger thinking traps, which serve to cause or intensify negative emotional reactions. ■ Jumping to conclusions: Believing the chance of something bad happening is much higher than the actual likelihood of it happening, with little to no evidence. Thinking the worst: Expecting the worst possible outcome in a ■ situation—​and convincing ourselves that we are not equipped to handle it. Although we differentiate between these thinking traps, many negative thoughts fulfill both criteria (i.e., we jump to the worst possible conclusion and believe we are unable to cope with it). Work with your client to identify examples of times when they jumped to conclusions, thought the worst, or both. You can use Worksheet 8.2: Identifying and Evaluating Automatic Thoughts to identify potential thinking traps in response to recent stressful situations. This worksheet is available near the end of Chapter 8 in the client workbook and can 175

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also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com.

Normalize Thinking Traps LGBTQ people may be particularly likely to feel shame about perceived personal flaws, especially if they were surrounded by early and ongoing societal messages telling them that LGBTQ people are to blame for their “deficient” sexual orientation and/​or gender identity. Perniciously, this shame can spread to characterize even the ways your LGBTQ client might think about their thinking. Therefore, it is important to remind your client that, like all automatic thinking patterns, these thinking traps are a natural reaction to LGBTQ-​related stress. In summary: Thinking traps are unhelpful and rigid ways of interpreting situations that can interfere with your client’s life.

Introduce and Help Clients Practice Cognitive Flexibility Build cognitive flexibility by inviting your client to pay attention to each interpretation they make and evaluate it not as “truth” but as one possible interpretation of the situation. As illustrated in Figure 10.3, cognitive flexibility is a useful skill for breaking the cycle of thinking traps leading to negative emotional states, which in turn lead to more thinking traps. Specific forms of cognitive flexibility can be used to increase one’s open-​minded thinking in interpreting situations and countering thinking traps (Table 10.1): ■ Countering jumping to conclusions involves objectively evaluating the likelihood of an event actually occurring, based on previous experience. Countering thinking the worst involves re-​evaluating the consequences ■ of a feared event and performing an objective assessment of one’s ability to cope with the feared event if it does occur.

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Ambiguous Event

Cognitive Flexibility

Negative Emotional Reactions

Figure 10.3. Model demonstrating how in the face of ambiguous events, cognitive flexibility can serve to avoid or alleviate negative emotional reactions. Examples Instead of inflexibly being guided by thinking traps, it is important to consider other possible interpretations. Thoughts about the worst scenario can still be there, but they can “coexist” with other possible assessments of the situation. For example, your client might learn to allow themselves to consider equally both the possibility that they could get rejected if they ask someone out on a date (i.e., thinking the worst) and the possibility that the person could accept the date (i.e., a thought that counters the thinking trap). The goal is to build flexibility in the client’s thoughts and allow for alternate interpretations and expectations in emotionally charged situations, taking into account the client’s current context.

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Table 10.1.  Identifying and Evaluating Automatic Thoughts—​LGBTQ-​Related Stress Examples Situation/​ Trigger

Automatic Thought(s) or Interpretation(s)

Emotion(s)

Identify “Thinking Trap”

Generate Alternative Thought(s) or Interpretation(s)

Called a friend in the morning and haven’t heard back yet.

She doesn’t like me. She thinks I’m annoying.

Ashamed, alone, self-​conscious

Jumping to conclusions

1. She’s busy and hasn’t heard my message yet. 2. Her phone died.

Saw another queer woman of color at a party and am interested.

If I introduce myself, Anxious, afraid, Thinking I’m going to make embarrassed the worst a fool of myself and they will reject me and make fun of me. I won’t be able to handle it.

1. They may not reject me. 2. I’ve been rejected before and survived.

Boss asked to meet with me later today

She doesn’t like my Anxious, tense, Thinking work. I’m going to afraid the worst get fired. I’m a failure and the worst person.

1. She may want to review my work or a new project. 2. I usually get good feedback and perform well during our meetings.

An attractive guy asks me out

He won’t like me when we actually go out. I’m not good-​ looking enough, fit enough, or smart enough. I have to work really hard tonight at getting him to like me.

1. He asked me out, so he’s clearly interested. 2. I’m a good person with much to offer. 3. No one is perfect.

A feminine, flamboyant gay male coworker is talking about his weekend

He’s so flamboyant, Uncomfortable, Jumping to feminine, and anxious, conclusions annoying. People will annoyed think I’m like that too. People don’t like gay people because of feminine gay guys like him.

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Insecure, pressured, afraid

Jumping to conclusions

1. He’s just expressing himself. I also want to be accepted for who I am. 2. He has the right to express himself how he wants. 3. Others may not find him annoying.

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Table 10.1.  Continued Situation/​ Trigger

Automatic Thought(s) or Interpretation(s)

Emotion(s)

Identify “Thinking Trap”

Generate Alternative Thought(s) or Interpretation(s)

Saw a politician on TV condemning trans people

I  have to work extra hard to show transphobic people that I’m just as good as they are, if not better than them.

Tense, angry

Thinking the worst

1. Even if some people won’t accept me for being trans, others accept me just the way I am. 2. The trans community is my family and nobody can take that from me.

Therapist Note Keep in mind that although fears of rejection may be quite common for LGBTQ people and other stigmatized groups, these fears may be grounded in an accurate perception of rejection in certain contexts. One of your primary tasks in these cognitive flexibility exercises, therefore, is to help clients assess how realistic their thinking traps are versus how much they may be rooted in early LGBTQ-​related stress experiences. If the client and you determine that the situations are actually threatening or dangerous, different coping skills (instead of building cognitive flexibility), to be discussed in subsequent modules, may be more appropriate. Overall and importantly, cognitive flexibility when applied to stigma-affected clients is appropriately used to critically examine the ways in which the client might have internalized stigmatizing ideologies. Cognitive techniques are not intended to be applied to questioning the veracity of stigma experiences. In summary: With practice, clients can develop cognitive flexibility, which can be applied to many situations, including ongoing experiences with LGBTQ-​related stress.

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Agree on Home Practice To reinforce the concepts from this module, collaboratively discuss the following home practice activities: 1. Worksheet 8.2: Identifying and Evaluating Automatic Thoughts allows clients to practice cognitive flexibility. The client should generate at least one alternative interpretation for every situation (although generating additional alternatives can be helpful as well): ■ Clients will first note the situation or trigger for the thought, the thought/​interpretation that they had in response to the trigger, and the emotions they felt following that thought/​interpretation, and then will evaluate the thought/​interpretation with regard to the thinking traps and experiences with LGBTQ-​related stress discussed in session. Clients can then use Box 8.1: The Core Belief Questions (see ■ p. 130 in the client workbook) to help them probe and counter thinking traps and generate alternate thoughts/​interpretations. Remind clients that the goal is not to “believe” a new interpreta■ tion, but rather to allow it to coexist with the automatic negative thought. Neither of the interpretations is necessarily correct—​ they are each examples of a range of possible interpretations. Therapist Note Some clients require more practice with this skill than others, and therefore it may take longer to address all material in session. You may elect to assign Worksheet 8.1: Downward Arrow Technique after one session, and subsequently assign Worksheet 8.2: Identifying and Evaluating Automatic Thoughts the following session. Optional: Clients can continue to practice skills introduced in the previous module. Although the main focus of the home practice should be to develop the skills learned in this module, you can feel free to assign one or two home practice exercises from the previous modules if extra practice would be of benefit. For example, it might be helpful for clients to continue practicing present-​focused awareness using Worksheet 7.2: Anchoring in the Present.

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Module 5: Additional Helpful Reference Materials Case Vignettes Case Vignette #1 In the following vignette, the therapist helps a 19-​year-​old cisgender queer female client, Kristin, identify her rejection-​ laden thoughts. Notice how the therapist’s inquiries explore and link future expectations with past experiences of LGBTQ-​related stress. Therapist:  What were you thinking at the time? Client:  I don’t know. I didn’t think anything. I mean, I just felt sick to my stomach. I was sure that she wasn’t attracted to me. Therapist:  What predictions were you making about how it might go? Or what concerns did you have about what might happen? Client:  Well, I was pretty sure it was going to go badly, just like the last time when that guy told me he wasn’t interested in seeing me anymore. I was really concerned that this new girl would think that I’m stupid or that she just wasn’t that attracted to me. Therapist:  You were expecting to be rejected again. Client:  I guess so. I just thought that when I came out, that queer women would be more accepting and that it wouldn’t be so hard to find someone to date. Therapist:  You thought that rejection wouldn’t be part of the picture anymore now that you’re out.

Case Vignette #2 In this vignette, the therapist is working with a 38-​year-​old cisgender gay male client, Sunil, to identify the source of his internalized homophobia in LGBTQ-​related stress. Notice how the therapist builds on the client’s criticism of other guys to inquire about how these negative views affect Sunil’s self-​view (e.g., internalized homonegativity). Client:  I’m just really turned off by gay guys and how shallow they are, like they only seem to care about pop culture and fashion. They’re also really mean and judgmental—​so catty. Therapist:  How do you explain that you’re gay, but don’t seem to be mean, shallow, or judgmental? 181

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Client:  I guess I’m just different from other gay guys. Maybe because I came out in my mid-​30s. Therapist:  What do you think about the possibility that most gay guys are not mean and shallow once you get to know them? Client:  I don’t know. I just haven’t seen that yet, I guess. Therapist:  You haven’t taken the time to get to know many gay guys on a personal level. Client:  Well, I don’t know, I mean, I’ve hooked up with lots of guys who seemed normal, but that was just for sex. Therapist:  So it sounds like there may be other gay guys who don’t conform to those stereotypes that you mentioned? Client: Sure. Therapist:  And that to get to know them at a deeper level beyond just sex may take some work. Client: Probably. Therapist:  How do you think those stereotypes you have of gay guys as not normal might affect your view of your own self as a gay man? Client:  I’m not sure. I’ve never thought about that. I know I tend to think the worst about other gay guys, but I don’t know how it affects how I see myself. Therapist:  OK, well, let’s start with your tendency to think the worst about other gay men. When you meet another gay guy for the first time, what are your automatic assumptions about how the conversation will go? Client:  I think, “This conversation is going to be exhausting.” Therapist:  OK, let’s use the “Core Belief Questions” to explore this thought more deeply.

Case Vignette #3 In this vignette, the therapist uses the downward arrow technique to help a 26-​year-​old trans gay male client, Sami, identify the core belief that drove him to cancel his date. Notice how the therapist uses the downward arrow technique to identify the core belief that was driving the client’s emotional response in that situation. Client:  So I canceled the date that I had scheduled last week.

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Therapist:  What happened? Client:  I was getting ready to go on that blind date with this cisgender guy and I started getting really anxious. Therapist: What did you notice while you were getting ready for your date? Client:  I noticed some of the usual physical symptoms, like increased heart rate and some sweating. I was worrying that I wouldn’t have anything to say. I got so anxious that I just called and said that I was sorry, but I couldn’t make it. Therapist: You were quite anxious about not having anything to say during your date. I’m curious: What would happen, or what would it mean about you, if you didn’t have anything to say? Client:  Well, I guess if I didn’t have anything to say, my date would think I am boring. I also started questioning why he’s interested in a trans guy like me. Therapist:  And what would happen if he thought you were boring or you realized he did not like you? Client:  I won’t get invited on a second date . . . or he wouldn’t. Therapist:  OK, so if one of you weren’t invited on a second date, what would happen next? Client:  Then there will be another chance gone, and I’ll remember how I’m not ever going to find someone.

Navigating Challenges in Module 5 Difficulty Identifying Automatic Thoughts As described in Case Vignette #1, some clients can have difficulty identifying their thoughts. Oftentimes, these individuals will become so focused on the intensity of the emotion in the moment that they will effectively “ignore” the events or moments that preceded their emotional or behavioral reaction. In cases like these, it can be helpful for you to help guide the client “back in time” to before they entered the situation or when they had just entered the situation to help them begin to identify their automatic interpretations. In such cases, clients will likely benefit from additional focus on and practice with identifying their automatic thoughts, before moving on to challenging these automatic thoughts. 183

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Validating Versus Colluding with Stigma In Case Vignette #2, the therapist is careful to not collude with the client’s internalized homophobia, but also treats it as a possibility in need of further validation. By returning to the client’s view of many gay men as abnormal, the therapist sensitively introduces the fact that the client’s language communicates homophobia towards other gay men and possibly towards the client’s own self.

Tracing Interpretations Back to Core Beliefs Another potential roadblock that can arise while administering the interventions presented in this module is when the client identifies an automatic interpretation, but there is a noticeable disconnect between the nature of the interpretation and the intensity of their response in that situation. The disconnect between the client’s emotional response and their interpretation of the situation is a cue that they have not identified their core beliefs that drive this more surface-​level interpretation. As illustrated in Case Vignette #3, the therapist used the downward arrow technique to identify the core belief that was driving the client’s emotional response in that situation (e.g., calling to cancel the date). It is essential to identify this core belief to maximize the benefit of challenging thinking traps. Worksheet 8.1: Downward Arrow Technique is a useful tool for helping clients to understand this disconnect.

Responding to Cognitive Avoidance Sometimes, an individual experiencing intrusive cognitions (e.g., obsessions or worry) will become fixated on evaluating the actual probability of the feared event occurring. This can become a form of cognitive avoidance. In this case, it is helpful for you to redirect the client away from evaluating probabilities to evaluating their ability to cope with the consequences and/​or the meaning they are ascribing to the event if it were to happen. In addition to redirecting these individuals to evaluate the consequences associated with the feared event itself, it can also be useful to establish a time limit for clients to spend on re-​evaluating the actual probability of the feared event to ensure they don’t get stuck in a cognitive avoidance cycle. 184

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CHAPTER 11

Module 6: Countering Emotional Behaviors

(Corresponds to Chapter 9 of the client workbook) This module explores the concept of emotional behaviors, such as avoidance, and how LGBTQ-​related stress experiences can contribute to emotional behaviors. Accordingly, you will: ■ Start the module by discussing the client’s home practice, in which they tracked and reappraised their automatic thoughts. Introduce the concept of avoidant emotional behaviors and discuss ■ how it relates to LGBTQ-​related stress. Help your client identity examples of emotional behaviors in their ■ life and how such behaviors emerge from LGBTQ-​related stress. Help your client develop alternative actions that are congruent with ■ their treatment goals.

Module Agenda Review current symptoms on the Progress Record ■ Review home practice from the prior module ■ Introduce the concept of emotional behaviors and the role of ■ LGBTQ-​related stress Present examples of different types of emotional behaviors ■ Explore your client’s own unhelpful emotional behaviors that derive ■ from LGBTQ-​related stress Demonstrate the paradoxical effects of emotion avoidance ■ Discuss how emotional behaviors get maintained and strengthened, ■ providing a rationale for alternative actions Help your client develop alternative actions that counter their emo■ tional behaviors in the context of LGBTQ-​related stress Agree on home practice ■

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Recommended Number of Sessions This module is intended to be delivered across two or three sessions. If you choose to complete this module in two or three sessions, you might divide the module content as follows: ■ Session 1: Focus on psychoeducation about emotional behaviors, exploring your client’s emotional behaviors related to LGBTQ-​ related stress and the impact of these emotional behaviors Sessions 2 and 3: Focus on helping your client develop specific alter■ native actions that are incompatible with their emotional behaviors and potentially help to begin practicing or planning to practice these alternative actions

Materials Needed ■ ■ ■ ■

Progress monitoring assessments (i.e., ODSIS, OASIS) Progress Record White board or piece of paper Worksheet 9.1: List of Emotional Behaviors, located in client workbook Chapter 9 ■ Worksheet 9.2: Alternative Action, located in client workbook Chapter 9 Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The Progress Record is located at the end of Chapter 3 in the client ■ workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be downloaded by searching ■ for this book’s title on the Oxford Academic platform at academic. oup.com.

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Review Current Symptoms on the Progress Record Continue using the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session, based on the assessments that they complete before the session (i.e., ODSIS, OASIS). ■ As with prior modules, explore any changes in symptoms (increases or decreases) and discuss your client’s perceptions regarding the source of these changes. You are now about halfway through treatment, depending on how ■ many sessions are planned. This is often a good time to check in about how your client feels about their progress thus far in treatment and review any changes to their initial treatment goals.

Review Home Practice from the Prior Module For home practice, you and your client agreed that they would track and challenge their automatic appraisals using Worksheet 8.2: Identifying and Evaluating Automatic Thoughts. Discuss how effectively your client identified and challenged their automatic thoughts. If they had difficulty identifying and/​or challenging their automatic thoughts (which is common): ■ Normalize that this is a challenging new skill (they are confronting automatic thoughts rooted in longstanding core beliefs). Instill hope that with more practice it gets easier. ■ Discuss the challenges of implementing this skill. ■ Some clients have difficulty slowing down to notice and/​or challenge their automatic thoughts while experiencing strong emotions. Encourage clients to try observing and challenging their automatic thoughts after the intense emotions have passed. Encourage them to use mindfulness skills (Module 4) to be aware of their automatic thoughts, even if they are not able to challenge them in the moment. Help your client identify and challenge their automatic thoughts from the past week, especially if your client was not able to complete this on their own. Reinforce the importance of continuing to practice

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this skill, which will increase their awareness of the sequence of their emotions and provide opportunities to alter their interpretations of emotional triggers.

Introduce the Concept of Emotional Behaviors and the Role of LGBTQ-​Related Stress The focus of this module is on emotional behaviors driven by LGBTQ-​related stress. The following are some key points to highlight regarding the concept of emotional behaviors and the role of LGBTQ-​related stress.

What Are Emotional Behaviors? Emotional behaviors are any behavior that an individual might use to: Avoid feeling strong emotions ■ Prevent emotions from becoming too intense ■ Reduce strong emotions once they have already begun ■ Some clients feel uncomfortable experiencing positive emotions, not just negative emotions. These clients may use emotional behaviors to reduce or avoid positive emotions.

LGBTQ-​Related Stress Begins Early in Life and Can Produce Strong, Negative Emotions LGBTQ-​related stress begins early in life, when LGBTQ people begin to develop an awareness of themselves as different from their heterosexual and cisgender peers. As a reminder, some of these experiences of LGBTQ-​related stress could include: ■ Being preoccupied about a newly formed LGBTQ identity and decisions about coming out. Concealment of one’s LGBTQ identity and feelings of shame/​guilt ■ for living a “double life.” Peer and family bullying, rejection, or other forms of discrimination. ■ 188

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■ Difficulties finding an LGBTQ community to which one feels a sense of belonging. Stress about the possibility of acquiring HIV. ■ Shame about feeling attracted to people of the same gender. ■ Review the LGBTQ-​related stress experiences that your client shared in prior modules and normalize that these experiences can produce strong, negative emotional experiences such as: ■ ■ ■ ■ ■

Intense emotional distress Emotional numbing Intrusive memories of LGBTQ-​related stress Physical reactivity upon remembering stressful events Pessimism about one’s ability to be happy and enjoy life

Emotional Behaviors Can Be Used to Cope with the Strong Emotions from LGBTQ-​Related Stress LGBTQ-​related stress can produce strong, uncomfortable emotions that LGBTQ people need to find ways to cope with. Emotional behaviors are one way of coping because they allow LGBTQ people to avoid or reduce the intensity of these emotions.

Help Your Client Understand the Difference Between Helpful and Unhelpful Emotional Behaviors Emotional behaviors are not necessarily “good” or “bad.” As discussed in Module 3, emotions serve an important function: They tell us to act in a certain way, driving us towards or away from certain behaviors, which is good for survival. However, some emotional behaviors are maladaptive (unhelpful), and whether an emotional behavior is adaptive (helpful) or maladaptive (unhelpful) depends on the function of the behavior. ■ Work with your client to analyze the function of an emotional behavior to determine whether the emotional behavior is helpful or unhelpful in the long term.

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■ Use Worksheet 6.2: Monitoring LGBTQ-​Related Stress to assess the triggers that led to the emotional behavior and the consequences, or “rewards,” that followed the behavior. Completing this functional analysis with your client will ■ help them identify the “reason” for engaging in that emotional behavior. Emotional behaviors can shift from being helpful (adaptive) to unhelpful (maladaptive) over time. Some emotional behaviors that may have been helpful for dealing with LGBTQ-​related stress at one point in the client’s life (e.g., concealing sexual orientation to avoid bullying in childhood) may now be unhelpful (e.g., concealing despite clear signs of inclusion in the workplace). Invite your client to consider that the same behavior might have been helpful in the past but is unhelpful in the present. Table 11.1 shows examples of how the same “emotional behavior” could be helpful (adaptive) or unhelpful (maladaptive), depending on the situation. In summary: Emotional behaviors are those used to manage intense emotions, often in relation to LGBTQ-​related stress. They may be helpful or unhelpful, depending on the context.

Table 11.1.  Emotional Behaviors: Helpful or Unhelpful? Emotional Behavior

Helpful Example

Unhelpful Example

Feeling angry motivates the individual to engage in aggressive behaviors, such as verbal threats, physical attack, or a facial/​bodily threat display.

It would be helpful to engage in this emotional behavior if the person is about to be physically attacked and needs to protect themselves.

It would be unhelpful to engage in this emotional behavior if the person had a verbal disagreement with someone and these behaviors escalated the conflict to a physical altercation.

Feeling afraid motivates the individual to engage in isolation behaviors, such as removing themselves from the feared situation.

It would be helpful to engage in this emotional behavior if the situation was not safe or threatened their physical well-​being.

It would be unhelpful to engage in this emotional behavior if the situation was not harmful and the fear is rooted in inaccurate perceptions about the situation (e.g., people will reject me).

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Present Examples of Different Types of Emotional Behaviors This section highlights different types of emotional behaviors, including those related to LGBTQ-​related stress. We recommend beginning with psychoeducation about these four types of emotional behaviors: ■ Overt behavioral avoidance involves completely avoiding situations, people, or other triggers that elicit strong emotions. Example: A client declines an invitation to go on a date—​even though this prospective dating partner seems like a good match—​due to fears that the client will be rejected, feeling not “good enough” for this person, and fears of judgment. Subtle behavioral avoidance refers to behaviors that a person can use ■ to reduce the emotional intensity of a situation when they cannot completely avoid the situation, person, or other trigger(s) for their emotions. Example: A client feels that she has to be perfect in all aspects of her life to “make up for” being a lesbian and subsequently becomes overwhelmed by the pressure to be “perfect” and begins to procrastinate on emotionally overwhelming tasks (e.g., schoolwork). Cognitive avoidance is the use of cognitive strategies to avoid ■ experiencing painful emotions. Example: A client who is depressed and got many “lectures” from his rejecting family members about being gay now tunes out whenever he starts feeling overwhelmed in a conversation, even when the conversation is not threatening to him. Safety signals are objects that people use to avoid emotions. Some ■ safety signal items prepare the individual to engage in cognitive avoidance (e.g., bringing a book to distract from unpleasant emotions) or behavioral avoidance (e.g., bringing sunglasses to avoid social exchanges). Example: A client fears that they will have a panic attack in any new social situation, so they carry anti-​anxiety medications with them at all times for safety. Explore your client’s emotional behaviors, how they relate to LGBTQ-​ related stress, and potential alternative behaviors: ■ After or as you describe the different types of emotional behaviors, try asking your client to think of any examples of their own emotional behaviors. Some clients are able to identify their emotional behaviors, how they ■ relate to LGBTQ-​related stress, and potential alternative behaviors 191

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on their own. Table 11.2 provides a long list of examples for those clients who struggle to identify their own emotional behaviors and the connection to LGBTQ-​related stress on their own. ■ Keep in mind during this discussion that different types of emotional behaviors may be associated with different types of psychological disorders (e.g., depression, anxiety, panic disorder).

Table 11.2.  Emotional Behaviors, LGBTQ-​Related Stress Correlates, and Alternative Behaviors Emotional Behavior

Possible LGBTQ-​Related Stress Origin

Alternative Behaviors

Not asserting one’s needs, opinions, and preferences

Fears of rejection; past victimization

Asserting one’s needs, opinions, or preferences

Leaving (escaping) from a social situation

Fears of rejection; concealment

Staying in a situation and approaching people; smiling at someone

Withdrawing socially

Fears of rejection; concealment; past victimization

Behavioral activation (engaging in enjoyable/​mastery activities)

Avoiding discussing safer sex (e.g., using pre-​exposure prophylaxis [PrEP], using condoms)

Avoiding reminders about sexual health/​HIV; internalized stigma; fears of rejection

Talking to a doctor about starting PrEP; using condoms; having a conversation with a partner about sexual health

Avoiding intimacy or romantic relationships

Internalized stigma; Establishing a profile on an LGBTQ experiences of rejection dating website; going on dates from heterosexual/​cisgender or LGBTQ people

Avoiding genuine relationships with other LGBTQ people

Internalized stigma; expectations of rejection; feelings of not fitting into a particular subgroup in the LGBTQ community

Joining an LGBTQ-​focused sports league and building a platonic relationship with other LGBTQ people

Avoiding heterosexual and/​or cisgender people

Early and ongoing experiences of actual or feared rejection; concealment

Asking a heterosexual/​cisgender coworker to lunch or to do an activity

Overt Behavioral Avoidance

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Table 11.2.  Continued

Emotional Behavior

Possible LGBTQ-​Related Stress Origin

Alternative Behaviors

Not attending LGBTQ pride or other social gatherings to avoid anxiety

Internalized stigma; concealment; fears of rejection

Making specific plans to attend an upcoming LGBTQ social gathering and following through on these plans

Not responding to friends’ text messages or phone calls

Feeling that one does not “fit in;” feeling a need for control or safety due to stigma

Answering messages in a timely manner, even if declining an invitation; being assertive with friends

Perfectionist behavior to avoid failure

Early and ongoing experiences of actual or feared rejection; contingent self-​worth

Leaving things untidy or unfinished

Interpersonal hostility (opposite of unassertiveness) to feel in control

Past experiences with rejection or victimization

Removing self from the situation; practicing relaxation; engaging in assertive (not hostile) communication

Being hypervigilant to avoid rejection

Fears of rejection; concealment; past victimization

Focusing on the specific task at hand instead of other potential triggers; meditating; relaxation

Seeking validation through sex

Expectations of rejection; contingent self-​worth based on appearance or attractiveness

Calling a friend for support when feeling low self-​worth or rejected

Using substances (in general or during sex) to avoid shame

Fears of rejection, internalized stigma

Having sober sex; attending a social function sober

Avoiding eye contact to avoid social interaction

Shame related to being LGBTQ; feeling that one does not “fit in”

Making eye contact with other people

Not consuming caffeine to avoid physical sensations

Discomfort with one’s emotions or bodily sensations

Consuming caffeine; exercising to elicit sensations of physiological arousal

Subtle Behavioral Avoidance

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Table 11.2.  Continued

Emotional Behavior

Possible LGBTQ-​Related Stress Origin

Alternative Behaviors

Trying to control breathing to avoid physical sensations

Feeling a need for safety or control due to stigma

Exposure to heavy/​rapid breathing or heart rate (e.g., exercise, breathing through a straw)

Avoiding exercise and other physiological arousal to avoid physical sensations

Feeling a need for safety or control because of stigma

Engaging in exercise that elicits physiological arousal

Avoiding touching sinks, toilets, or other things perceived to be dirty

Feeling a need for safety or control because of stigma

Purposefully touching surfaces or objects that are perceived to be dirty

Procrastinating on emotionally triggering tasks

Fears of failure or inferiority; Approaching tasks that are self-​worth being contingent emotionally triggering well before on “success” or achievement a deadline

Cognitive Avoidance Distraction (reading a book, watching TV, browsing social media/​internet to avoid emotions)

Fears of failure and inferiority; contingent self-​worth based on achievement; need for safety or control; fears of rejection; internalized stigma; fears of discrimination or victimization

Mindfulness skills to fully experience emotions and counter distraction; staying focused on an emotionally triggering person or situation

“Tuning out” or not being fully present during a conversation that is emotionally intense

Shame related to being LGBTQ; feeling different; feeling that one does not fit in or have the skills to cope

Mindfulness skills to stay present and focused on the words the other person is saying

Excessively reassuring oneself that everything is OK

Feeling the need for safety Engaging in activities where the or control because of prior outcome is unknown experiences of or anticipated stigma

Trying to stop emotionally intense thoughts

Early/​ongoing LGBTQ-​ related discrimination or victimization; trauma

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Mindfulness skills to allow thoughts to fully express themselves and subside

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Table 11.2.  Continued Emotional Behavior

Possible LGBTQ-​Related Stress Origin

Alternative Behaviors

Forcing oneself to “think positively” (instead of allowing any non-​positive thoughts)

Feeling the need for safety Cognitive restructuring to generate or control because of stigma balanced/​accurate thoughts (that are not overly positive or overly negative)

Excessive or persistent worrying

Fearing failure and being inferior; having one’s self-​ worth be contingent on “success” or achievement

Suppressing (pushing down) emotionally intense thoughts

Fearing failure or inferiority; Mindfulness skills to experience need for safety and control and accept emotionally intense related to stigma; fearing thoughts rejection; internalized stigma

Setting aside “worry time” that is gradually reduced each day

Safety Signals Having to always carry a cell phone when leaving the house

Feeling a need for safety Going to a social activity without or control because of past bringing a cell phone LGBTQ-​related trauma; fear of rejection from others

Always carrying medication (even ones that are not needed)

Feeling a need for safety or control because of stigma

Going to school or work without bringing medication bottles

Holding on to or carrying “lucky” items

Feeling a need for safety or control because of stigma

Asking a friend to hold on to a “lucky” item to practice being places without it (and without knowing where it is)

Keeping something to read or browse on hand at all times

Fears of failure and inferiority; self-​worth being contingent on achievement; need for safety, control due to stigma

Sitting in a coffee shop or other public location without reading material, a cell phone, or other distraction materials

Carrying or wearing sunglasses, hat, or other items that hide one’s face or eyes

Shame related to being LGBTQ or being different; believing that one does not fit in; fears of rejection

Walking around without eyes covered; making eye contact with a stranger and smiling in their direction

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Box 11.1. Emotional Behaviors, Substance Use, and Sex

For some LGBTQ people, emotional behaviors can be especially strong in the context of sexual or romantic relationships. For LGBTQ people, intimate relationships can bring up emotions related to messages that same-​sex sexuality is dirty, dangerous, or laden with possibilities for rejection and that LGBTQ people are inferior, unlovable, or incapable of having loving relationships. LGBTQ people are also disproportionately targeted by perpetrators of childhood sexual abuse, which can further exacerbate strong emotions in the context of intimate relationships or sex. The intense emotions related to intimate relationships can lead to emotional behaviors such as: ■ Using substances during sex or seeking out anonymous sexual partners to avoid or prevent uncomfortable emotions in the context of intimacy. Seeking sex to avoid emotions related to the possibility of being rejected or to maintain ■ contingent self-​worth related to appearance or attractiveness. Remember: A guiding principle of this treatment is that same-​sex sexuality is healthy and can be used to reduce stress in helpful ways (e.g., in consensual and enjoyable contexts). This is different than sex functioning as an emotional behavior (e.g., as a way to avoid uncomfortable emotions). As with all emotional behaviors, we encourage examining the function of sex and substance use to understand whether or not they are helpful or unhelpful.

Box 11.1 presents some background and examples of the relationship between sex, substance use, and emotional avoidance that some LGBTQ clients may experience. In summary: Describe the different types of emotional behaviors and explore the emotional behaviors in your client’s life, as they connect to LGBTQ-​related stress.

Explore Your Client’s Own Unhelpful Emotional Behaviors That Derive from LGBTQ-​Related Stress Help your client continue exploring additional examples of unhelpful emotional behaviors that might be driven by LGBTQ-​related stress in

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their own lives. We suggest using the discussion questions below, while the client fills out Worksheet 9.1: List of Emotional Behaviors. This worksheet is available near the end of Chapter 9 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Ask about your client’s emotional behaviors: What kinds of emotional behaviors do you see yourself engaging in? ■ To what extent do the examples from Table 11.2 resonate with you? ■ What are some examples from your own life that don’t appear in ■ Table 11.2? How do these emotional behaviors relate to your past or ongoing ■ LGBTQ-​related stress experiences? Assess the function of your client’s emotional behaviors: ■ What function do you think that these emotional behaviors serve for you? What emotions do these behaviors help you avoid? ■ In what ways are these behaviors useful in the short term? What benefit ■ do they bring you? Explore the consequences of your client’s emotional behaviors: ■ What are the longer-​term consequences of these behaviors? (This is explored more in the next section.) In summary: Before moving on to the next section, be sure that your client has a good understanding of at least a few of their unhelpful emotional behaviors and how they might be driven by LGBTQ-​ related stress.

Demonstrate the Paradoxical Effects of Emotion Avoidance Emotion avoidance typically does not work in the long run and can even backfire, which is demonstrated through two exercises. Below are some points to cover to illustrate this: ■ Emotion avoidance typically works in the short term, but in the long term it can backfire.

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■ Trying not to think about something important or distressing might work in the short term, but in the long term, trying to suppress thoughts actually leads to thinking about those thoughts more. The exercises in Table 11.3 are two ways of showing your client why emotion avoidance does not work; however, the therapist should feel free to develop other exercises to demonstrate this point. Table 11.3.  Exercises to Demonstrate the Paradoxical Effects of Emotion Avoidance Exercise 1

Exercise 2

Instructions to Client

To get us started, I want you to mentally picture a white bear. Imagine exactly what the bear looks like, calling all the details to mind. Do you have it? OK, great. For the next 60 seconds, you can think about anything except that white bear. (During the exercise, remind the person not to think about the white bear.)

For this exercise, I want you to choose an LGBTQ-​related stress situation or a memory that is especially emotional for you. Please recall this memory in as much detail as possible. How intense are your emotions (on a scale of 1 to 8) now? Please keep the memory in your mind until its emotional intensity begins to diminish.

Questions to Guide Debriefing

■  How successful were you in not thinking of the bear?   Although you may have been ■ able to avoid thinking about the bear for a period of time, to be sure that you weren’t thinking about it, you at least had to “check” to make sure thoughts were not coming to mind.

■  What happened as you maintained this memory in your mind without engaging in avoidance behavior?   What avoidance behaviors would ■ you normally engage in related to this type of experience?   What are the short-​term and ■ long-​term consequences of those avoidance behaviors?

Purpose of the Exercise

This is an adaptation from an experiment from Drs. Daniel Wegner and David Schneider, who found that thought suppression (pushing a thought away) leads to increased thinking about the suppressed thought.

The purpose of this exercise is to engage your client in an imaginal exposure to an LGBTQ-​related stress situation, and demonstrate that through allowing the thoughts (instead of engaging in avoidance behavior), the emotional intensity will diminish on its own.

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In summary: Trying to block out unpleasant emotions through emotional avoidance typically increases distress, whereas alternative behaviors, such as fully experiencing the emotions, typically leads to a natural reduction in emotional intensity over time.

Discuss How Emotional Behaviors Get Maintained and Strengthened, Providing a Rationale for Alternative Actions Emotional behaviors are often counterproductive, yet they are maintained and strengthened because of their short-​term benefits. Below are some points to highlight to help your client build insight related to the maintenance and strengthening of their emotional behaviors.

Emotional Behaviors Are a Common Response to LGBTQ-​Related Stress Stigma creates a pervasive threat in LGBTQ clients’ daily environments, which can interfere with pursuing life goals. These constant encounters with and reminders of stigma can lead LGBTQ people to experience painful emotions and to engage in emotional behaviors to try to prevent that pain.

Emotional Behaviors Are Repeated Because They Take Away Something Uncomfortable It may be helpful to explain the process of “negative reinforcement,” which refers to how emotional behaviors get reinforced because they immediately remove or prevent something uncomfortable from happening. Having the ability to learn how to avoid discomfort and pain is an adaptive human function! The problem is that people start to engage in these behaviors any time they experience or anticipate emotional discomfort, which is usually unhelpful in the long run.

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Emotional Behaviors Prevent Clients from Learning About Themselves and Their Emotions Emotional behaviors prevent three important learning processes from happening: habituation, extinction, and self-​efficacy: ■ Habituation refers to when a situation that was once emotionally painful no longer triggers the same intensity of emotional pain after repeatedly experiencing that pain. So, if you stay in the situation long enough, you habituate to it. For example, people who live near the train station stop noticing every time a train goes by. Emotional behaviors that involve avoidance of a feared situation prevent habituation. Extinction refers to when a person encounters the painful situation ■ multiple times and learns that the feared negative consequences do not actually happen. This results in the emotional behaviors not being needed (i.e., there is nothing to avoid). For example, someone afraid of the dark who never shuts off the light in their own house, even though it is totally safe there, never learns that it is safe to be in the dark at home. However, extinction cannot happen unless the client exposes themselves to the situation without engaging in their emotional behaviors. Self-​efficacy refers to when a person has a sense that they can handle ■ or cope with the negative consequences of a painful situation. In other words, they feel that even if the painful outcome happens, they can cope. However, if the client always engages in their emotional behaviors, they never have a chance to build a sense of self-​efficacy to tolerate their intense emotions.

Map Out Your Client’s Pattern of Emotional Behaviors It is important that your client understands the relationship between their emotions, emotional behaviors, and the consequences of their emotional behaviors (short-​ term and long-​ term consequences). Try mapping out (using a white board or a piece of paper) how engaging in emotional behaviors makes your client feel. You might also use Worksheet 6.1: Three-​Component Model of Emotions to help your

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client understand the role of their emotional behaviors in maintaining their distress. Try asking your client: What are the short-​term benefits of this emotional behavior? ■ What are the long-​term consequences of this emotional behavior? ■ In summary: Be sure that your client has a good understanding of how emotional behaviors are strengthened through “negative reinforcement” and the missed learning opportunities that happen as a result of emotional behaviors.

Help Your Client Develop Alternative Actions That Counter Their Emotional Behaviors in the Context of LGBTQ-​Related Stress The final goal of this module is to foster healthy, goal-​and value-​ consistent behavior that counters your client’s unhelpful emotional behaviors. Below are some key points to discuss to help your client develop alternative, healthy actions that counter their emotional behaviors.

Break the Cycle of Emotional Behaviors and Shift Towards Healthy Behaviors by Helping Your Client Adopt Alternative Actions In the same way that we learn to engage in emotional behaviors to avoid discomfort in the short term, we can also learn to engage in alternative behaviors that generate more goal-​and value-​congruent long-​term consequences.

Explore Safe Alternative Behaviors One of your primary roles as the therapist delivering this module is to help your client determine the degree of real threat in their daily life and the helpful versus unhelpful role that their emotional behaviors may play against the backdrop of real stigma-​related threats. Once the true threats (versus non-​threatening aspects of the situation) are established, you as the therapist will help your client face previously avoided, but safe, situations with more helpful, approach-​oriented behavior.

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Help Your Client Generate Alternative, Healthy Behaviors That Counter Their Emotional Behaviors Help your client think through alternative behaviors, even ones that they may not yet be ready to try out, that would counter their own emotional behaviors (see Table 11.2 for examples). For instance, if a client experiencing sadness and depression related to a recent break-​up is now withdrawing from friends and not going to their classes, in order to act alternatively, they might call a friend and make social plans. Normalize that it may take time to begin trying these alternative behaviors, and that your client is in charge and can determine the pace of treatment. If your client is ready to try an alternative behavior, suggest that they start with an achievable, smaller alternative behavior and gradually try out even more flexible ways of responding to painful emotions. For example, if your client is withdrawing from all social plans, an initial alternative action might be to call one friend rather than trying to join a club or go to a party. After some successes with initial actions such as this, your client might be ready for group gatherings and more impromptu social events.

The LGBTQ Community Can Play an Essential Role in Countering Emotional Behaviors For some LGBTQ clients, their emotional behaviors may be due to LGBTQ-​related stress within the LGBTQ community (e.g., not feeling like they belong within the LGBTQ community; experiencing unrealistic standards regarding income, age, gender expression, body type, or HIV status within the LGBTQ community; difficulty finding supportive LGBTQ role models). ■ Be sure to consider with your client how building genuine connections in the LGBTQ community could support them countering their emotional behaviors. Even if they have not been successful in the past, you can help your ■ client to find a supportive niche within the LGBTQ community. You can also challenge any assumptions your client may have that ■ “all LGBTQ people are like that” as based in negative stereotypes

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about the LGBTQ community and over-​generalizations about the likelihood of finding supportive people within these communities. In summary: End the module with a concrete plan about how your client might begin to engage in alternative actions that counter their emotional behaviors and are congruent with their treatment goals and values.

Agree on Home Practice By the end of this module, your client will likely have a good understanding of their emotional behaviors and how they relate to their own LGBTQ-​related stress experiences. They also will have generated some ideas for engaging in alternative behaviors. For home practice, collaborate with your client on the following: 1. Continue to track emotional behaviors and alternative behaviors on Worksheet 9.2: Alternative Action. This worksheet is available near the end of Chapter 9 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. 2. To prepare for behavioral experiments in the final modules, it may be helpful to encourage clients to begin entering situations that may provoke difficult emotions, and to try to engage in alternative (rather than emotional) behaviors in these situations. Examples of such situations (although this depends on your client’s unique presenting concerns) may include talking to a friend about a difficult topic or watching a distressing television show or movie. Clients do not yet need to elicit strong emotions that are personally relevant, per se. It is most important that they begin to practice entering mildly emotionally challenging situations to get a sense of what it might be like to approach any emotion more flexibly. Instruct clients to practice being aware of their emotional experiences in these situations, including their automatic appraisals and emotional behaviors. Some clients may feel ready to begin engaging in alternative behaviors in these mildly emotionally distressing situations. If so, encourage this to prepare them for the final modules.

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Module 6: Additional Helpful Reference Materials Case Vignettes Case Vignette #1 In this vignette, the therapist is working with a 43-​year-​old Caribbean Black cisgender gay man to better grasp the concept of emotional behaviors and how his emotional behavior of overworking may be protecting him from certain emotions in the short term but preventing him from achieving his long-​term goals at the same time. The therapist identifies how a behavior that might seem adaptive and even positive can backfire to have unhelpful consequences over time. Therapist:  You were telling me last week about how you often work really long days. Tell me more about what’s driving that for you. Client:  Well, it’s just that I work in the tech industry, and if I want to get to my goals, to really become a leader in the company, that’s what I have to do. I don’t want to lose my job or get fired. It’s really important to me to get to where I want to be professionally. I’m sorry about being late for our last few sessions because I was still at work, but it’s just something I really value. Therapist:  Got it. So being successful is really important to you and working long hours feels like a requirement for achieving that. Client: Exactly. Therapist:  How realistic do you think it is that you would be fired if you didn’t work 14-​hour days? Client:  OK, well, it’s not that I think I would be fired, I just want to make sure I’m successful; it’s something that’s important to me. Therapist:  Right, and it’s totally valid to value your work. I’m wondering what other emotions might drive that behavior? What might happen if you didn’t work such long hours? Client:  I just hate the thought of failing at what I do. Most of the guys within the gay community here are not Black or Caribbean—​and they can say some pretty ignorant things. I think I try to prove their stereotypes wrong. For example, when I’m around guys, they’re always really impressed with how successful I am financially, and I feel like that’s the biggest thing in the community that

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I hang out with—​it’s just all about being hot and successful, so even if people make assumptions about me and where my family comes from, at least I have the successful part going for me. Therapist:  So as we’re talking about this idea of emotional behaviors, it sounds like working really long hours maybe isn’t just about pursuing something you value, but also at least partially about avoiding or preventing yourself from feeling not good enough in the eyes of guys who may judge you and hold cultural stereotypes? Client:  Maybe that’s true. I hadn’t really thought about it that way; it seems weird to think that working a lot is a bad thing. Therapist:  I don’t think it’s about good or bad, but it’s more important to understand what the function of the behavior is, and the extent to which that function moves you towards or away from your goals. Client:  OK, that makes sense. So what do you think, does this mean I need to change something? Therapist:  Well, let’s talk that through some more, because this treatment is really about you achieving your own goals. You’ve already told me that, at least in the short term, working long hours leads to you feeling impressive compared to other guys. What about the long-​term consequences of working a lot of hours? What is this potentially costing you? Client:  That’s the thing. It’s not really costing me anything, it’s helping me because I’m financially successful, and guys are more into me for that reason. I feel less judged. Therapist:  OK, so those are definitely some things that make working a lot seem more appealing. What about being late to your sessions because of work? You mentioned last time that you wished we had been able to have our full session. What other things that you value have you missed out on because of working so much? Client:  Oh, OK, I see what you’re saying. Well, I think one thing is that, even though I do feel like I’m more attractive to guys, the thing is that I work so much that even if I do go out with someone, I usually don’t go out with them again because I’m too busy working, so it’s just hard to really get into a relationship, which I know is something I said I wanted, but it’s also kind of scary. So maybe I’m avoiding that too.

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Case Vignette #2 Here, the therapist is working with a 25-​year-​old cisgender lesbian woman to better understand the function of her emotional behavior of social withdrawal and isolation in the current painful situation she is facing—​a recent break-​up. In this vignette, the therapist compares the client’s current emotional behavior to her emotional behavior in high school, as well as early lessons of self-​efficacy to tolerate difficult emotions. Client:  I know that it’s bad that I’m always staying at home, and that lying in bed all day just makes me feel more depressed, but I don’t understand why I keep doing it if I know it’s not helping me. Therapist:  I can imagine that feels frustrating. So if staying in bed all day is an emotional behavior, you would say that you already know that there are some long-​term downsides. What do you think is reinforcing that behavior? In other words, what do you think staying in bed all day helps you to avoid? Client:  I don’t have to face any of that stressful stuff that I was telling you about. After my girlfriend dumped me, everything reminded me of her, and it just felt better to stay home and not think about her or have to deal with the reminders. Therapist:  That makes a lot of sense, so you’re doing something to keep yourself from feeling bad. Client:  Yeah, I mean, I still end up feeling bad because I’m embarrassed by how little I’m doing, but it’s a relief not to have to think about her, or to think about how I’m probably going to be alone forever. Therapist:  And the more that you stay in bed to avoid those uncomfortable feelings, the more likely you are to do it the next day, because as a human, you are learning with each day of practice with that emotional behavior that it works to keep away those especially painful feelings about your break-​up. Client:  Right. Wow, it feels just like when I was in high school all over again. Therapist:  In high school, what was the trigger for staying in bed all day? Client:  It wasn’t the same; it was more just that I felt like things were never going to get better, so I would fake sick and get to stay home from school. I just felt like I didn’t fit in with anyone at school, like there was something wrong with me and I hated going. 206

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Therapist:  And when you stayed home, what happened? Client:  Same as now, it was a relief, but then I ended up feeling worse, especially because then I really lost touch with the few friends I had, and my grades started slipping. My dad eventually got me to stop skipping school. Therapist:  OK, so that was an opportunity to learn about what it was like to face a situation that was distressing for you. While it may not have been the perfect situation, I’m willing to bet that you learned something about yourself or the situation through being in the situation. Client:  Well, it sucked, but I got through it, so maybe I learned that I’m able to make it through tough things. Therapist:  Right, so even if it wasn’t a fun situation, you did have the ability to tolerate and survive those difficult experiences. That’s a very different learning experience than what you’re learning now about yourself with respect to your break-​up. Client:  I can see that, so maybe if I don’t keep myself locked up in my apartment all the time, I might get triggered and reminded of her, but I guess I can survive it even if it’s hard.

Navigating Challenges in Module 6 Differentiating Helpful Versus Unhelpful Emotional Behaviors Clients are typically able to identify when patterns of avoidance (i.e., emotional behaviors) have become problematic. However, avoidance of painful situations can sometimes be helpful and serve an important function for survival. This is especially important to keep in mind when working with LGBTQ clients, who may face numerous painful situations on a regular basis. Some clients find this confusing and may struggle with differentiating when, and under what circumstances, emotional behaviors can be helpful. Therefore, you will most likely find it beneficial to work with the client to collaboratively define what constitutes helpful versus unhelpful emotional behaviors, taking into consideration the client’s expectations of their own behavior, the specific context in which the behavior occurs, and the consequences with which it is associated. The ability to recognize when, and under what circumstances, a behavior should be considered helpful or unhelpful is essential to 207

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behavioral change. Building the client’s ability to differentiate between helpful and unhelpful emotional behaviors can be an important part of treatment, especially for LGBTQ clients with LGBTQ-​related stress backgrounds.

Clients Not Recognizing That an Emotional Behavior Is Unhelpful (Maladaptive) Some clients may also have difficulty recognizing that a behavior is an unhelpful emotional behavior, even though this may appear to be the case. For instance, some clients may indicate that they prefer not to socialize with other LGBTQ people or that they simply prefer to work very long hours. While they may see those behaviors as simply reflecting personal preferences, as opposed to unhelpful (maladaptive) emotional behaviors, you can work with the client to respectfully consider the possibility that these “preferences” may in fact reflect an underlying fear. It may be useful to have the client imagine what it would be like if they continued doing this for an extended period of time. Following this, you can have them imagine what life might be like if they decreased the behavior to some extent.

Emotional Behaviors That Are Difficult to Track and Modify Using the Alternative Action Worksheet Depending on the client’s presenting symptoms, Worksheet 9.2: Alternative Action may not always be enough for tracking and modifying these behaviors. For instance, for clients presenting with more compulsive behaviors, such as repeatedly looking in the mirror or other checking behaviors, tracking the behaviors using the worksheet may become too tedious, which could then affect engagement in the home practice. An alternative approach might be to have the client use a simpler method such as a frequency counter on their phone. The most important part of the home practice is that the client begins the next module with a clear sense of their emotional behavior patterns, which they can then counter through the remaining modules.

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CHAPTER 12

Module 7: Experimenting with New Reactions to LGBTQ-​Related Stress

(Corresponds to Chapter 10 of the client workbook) This module focuses on developing the behavioral skills necessary to assert oneself in the face of difficult interpersonal situations involving LGBTQ-​related stress. Accordingly, you will: ■ Start the module by reviewing the client’s home practice, in which they tracked their emotional behaviors and alternative behaviors in the context of LGBTQ-​related stress. Introduce the concept of assertiveness and discuss what it means to ■ assert one’s personal needs, wants, and desires. Discuss the role of LGBTQ-​related stress in the development of un■ assertive behavioral patterns. Help the client identify their personal rights in challenging interper■ sonal situations and identify situations in which it is most difficult to engage in assertive behavior. Facilitate the client practicing assertive behavior and effective com■ munication skills during an in-​session roleplay exercise designed to manage the negative impact of LGBTQ-​related stress on interpersonal skills.

Module Agenda Review current symptoms on the Progress Record ■ Review home practice from the prior module ■ Introduce the concept of assertiveness and the role of LGBTQ-​ ■ related stress Identify situations in which the client finds it challenging to engage ■ in assertive behavior Identify and challenge unassertive thoughts ■

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Enact assertive behavior in a roleplay exercise ■ Agree on home practice ■

Recommended Number of Sessions This module is intended to be delivered across one to three sessions to provide sufficient time for the client to adequately explore and practice key concepts. For example, one might divide the module content as follows: ■ Session 1: Review Module 6 home practice, discuss assertiveness and LGBTQ-​related stress, identify unassertive situations, identify and challenge unassertive thoughts, discuss home practice Sessions 2 and 3: Review assertiveness home practice, reinforce ■ material from prior session, conduct in-​ session assertiveness roleplay

Materials Needed Progress monitoring assessments (i.e., ODSIS, OASIS) ■ Progress Record ■ Box 10.2: Assertiveness Bill of Rights, located in client workbook ■ Chapter 10 Worksheet 10.1: Asserting Yourself in Challenging Situations, ■ located in client workbook Chapter 10 Worksheet 10.2: Building Assertive Thoughts, located in client ■ workbook Chapter 10 Worksheet 10.3: Reflecting on Acting Assertively, located in client ■ workbook Chapter 10 Worksheet 10.4: Record of Assertiveness Practice (Exercise 1), ■ located in client workbook Chapter 10 Worksheet 10.5: Record of Assertiveness Practice (Exercise 2), ■ located in client workbook Chapter 10 Worksheet 10.6: Record of Assertiveness Practice (Exercise 3), ■ located in client workbook Chapter 10

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Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The Progress Record is located at the end of Chapter 3 in the client ■ workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be downloaded by searching for this ■ book’s title on the Oxford Academic platform at academic.oup.com.

Review Current Symptoms on the Progress Record Continue using the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session, based on the assessments that they complete before the session (i.e., ODSIS, OASIS). Explore any changes in symptoms (increases and/​or decreases) and discuss your client’s perceptions regarding the source of these changes (particularly as they may relate to the skills acquired in the modules so far).

Review Home Practice from the Prior Module For home practice, your client tracked their emotional behaviors and alternative behaviors using Worksheet 9.2: Alternative Action, and they may also have begun to experiment with trying out alternative behaviors. Discuss with your client the emotional behaviors that they identified in the past week and any alternative behaviors in response to LGBTQ-​ related stress that they were able to identify. At this point, clients may be able to identify alternative behaviors but have not yet been able to implement these new responses. Normalize that it may be challenging to engage in these alternative behaviors at first, but that it gets easier with practice. Explore with your client what barriers they face to implementing these alternative behaviors. In our experience, clients are sometimes reluctant to try alternative behaviors because this requires engaging with the very emotions that they have had difficulty experiencing in the past. 211

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Draw on skills from prior modules to support your client in overcoming barriers to implementing alternative behaviors. For example: ■ If your client feels that they will be unable to cope with the emotions that an alternative behavior will cause or strengthen, try using cognitive appraisal and reappraisal skills to address this concern and “clear the path” for trying the alternative behavior. Reinforce that it takes time and practice to begin adopting alterna■ tive behaviors in place of emotional behaviors, and that experiencing some discomfort is an inherent part of this learning process. Therapist Notes It is important to continue to use motivational interviewing in this phase of treatment. ■ You are now in the phase of treatment in which clients will be asked to engage in behavior change during and between sessions. Ambivalence about change is a natural part of the change process. ■ Recall the motivational interviewing techniques introduced in ■ Chapter 6 (Module 1): Express empathy, develop discrepancy, roll with resistance, support self-​efficacy. Consider using motivational interviewing to help your client resolve ■ ambivalence about engaging in behavior change.

Introduce the Concept of Assertiveness and the Role of LGBTQ-​Related Stress The focus of this module is on a common emotional behavior that occurs in response to LGBTQ-​related stress: unassertiveness. Below are key points to discuss in introducing the concept of unassertiveness and the role of LGBTQ-​related stress.

What Does It Mean to Be Assertive? Try starting out the module by asking your client what they already know about what it means to be assertive. In our experience, it is common for clients to believe that being assertive means being “selfish” or “all for oneself.” Instead of using the word “assertiveness,” some therapists may 212

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Box 12.1. Spectrum of Interpersonal Responses PASSIVE

Others’ rights are respected. Own rights are denied.

ASSERTIVE

Own and others’ rights are respected.

AGGRESSIVE

Own rights are respected. Others’ rights are denied.

wish to frame this concept as “self-​affirmation” (being assertive is equivalent to affirming one’s own needs, preferences, and wants). Being assertive or self-​affirming is different than being aggressive or being passive. As shown in Box 12.1, being assertive means respecting one’s own rights and the rights of others. We have found it to be helpful to show the visual tool in Box 12.1 to clients to explain this concept.

What Is the Impact of LGBTQ-​Related Stress on Assertive Behavior? Because many LGBTQ people experience isolation, guilt, and shame in the context of a society that often invalidates their experiences and denies them some of the rights and respect afforded to others, LGBTQ people may feel that they do not have the right to express their personal needs, wants, or desires. LGBTQ people may also feel that they need to yield to the wants and needs of others in order to gain social acceptance. For example, it might be difficult to assertively express yourself when, based on the past, you have learned to expect that when you express your needs or preferences, it can lead to rejection. In fact, one research study showed that past experiences of rejection (from one’s parents) were associated with future chronic expectations of rejection and unassertiveness among gay and bisexual men (Pachankis et al., 2008). Normalize that early and ongoing LGBTQ-​related stress experiences can result in feeling inadequate and unable to act assertively on behalf of one’s own rights.

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In the short term, being unassertive takes away the emotional discomfort and uncertainty of asserting one’s needs, but in the long term, unassertiveness can have great personal costs (e.g., loss of genuine self-​expression, negative experiences). On the other hand, some people may act aggressively when expressing their wants and needs due to feeling like they will not be taken seriously or that their rights will be otherwise denied. While this may lead to satisfying one’s needs in certain situations in the short term, it is also a form of unassertiveness and can cause interpersonal strain and conflict as well as increased distressing emotions over time.

Review the “Assertiveness Bill of Rights” A core part of being assertive involves identifying and standing up for one’s personal rights. All human beings have certain fundamental rights, including, for example, the right to express one’s feelings and opinions and to have them taken seriously, the right to make mistakes, and even the right to not assert oneself. Invite your client to review the Assertiveness Bill of Rights (see Box 10.2 in the client workbook), which outlines a set of rights that all people automatically have, independent of their identities. LGBTQ-​related stress can make LGBTQ people forget that they have these rights. Try exploring with your client: ■ Which of the rights on the Assertiveness Bill of Rights do you sometimes forget that you have? What experiences have you had as an LGBTQ person that may make it ■ difficult to assert these rights to other people? In what types of situations or with what types of people have you had the ■ most difficulty asserting these rights?

Unassertiveness Is an Emotional Behavior That Often Occurs in Response to LGBTQ-​Related Stress Unassertiveness is one type of emotional behavior that we spend extra time on during this module because it is a very common response to a lifetime of LGBTQ-​related stress.

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Try asking your client: “What types of uncomfortable emotions do you avoid in the short term when you behave unassertively?” (or “aggressively,” if that is more consistent with your client’s presentation). Common examples of avoided emotions include: Feelings of rejection ■ Fears of being “discovered” as different or as LGBTQ ■ Shame and embarrassment from perceptions that one is “bad,” “de■ viant,” or “unlovable” Try asking your client: “What are the long-​term consequences of behaving unassertively?” (or “aggressively,” if more consistent with your client’s presentation). Share with your client that common long-​term consequences can include: Depression ■ Anxiety ■ Hostility ■ Resentfulness ■ Relationship problems ■ Substance use ■ Risky sex ■

What You Will Be Doing Today to Build Assertiveness Skills Share the following points with your client: ■ The goal of today is to learn behavioral skills so that you can handle difficult situations in which it may feel like you do not have the right to assert your personal rights, many of which are situations involving LGBTQ-​ related stress. Assertiveness techniques that will be practiced in today’s session draw ■ upon the cognitive and behavioral skills that you learned in prior sessions. In summary: Unassertiveness is an emotional behavior that is a very common response to past or current LGBTQ-​related stress, and it can have long-​term social, behavioral, and mental health consequences.

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Identify Situations in Which the Client Finds It Challenging to Engage in Assertive Behavior This part of the module is focused on helping your client narrow in on situations in which they find it especially challenging to engage in assertive behavior. Therapist Note Teaching assertiveness requires a cognitive-​behavioral case conceptualization in which unassertive behavior is understood as occurring in response to certain situational challenges (Lange et al., 1976). For many LGBTQ people, these situational challenges either directly emerge from current LGBTQ-​related stress or are made more challenging because of past experiences with LGBTQ-​related stress.

Narrow In on Specific Situations in Which LGBTQ-​Related Stress Leads Your Client to Unassertive Behavior Explore situations in which your client tends to deny their rights. If your client gets stuck or has difficulty identifying these, it may be helpful to look back at the Assertiveness Bill of Rights, and ask: ■ In what situations or with which people are you most likely to forget or not assert your right to _​_​_​_​_​_​_​_​_​_​_​? The goal is to identify specific situations involving other people. You can use Worksheet 10.1: Asserting Yourself in Challenging Situations to help your client identify situations involving other people in which it is currently difficult for them to be assertive. This worksheet is available near the end of Chapter 10 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Some situations may be related to LGBTQ-​specific stressors and others may have generalized beyond LGBTQ-​related stress—​for example: ■ Not asserting oneself or standing up for oneself in general or as an LGBTQ person

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Not expressing one’s feelings in many different situations ■ Deferring to other people’s wishes or desires (for example, with friends, ■ family, coworkers, or sexual or romantic partners) Narrow in even further with focusing questions to find a few concrete examples (at least one, which will be the focus of a subsequent roleplay exercise): Where does this situation usually take place? ■ With whom do you tend to forget or deny that you have these rights? ■ How do other people behave (or how do you anticipate they will behave) ■ in situations that are hard for you to assert yourself? How do you typically behave in situations that are hard for you to be ■ assertive? [It may be helpful to look at Box 12.1.] Although we have found it common for clients to deny their own rights in these situations, it is also important to consider the possibility that your client may lean more toward the “aggressive” end of the interpersonal scale (Box 12.1) in general or in certain situations, which is another understandable response to a lifetime of LGBTQ-​related stress experiences. For some LGBTQ clients, sex and substance use are closely tied to unassertiveness. See Box 12.2 for more information, as relevant, about this. By the end of this discussion, you and your client will have a clear idea of a specific situation or situations in which they find it most challenging to be assertive.

Discuss Your Client’s Personal Rights in the Context of These Challenging Situations Referring to the Assertiveness Bill of Rights, ask your client: ■ What rights do you think that you have but might be forgetting about or ignoring in the moment when you face this challenging situation? Normalize that although LGBTQ clients have these rights, it is common to forget them because of LGBTQ-​related stress.

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Box 12.2. Assertiveness, Sex, and Substance Use

Many LGBTQ people say that feeling worthless or having low self-​esteem can make it difficult to engage in healthy behaviors and form connections with healthy peers. Thoughts related to LGBTQ-​related stress can lead LGBTQ people to avoid healthy activities or people, experience emotional distress in the context of these activities or people, or cope with their negative emotions in these contexts with emotional behaviors, such as sex or substance use. Here is an example that we have found to be common among some of our clients, highlighting the relationship between assertiveness, sex, and substance use: Jeff is a young gay man, working with a therapist. In session, Jeff shares that when he was on a hook-​up app this past week, he used substances to push away the discomfort he felt about not being desirable and to help him get the courage to reach out to men he considered to be attractive. He said that he ended up hooking up with a man he had found to be very attractive. He felt like he was lucky to be with this guy. When it came time to ask this sexual partner to use a condom, ask about HIV status, PrEP (pre-exposure prophylaxis, a daily medication with high efficacy for preventing HIV infection when taken by HIV-negative individuals), or testing history, or disclose his own status, Jeff was not able to, because he was afraid that this would lead to being rejected by this attractive guy. In fact, Jeff was thinking to himself at the time that this guy was “out of my league” and would probably lose interest. When his therapist asked him to describe his unassertive thoughts in this situation, Jeff shared several: “Who am I to ask this hot guy about his HIV status?” “If I say I want to use a condom, he’ll just find someone else,” and “It’s easier to just go on without a condom.” On top of that, both he and the guy had already been using substances, so their decision-​making about using condoms and their ability to assertively disclose their HIV or PrEP status or ask about their partner’s status was further impaired. In the end, this led to Jeff unassertively avoiding emotional discomfort in the short term and putting his sexual health at risk. This is just one example of how unassertiveness can have a negative long-​term impact on LGBTQ clients’ health behavior (in this case, sexual health). Unassertiveness can lead to other types of long-​term negative health behavior (Speed et al., 2018), such as: Substance use problems, ■ Self-​harm, and/​or ■ Unhealthy food or exercise behaviors. ■

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Explain that being assertive does not guarantee getting what one wants or needs, but that the act of being assertive (regardless of the outcome) and choosing for oneself how to act usually results in a good feeling, regardless of the other person’s response. To facilitate this discussion, you might ask your client: What personal rights do you have in this situation? ■ What makes it hard for you to affirm or assert yourself in this or similar ■ situations? How would you usually respond to this type of situation? ■ What would you like to say to this person? ■ How would you like this person to respond? ■ What statements could you make or what actions could you take to ■ achieve your goals in this situation? Your client can record their answers to these questions on Worksheet 10.1: Asserting Yourself in Challenging Situations.

Ground Your Client’s Understanding of Unassertiveness Using an LGBTQ-​Related Stress Lens While at the Same Time Reinforcing the Resilience of the LGBTQ Community It is important throughout this module to ground unassertive behavior in the context of LGBTQ-​related stress. Unassertive behavior is not a personal deficiency; it is an understandable (and perhaps at times adaptive and helpful) response to LGBTQ-​related stress. Clients’ recognition of the source of these difficulties in LGBTQ-​related stress may help to motivate them to stand up to this stress, and thereby protect their mental and physical health. Consistent with the overall principles of this treatment, it is also important to infuse this module with an overall appreciation of the unique strengths of the LGBTQ community: LGBTQ people have shown remarkable resilience and collective assertiveness in the face of

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LGBTQ-​related stress at both an individual and community level. To reinforce this, you might ask your client: ■ What unique strengths do you have as an LGBTQ person in the face of LGBTQ-​related stress that may help you to engage in assertive behavior in these situations? What unique strengths have you observed or learned that the LGBTQ ■ community has shown in the face of LGBTQ-​related stress, which may lead to being assertive even when it is challenging? If the client cannot identify strengths of the LGBTQ community, you as the therapist might wish to share examples of LGBTQ collective assertiveness or individual courage and creativity shown by LGBTQ people across modern history. In summary: This portion of the module is about helping your client identify specific situations in which they find it particularly challenging to engage in assertive behavior, and to ground any unassertive behavior in its LGBTQ-​related stress origins.

Identify and Challenge Unassertive Thoughts Next, consistent with the cognitive-​behavioral LGBTQ-​related stress conceptualization that began with the review of situational challenges above, you will help your client move towards assertive thinking and behavior in the context of the challenging interpersonal situation that they just identified. The first step is to use cognitive appraisal and reappraisal skills (from Module 5) to build assertive thinking, with the discussion points presented below.

Thoughts Influence Behaviors The way clients think about themselves and their personal rights undoubtedly influences their decisions about whether to behave assertively. Thinking “people will reject me if I say what I want” will most likely lead to not saying what one wants. On the other hand, thinking “my opinion is valuable regardless of whether others listen” is more likely to lead to genuine self-​expression. Table 12.1 shows the power of thoughts on assertive behavior. 220

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Table 12.1.  Influence of Thoughts on Assertive Behavior Situation: “My friend borrows money and does not pay me back.” Scenario 1: Unassertive Thinking

Scenario 2: Assertive Thinking

Thought: If I stand up for myself and ask her to pay me back, she will think I’m rude and then our friendship will be ruined.

Thought: I have the right to get my money back and if I ask her politely, she might respect my ability to be upfront. If she gets offended, it’s not the end of the world.

Behavior: I don’t ask for my money back and instead talk to her in a frustrated way the next time we hang out.

Behavior: I politely ask her to pay me back.

Short-​term consequence: I avoid the discomfort of standing up to her.

Short-​term consequence: I feel uncomfortable asking to be paid back.

Long-​term consequence: My unexpressed thoughts and feelings negatively impact our friendship. I start complaining about her to other friends and become hostile with her, and our friendship worsens.

Long-​term consequences: I have affirmed my own rights and expressed these rights to my friend. My friend respects my assertiveness. She acted a little uncomfortable at first, but when we talked about it, I found out that she was feeling guilty for not having paid me back and it was actually good for our friendship to have an open conversation.

Review Thinking Traps (from Module 5) That May Lead to Unassertive Behavior Many LGBTQ clients have significant interpersonal fear, including fears of being judged, criticized, negatively evaluated, and maybe even harassed or attacked. These fears can have a negative impact on one’s ability to behave assertively because of the way interpersonal situations make one feel and think. Some of these feelings and thoughts are perfectly rational and may be adaptive/​helpful, whereas others—​upon closer examination—​are likely no longer based in reality. For example, remaining silent or not standing up for one’s rights in a situation often results from thinking that we don’t have the right or that the consequences will be seriously endangering (which may or may not really be the case). Use the skills from the cognitive appraisal/​reappraisal module to help your client identify unassertive thoughts that may be grounded in inaccurate 221

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beliefs about themselves, others, or the world, and to challenge these unassertive thoughts to be more balanced. Worksheet 10.2: Building Assertive Thoughts presents questions that your client can ask themselves to challenge unassertive thoughts in order to identify more self-​empowering beliefs. This worksheet is available near the end of Chapter 10 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. See Box 12.3: Identifying and Challenging Unassertive Thoughts for an in-​session exercise to conduct with your client.

Box 12.3. Identifying and Challenging Unassertive Thoughts

1. Identify Unassertive Thoughts Begin by eliciting your client’s automatic, unassertive thoughts that prevent them from behaving in an assertive manner. Have your client think of the specific situation in which they find it difficult to assert themselves and ask: What goes on in your head when you imagine yourself in this situation? ■ What happens to your own self-​evaluation in this situation? For instance, do you feel worth■ less? Invalidated? Invisible? 2. Challenge Unassertive Thoughts Now that your client has identified their automatic unassertive thoughts that get triggered in this situation, help them to use their cognitive reappraisal skills to challenge these unassertive thoughts by asking: ■ Which thinking traps might be related to this thought (e.g., catastrophizing, probability overestimation)? Is the consequence that you fear definitely going to happen? ■ What do you know about yourself or the other person (or people) that says this may not happen? ■ Even if the bad consequence did happen, is it a catastrophe? Could you handle or survive it? ■ What would it mean if you did assert yourself and it resulted in a less-​than-​ideal outcome ■ (e.g., you expressed your needs and others did not comply)? Does it make you a bad or worthless person (if you were to express this want/​need/​desire)? ■ Does it make the other person bad (if they weren’t able to meet your request/​need)? ■ Do you need approval from everyone? ■ 222

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In summary: Unassertive thoughts, many of which are rooted in LGBTQ-​related stress, lead to unassertive behavior. Invite your client to use the cognitive appraisal and reappraisal skills from Module 5 to challenge unassertive thoughts.

Enact Assertive Behavior in a Roleplay Exercise The final part of the module is to invite your client to enact assertive behavior using a roleplay exercise. Follow the discussion points below to conduct this exercise: ■ What does assertive and effective communication look like? Review the verbal and nonverbal elements of assertiveness, discussing the role of eye contact, voice volume/​tone/​inflection, posture, body language, fluency, and facial expressions. Although there are some common elements of assertive and effective communication, it is important for your client to find their own assertive voice that works for them. Engage in an assertiveness roleplay exercise. Ask your client to se■ lect one of the specific situations that they discussed in this module in which they find it difficult to engage in assertive behavior. Invite them to engage in a short roleplay exercise in which they use assertiveness and effective communication skills and challenge any unassertive thoughts that come up. Agree on the topic of the roleplay and the role that you (the therapist) will play. Once you complete the roleplay, debrief and provide feedback. Debriefing questions may include: What assertive behaviors did you engage in during this roleplay? ■ What interpersonal avoidance or unassertive behaviors did you engage ■ in during this roleplay? What unassertive/​assertive thoughts came up? How did you challenge ■ unassertive thoughts? If you were to try this again, what would you do differently or keep ■ the same? [Time permitting, you might redo the roleplay.] Ask your client to use Worksheet 10.3: Reflecting on Acting Assertively ■ to record their answers to each of these questions. Completing this worksheet can help your client consolidate their new learning about assertiveness and point to areas for future growth. This worksheet is available near the end of Chapter 10 in the client workbook and can 223

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also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. ■ Remember to keep the debriefing focused on how your client feels about having asserted themselves, the sense of accomplishment and self-​mastery that can follow assertive action regardless of the other person’s reaction, and whether the client ended up receiving their request. Based on client needs and time, consider additional roleplays. If you ■ have the time to do so, you might start with a relatively easy roleplay, involving a situation that the client approaches with a moderate degree of confidence. Subsequent roleplays can then mimic more challenging situations. Therapist Note These roleplays serve as a corrective emotional experience for the client, perhaps one in which they see themselves behaving in ways they have not been able to behave before. With continued roleplaying and home practice, these corrective emotional experiences will perpetuate increasingly assertive behavior and accompanying positive self-​evaluations. In summary: Use an in-​session roleplay exercise to build your client’s self-​efficacy to challenge unassertive thoughts in the moment and enact assertive behavior in a challenging situation.

Agree on Home Practice By the end of this module, you and your client will have a shared understanding of interpersonal situations in which the client finds it difficult to assert or affirm themselves. They will also have practiced challenging unassertive thoughts and engaging in assertive behavior through the roleplay exercise with you. For home practice, work with your client to identify a situation in which they can practice engaging in assertive behavior prior to the next module: 1. Take out Worksheet 10.4: Record of Assertiveness Practice (Exercise 1) and ask your client to select a situation in which they can engage in assertive behavior in the next week. Several copies of this worksheet 224

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are available (as Worksheets 10.4, 10.5, and 10.6) near the end of Chapter 10 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. We recommend choosing a situation that is challenging but real■ istic and attainable. The more specific the situation the better. For example, “Tell my ■ girlfriend I want to do more sober activities” is much more specific than “Tell my girlfriend something needs to change in our relationship” and is more likely to be implemented because of its specificity. Sometimes, clients will choose a situation that is unlikely to come ■ up in the next week. For example, “If my mom says . . ., I will . . .” is not likely to be an effective assertiveness practice because it is contingent on whether their mother engages in a certain behavior. Encourage your client to choose an exercise they can complete regardless of others’ behavior. As always, help your client choose objectively safe situations in ■ which to assertive themselves. There are likely many safe situations in which to assert oneself. Examples of unsafe situations might be those that might reasonably put your client at risk for psychological harm (e.g., verbal abuse) as well as other serious negative consequences (e.g., being kicked out of their home, being financially cut-off if dependent, losing their job or a scholarship) if they were to assert themselves. Also be sure to work with your client to assess the relative degree of physical safety in situations in which they practice assertiveness. Help your client identify situations in which to assert themselves that do not introduce the potential for physical harm. For example, it is important for the client to practice this skill with people in their life who do not have a history of or tendency toward violence. Your role here is to work with the client to ascertain the realistic potential consequences so as to protect the client’s safety. 2. Once you and your client have agreed on an assertiveness practice exercise for the upcoming week, walk your client through Worksheet 10.4 to ensure that they understand the nature and purpose of the exercise. Prior to the experiment, the client will rate their anticipatory ■ distress (0 =​none, 8 =​the most distress). It is ideal to select an 225

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exercise that elicits somewhere between a 3 and a 6 in anticipatory distress as the first exercise. ■ The client will then identify and challenge unassertive thoughts prior to the assertiveness exercise. After the exercise is completed, the client will retrospectively ex■ amine their thoughts, feelings, and behaviors, noting whether they engaged in any avoidance behaviors (which might be a focal point for a future exercise). The client will note their maximum distress and distress at the end ■ of the exercise. Finally, they will note any new learning that they experienced as a ■ result of the exercise. 3. Clients are generally encouraged to practice engaging in assertive behavior one to three times in the next week, which is why we have included multiple versions of the worksheet. 4. As treatment progresses, the assertiveness experiments should increase in difficulty, with you encouraging your client to take more responsibility for designing encounters that will be helpful and useful.

Module 7: Additional Helpful Reference Materials Case Vignettes Case Vignette #1 In the following vignette, the therapist is working with a 38-​year-​old Cuban American cisgender gay man to identify the interpersonal situations in which he does not fully assert himself. In this situation, he discusses cultural and situational factors that impact his comfort in affirming his identity to others, using his personal values and motivations to determine whether he may wish to engage in more assertive behavior (e.g., coming out) with his family. Notice that the therapist remains focused on the client’s needs and emotions when he brings up his partner’s frustrations. Therapist:  Tell me about some situations where you find it harder to say what you want or need with other people. Client:  To tell you the truth, I’m pretty good at doing that with most people. Living in my neighborhood, which is very defined by 226

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Cuban cultural values and surrounded by everyone my family knows, it is hard to be out, but otherwise it’s not a big deal to just be myself. Therapist:  You’ve found a lot of ways to be authentically yourself outside of your family and neighborhood. What’s different there? Client:  If you’re different, it’s a big deal. It’s the fact that I know if my neighbor found out about me, they’d tell someone, and so on and so on. I feel like it would embarrass my family if everyone were talking about me, and us. Therapist:  How is that for you in your relationship? I know you’ve been talking about your relationship getting pretty serious. Client:  It’s really hard. He’s not Cuban, he’s from a totally different world than me and he really doesn’t get why I’m so private with my family and in my neighborhood. I always go to meet him at his place and we don’t hang out in my neighborhood because it would be awkward. I wouldn’t want him to feel like I’m hiding him, but I think that’s how he feels anyway. Therapist:  What about for you? What is it like for you to conceal this relationship in some aspects of your life? Client: Well, it’s something I always thought I would have to do. I never really let myself think about being in a relationship with a guy and being out and proud of it. But now that I’m more involved in the LGBTQ community—​going to community events and stuff—​I’m seeing these couples who are out and open about themselves, and they’re respected by their communities. It makes me wish I could have something like that, but I really don’t know about being so open. Therapist:  It’s important to you to be able to be yourself and be open about this relationship in different parts of your life. Client:  Right, it’s been great to be recognized among my friends as a couple—​it’s weird, it just feels good letting people know that we’re together, and we’re happy. Other people in my friend group seem happy for us and it feels good. Therapist:  Among friends, it’s easier to affirm your own identity and share about your relationship. With family and your local community, it’s harder and, at the same time, something you might want for yourself. Client:  I think for now, my family is where I want to be more open. I just want them to know me and who I really am more. They 227

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have to know something since I’m in my late 30s and have never brought anyone home. They sometimes ask, but I always just avoid the topic. It will just be so awkward to have that conversation with them, and I don’t want them to be embarrassed by me. Therapist:  How do you imagine feeling if you decide to tell them? Client:  It would probably feel like a weight has been lifted off my shoulders. It would just be nice not to have this thing I’m hiding all the time. I don’t know if they would be completely welcoming, but I also don’t think they would reject me or anything. It just might be awkward, but still a relief. Therapist:  There are some real benefits to coming out to them, regardless of how they might react. Client:  Maybe. I just feel so anxious when I think about doing it. But we’ve been getting along pretty well lately and this feeling of needing to share more with them has been building in me for a while now. So maybe now is the time. But how do you think I should tell them? Therapist: Going back to the Assertiveness Bill of Rights that we were looking at earlier, I wonder if a first step might be to believe that you have the right to tell your family that you’re gay.

Case Vignette #2 Here, the therapist is working with a 27-​year-​old cisgender pansexual woman who grew up in a poor rural family and did not attend college. She is now financially stable, living with roommates in the city closest to where she grew up. Although she identifies privately as pansexual, she conceals her sexual orientation identity in most aspects of her life. In this vignette, the therapist explores the client’s primary relationship with a woman, in which the client feels there is a power imbalance. They explore the client’s unassertive thoughts in the context of this relationship. Therapist:  One situation that you find it hard to assert yourself in is when you’re out with this woman who you have been seeing off and on. You were saying that she is pretty wealthy and takes you on extravagant trips and dates? Client:  Right, it’s a lot of fun—​she’s flown me first class to Europe, and we’ve gone to five-​star restaurants, and I’ve even met some 228

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famous people when I’m with her. Whenever I’m with her I always think, “I can’t believe she would want to be with me.” Therapist:  Tell me more about your relationship with her. Client:  Well, we’re not really in a relationship, it’s more like, I live here and she lives in another city. When she wants to do something, she’ll call me and invite me and I just can’t turn her down because the opportunities are always really amazing. I feel like I can’t say “no” to her whenever she wants something from me. Therapist:  What sorts of things do you have a hard time saying “no” to with her? Client: The biggest thing is drinking and sometimes using other substances too. I feel like she’s been so generous to me, and I don’t want to kill the party, so I always say “yes” even when it makes me uncomfortable. I usually have to take a few days to recover after being with her because it’s so hard on my body. I’ll black out sometimes and I really don’t feel good about that. Therapist:  OK, you find that you end up drinking and sometimes using other substances in a way that isn’t really consistent with what you want for yourself when you’re with her. Client:  Yeah, it’s not that I don’t want to spend time with her—​it’s a lot of fun and I want to keep being around her, but that part I don’t really like. I just think that if I’m going to spend time with her, it’s going to be on her terms, though, since she’s paying for everything and it’s her friends. Therapist: OK, so let’s think through some of those automatic thoughts that we’ve talked about before, that you have in those situations. So you’re with her and people are drinking a lot and inviting you to do the same. What thoughts are running through your head? Client:  The biggest one is, “don’t ruin it.” I’m lucky to be with her at all, to be with a group of people who sees us together and is fine with it. At home, I’m not out, I don’t go out on dates or anything because I don’t want people to know I’m pan. It’s also that I feel totally out of place at those parties—​I like being there, but I’m not rich like them and I never have been. I’m sure I already stick out, and so I’d rather try to blend in and be more like them. To not party with them would just prove that I don’t belong there.

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Therapist:  In those moments, you’re thinking about your gratitude for being able to be comfortable and with a woman, and at the same time, you still feel out of place and uncomfortable, which leads to drinking or using other substances. Client:  Right. And I think maybe the biggest thing is that I’m afraid she’ll realize that I’m not worth hanging out with. Because I don’t really bring anything to the table except that I’m agreeable to whatever she wants to do—​I can’t pay for any of it, and I don’t have cool events to take us to. I try to be deferential to her. Therapist:  What rights do you have in this situation? Client:  Not many, it seems. I know that sounds ridiculous, but I just don’t feel like I have a lot of rights when I’m with her. Wow, that sounds awful. Therapist:  You feel unentitled to your basic rights in this situation. What do you think about trying to challenge those unassertive thoughts and roleplay some assertive behavior for the rest of the session? Client:  That would be really helpful.

Navigating Challenges in Module 7 Assertiveness Versus Aggressiveness Some clients may mistake assertiveness for aggressiveness, believing that to assert one’s rights and desires at all would be perceived as aggressive or “selfish.” Some clients may believe that they are acting assertively when they are, in fact, behaving aggressively. You can highlight that assertiveness involves communicating and behaving in a way that respects one’s own rights as well as the rights of the other person or people (see Box 12.1).

Agreeableness Versus Passivity Some clients may not act assertively because of their preference for coming across to others as nice, agreeable people. In fact, passivity is frequently reinforced by others in the short term because the other 230

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person typically gets what they want, while the passive person ends up in a subservient role. These same clients may fail to see a link between their chronic passivity and their feelings of frustration or tension in interpersonal situations. In some cases, these clients could be described as passive-​aggressive in that they stanch any assertion of their personal opinions, needs, or preferences, only to later become frustrated with other people for taking advantage of them. In these situations, it is important to provide a clear explanation of the difference between passivity and assertiveness. You can also point out the possibility that over time, others can start losing respect for people who chronically diminish their own rights in favor of being agreeable or likeable. The possibility that assertiveness could garner self-​respect and respect from others can be highlighted.

Deciding When to Be Assertive Some LGBTQ clients may easily identify situations in which they are treated unfairly or disrespectfully but do not believe that standing up for their personal rights in these situations is worth the effort involved. In these situations, you might ask the client to imagine how their life would be different or how they would feel differently if they were to behave assertively in these situations. If the client shows difficulty in providing answers to these prompts, you can volunteer possible benefits that would accrue from behaving assertively in these situations. Although there may be some situations in which the client chooses not to assert themselves (this in fact is one of the items listed in the Assertiveness Bill of Rights), it is helpful to use the therapy session to thoroughly process the utility of assertive behavior in these situations.

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CHAPTER 13

Module 8: Emotion Exposures for Countering LGBTQ-​Related Stress

(Corresponds to Chapter 11 of the client workbook) This module focuses on confronting both internal triggers (e.g., bodily feelings) and external triggers (e.g., LGBTQ-​related stress) and provides the client with opportunities to increase their tolerance of emotions while allowing for new learning to occur. Accordingly, in this module you will: ■ Start the module by reviewing the client’s home practice, in which they practiced assertive behavior. This is complemented with a review of your client’s progress in general throughout the treatment. Introduce the concept of emotion exposures and how they can sup■ port learning and lasting change. Prepare your client to conduct emotion exposures, which will in■ clude identifying situations and emotions they typically avoid. Discuss bodily feelings and how they relate to emotions and ■ LGBTQ-​related stress. As appropriate, guide your client in engaging their bodily feelings, in ■ and out of session.

Module Agenda Review current symptoms on the Progress Record ■ Review home practice from the prior module and general treatment ■ progress Help the client to understand the purpose of emotion exposures ■ Work with the client to develop an emotion exposure ladder ■ Design, prepare for, engage in, and process one or more in-​session ■ emotion exposures

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■ Help clients who fear their bodily feelings understand how avoidance of bodily feelings maintains maladaptive emotional responses Assist clients who fear their bodily feelings to practice confronting ■ bodily feelings Agree on home practice ■

Recommended Number of Sessions This module is intended to be delivered across two or three sessions to provide sufficient time for the client to adequately explore and practice key concepts. For example, you might divide the module content as follows: ■ Session 1: Introduce emotion exposures; build the emotion exposure ladder; design and complete an in-​session emotion exposure Sessions 2 and 3: Introduce bodily feelings; design an exercise for ■ clients to engage bodily feelings in session

Materials Needed Progress monitoring assessments (i.e., ODSIS, OASIS) ■ Progress Record ■ Box 11.1: Guidelines for Designing and Carrying Out an Effective ■ Exposure Exercise, located in client workbook Chapter 11 Worksheet 11.1: Reviewing Your Progress, located in client work■ book Chapter 11 Worksheet 11.2: Emotion Exposure Ladder, located in client work■ book Chapter 11 Worksheet 11.3: Bodily Feelings Exposure Test, located in client ■ workbook Chapter 11 Worksheet 11.4: Bodily Feelings Exposure Practice, located in client ■ workbook Chapter 11 Worksheet 11.5: Record of Exposure Exercises, located in client ■ workbook Chapter 11

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Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The Progress Record is located at the end of Chapter 3 in the client ■ workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be downloaded by searching ■ for this book’s title on the Oxford Academic platform at academic. oup.com.

Review Current Symptoms on the Progress Record Continue using the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session based on the assessments that they complete before the session (i.e., ODSIS, OASIS). ■ Highlight any positive change and explore your client’s perceptions regarding the source of this change. If you see a bump in symptoms, explore this with your client, ■ reminding them that progress in therapy is not linear. In fact, you may see more increases in symptoms as they begin engaging in behavior change (e.g., assertiveness practice, emotion exposures), which is normal. Use the Progress Record review as an opportunity to see what you ■ might need to focus on in today’s session, to determine if any shifts in treatment focus may be needed, or to generally explore with your client how they feel that treatment is going.

Review Home Practice from the Prior Module and General Treatment Progress Review the home practice that was agreed upon in the last session. For home practice, your client practiced assertive behavior using (at least) Worksheet 10.4: Record of Assertiveness Practice. Review your

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client’s assertive behavior over the previous week as recorded on the worksheet(s). Provide positive feedback regarding your client’s attempts to assert their feelings, wants, needs, and/​or opinions during difficult interpersonal situations. Review the benefits of open, genuine self-​expression that the client experienced following assertive behavior, regardless of any other outcome of the situation. If your client had difficulty with responding assertively to a situation, we recommend the following: ■ Explore any emotional behaviors (e.g., subtle behavioral avoidance) that might underlie the problem and guide your client in generating appropriate strategies for responding to similar situations in the future. Remind your client that building effective communication skills ■ takes time and encourage them to continue practicing assertiveness across different situations. Remind your client that the ultimate goal of assertiveness practice is ■ a chance to practice genuine self-​expression. Even if your client did not receive other anticipated outcomes of the situation, the fact they practiced sharing their authentic voice is the most important aim of this exercise. Troubleshoot any other challenges your client experienced with the home practice, and if they had any difficulty, you may want to review the key concepts from Module 7. You may consider keeping your focus on assertiveness training rather than proceeding with the present module if your client experienced significant challenges while completing the home practice. Also take a moment to review your client’s general treatment progress using Worksheet 11.1: Reviewing Your Progress. This worksheet is available near the end of Chapter 11 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. At this stage in the treatment, it will be important to support your client in continued practice with mindfulness, challenging automatic thoughts, and identifying and replacing

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emotion avoidance tendencies. All of these new skills become relevant at this latter stage of treatment as you help your client put these skills together to face challenges in their daily life.

Help the Client to Understand the Purpose of Emotion Exposures Begin by introducing what will be the final skill you will focus on within this treatment—​emotion exposures, which include: ■ Approaching situations that may produce strong or intense emotional reactions; and Using behavioral skills to successfully confront—​rather than avoid—​ ■ these situations. Emotion exposures are an opportunity to practice previously learned skills, including: Maintaining nonjudgmental, present-​focused awareness ■ Identifying automatic appraisals ■ Countering emotional behaviors ■ Emotion exposures are difficult for most clients. ■ It is integral that clients commit to making time to complete emotion exposures, in order to reduce avoidance. We suggest letting your client know that among all the skills in ■ this treatment, emotion exposures lead to the highest chance for change to occur, which underscores how important it is to complete them. Therapist Note The goal of the emotion exposures is not immediate reduction in the emotional response. Rather, the goal is for clients to learn something new as a result of the experience. Consistent with a focus on emotions and emotion regulation, all exposures are meant to help clients experience their emotions fully (which means reducing patterns of avoidance) and implement new behavioral responses. Tolerance of emotions is a critical learning goal of emotion exposures.

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As a result of completing emotion exposures, your client will build confidence and self-​efficacy in their ability to handle future emotional experiences. With practice, your client can expect the following: ■ Automatic interpretations and thinking patterns about the dangerousness of situations will change. Newer, more adaptive interpretations and automatic thoughts will ■ emerge. Avoidance, and subsequent impairment, will reverse. ■ Emotional behaviors will be easier to recognize and modify. ■ Emotion exposures are well suited to address LGBTQ people’s reactions to LGBTQ-​related stress. ■ As discussed in prior modules, LGBTQ-​related stress often leads to expectations of rejection, self-​consciousness, and internalizing a sense of inferiority or shame. In turn, LGBTQ-​related stress experiences might lead to emotional ■ behaviors, such as avoidance of platonic, romantic, or sexual intimacy; avoidance of emotional vulnerability; or avoidance of uncomfortable bodily feelings associated with emotions. By helping your LGBTQ clients gradually confront their experiences ■ of LGBTQ-​related stress and the emotions associated with these experiences, their ability to identify and modify unhelpful emotional behaviors can be enhanced. In summary: Emotion exposures help clients approach situations that may produce strong or intense emotional reactions (e.g., LGBTQ-​related stress experiences) and implement behavioral skills to confront those challenging situations. With practice, old fearful associations are forgotten, and over time, new adaptive and empowering associations will become more salient.

Work with the Client to Develop an Emotion Exposure Ladder To prepare for emotion exposures—​ both in-​ session exposures and for home practice—​the client will need to prepare a list of triggering situations and emotions that they typically avoid. Developing an emotion exposure hierarchy, or ladder, is critical to this. Key points to discuss with your client are listed below.

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In-​Session Emotion Exposures Help Clients Learn How to Conduct Emotion Exposures, While Being Able to Process Emotions Immediately with the Therapist While not always feasible, initial emotion exposures should be conducted within the session whenever possible. When you lead the client through an emotion exposure during a session (versus for home practice), you will be able to: Give clear instruction and immediate corrective feedback. ■ Provide modeling. ■ Help the client build their tolerance of uncomfortable emotions ■ during the exposure.

Emotion Exposure Ladder Worksheet Use Worksheet 11.2: Emotion Exposure Ladder to get a sense of the types of situations that trigger uncomfortable emotions for your client, and the situations they most often avoid. This worksheet is available near the end of Chapter 11 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. All of these exposures can be used to assist clients in practicing skills they have learned during the course of treatment. With any of the in-​session exposures, make sure to leave at least 15 minutes of time to process the exposure with your client.

You and Your Client Are Now Likely Aware of Emotion Exposures That Might Represent Suitable Experiences to Approach These include exposures that are situational, imaginal, and interoceptive. Therapist Note When designing exposures, it is important to consider that uncomfortable or aversive emotions can be negative, but also can be positive in valence. For example, a client struggling with recurrent worry and tension may

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find it difficult to fully engage in a pleasurable activity and “leave their worries behind.” The experience of positive emotions may evoke anxiety about “being off guard.” Similarly, a client struggling with obsessive doubts may find it difficult to enjoy dinner out with friends. Allowing themselves to be fully present in the moment without retreating into engagement with intrusive thoughts may be particularly anxiety-​provoking. Therefore, it may be important to design emotion exposures around both negative and positive emotional experiences.

Situational Exposures Situational exposures involve being with people or events in the real world in a different way than usual. The goal of these exposures is to experience being in these events in a less avoidant and more empowered, flexible way. Some situational exposures might include (depending on your client’s presenting concerns, treatment goals, and LGBTQ-​related stress experiences): ■ Having difficult conversations with friends, partners, family members, or coworkers Having sex without using substances ■ Expressing intimacy towards partners ■ Socializing with heterosexual and/​or cisgender people ■ Making connections within the LGBTQ community ■ Expressing vulnerability ■

Imaginal Exposures Imaginal exposures involve vividly imagining oneself going through the avoided situation and allowing oneself to fully experience one’s emotions during this imagined situation. The above examples also lend themselves to imaginal exposures. Imaginal exposures can often serve as lower-​rung exercises on Worksheet 11.2: Emotion Exposure Ladder.

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Interoceptive Exposures Interoceptive exposures involve approaching previously avoided bodily feelings in a less avoidant and more empowered, flexible way. Suitable interoceptive exposures are described in more detail below. In summary: Having the client take the time to identify the triggering situations and emotions that they typically avoid will help them choose appropriate emotion exposures, which can range from situational to imaginal to interoceptive.

Design, Prepare for, Engage in, and Process One or More In-​Session Emotion Exposures Identify and Design One or More In-​Session Emotion Exposures It may be helpful to point the client to Box 11.1: Guidelines for Designing and Carrying Out an Effective Exposure Exercise (on pp. 203–204 in the client workbook) to assist them in conducting emotion exposures. Do not suggest to your client that a particular situation may be too difficult or too distressing—​but that said, early on it may be best to guide your client to choose activities towards the middle of their ladder so that the likelihood of success is high. This allows your client to gain a sense of mastery and self-​efficacy over an aversive experience, while simultaneously becoming more tolerant of their emotions. Over time, you will help your client gradually and systematically work their way up their emotion exposure ladder. We suggest structuring the exposure in a way that best permits new learning to occur by considering the following: ■ Clarify what it is that your client is most worried about happening so that the emotion exposure can then be directed towards challenging those negative outcome expectancies.

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■ If your client is most concerned about the emotional response itself, then the corrective learning is about your client’s ability to tolerate sustained levels of a negative emotion. Therapist Note If the situation for the emotion exposure involves LGBTQ-​related stress, it is essential that you assess the function of the client’s LGBTQ-​ related stress reactions. While many emotional behaviors provide a sense of safety, this perception of safety may actually hold a client back from flexibly engaging with valued activities. For some LGBTQ clients, however, the safety provided by their emotional behaviors driven by LGBTQ-​related stress may be quite helpful and functional. For example, some clients may exist in stigmatizing home or work environments, where approaching uncomfortable situations may actually lead to physical danger. Thus, we encourage you to thoroughly assess the function of LGBTQ-​related stress-​driven emotional behaviors and be prepared to focus only on approaching feelings or situations that will ultimately improve the client’s emotional and physical welfare.

Spend Time Preparing for the Exposure(s) Engage in some or all of the following steps before attempting an exposure: ■ Agree upon a specific exposure that your client will complete (usually drawn from Worksheet 11.2: Emotion Exposure Ladder). Discuss the anxious or negative thoughts your client is experiencing ■ prior to initiating the exposure, or those they expect to occur during the exposure, and practice challenging these automatic thoughts. Remember, though, not to provide reassurance, as reassurance can serve as an avoidance behavior (e.g., to avoid uncertainty). Remind your client to use present-​ ■ focused awareness of their emotions during the exposure.

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■ Identify emotional behaviors that are likely to interfere with the exposure (e.g., reassurance seeking, cognitive distraction) and how the client can modify these emotional behaviors.

Complete an Emotion Exposure During in-​session exposure, you, as the therapist, can be directive and confident, encouraging your client to continue the exposure despite any intense or uncomfortable emotions. With all emotion exposures, it is extremely important for you, as the therapist, to “catch” any moments where your client is engaging in emotional behaviors (i.e., avoiding their emotions), through, for example, changing the topic, “breaking” the role of the exposure, fidgeting, or other behaviors. Allowing these emotional behaviors to continue will reinforce your client’s perception that they cannot tolerate negative emotions. As soon as you notice any emotional behaviors, kindly make your client aware that they are avoiding their full emotional experience and invite them to redirect their attention back to the emotion.

Process the Emotion Exposure and Provide Constructive Feedback After completing an in-​session emotion exposure, spend at least 15 minutes processing it: ■ Ask about your client’s emotions before the exposure, and what thoughts and bodily feelings came up during the exposure. You may wish to use Worksheet 6.1: Three-​Component Model of ■ Emotions to help clients explore their emotional experience during the in-​session emotion exposure. Also, it is important to note any emotional behaviors throughout the ■ exposure process. Identifying ways to increase the level of difficulty of the exposures ■ and discussing ways to make the exposures more effective can also be helpful.

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Therapist Note Outline the accomplishments the client made and ways that they could improve the emotion exposures. At minimum, the client should always receive positive reinforcement for attempting an exposure. In summary: In working with the client to identify, prepare for, complete, and process emotion exposures, each step plays a critical role in promoting change—​and in developing your client’s ability to effectively design, implement, and learn from emotion exposures on their own.

Help Clients Who Fear Their Bodily Feelings Understand How Avoidance of Bodily Feelings Maintains Maladaptive Emotional Responses For some LGBTQ clients, fear and avoidance of their bodily feelings interfere with their ability to engage in valued behaviors. Some bodily feelings such as rapid heartbeat, sweatiness, and dizziness are common in panic disorder. These same bodily feelings can also characterize people who are simply more prone to experiencing and anxiously interpreting otherwise normal bodily sensations. For instance, shaking, trembling, and shortness of breath are common experiences in high-​pressure situations. For clients who experience these sensations as seriously uncomfortable, it might be particularly helpful to provide education about the ways emotions are influenced by bodily feelings and the avoidance of bodily feelings. For these clients, it is also important to underscore the potential benefits of intentionally engaging bodily feelings through practice.

Discuss the Connection Between Bodily Feelings and Emotional Responses In the same way that clients learn to recognize thoughts and behaviors as part of the emotional response, it is important for them to have a good understanding of how bodily feelings can also contribute to emotions.

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As the therapist, you will want to emphasize the idea that how clients think about and experience these bodily feelings can actually contribute to the emotional response. For instance, consider an asexual woman standing up for herself against a heterosexist insult who begins experiencing an increased heart rate, sweaty palms, lightheadedness, and slight feelings of unreality. How might her interpretation of her bodily feelings affect her overall emotional response?

Further Explore the Potential Role of LGBTQ-​Related Stress in This Link Early and ongoing experiences with LGBTQ-​related stress can produce these types of bodily feelings and the response to them, which may be helpful in some situations. However, if the client’s attention is focused on those bodily feelings in safe situations and those feelings are viewed as a threat to their ability to stand up for or express themself, they are likely to experience an intensification of the emotional response (including the bodily feelings), which, in turn, will cause them to become even more concerned about the feelings, and so on. If, on the other hand, the LGBTQ client who needs to stand up for or express themselves understood that the feelings are a normal reaction that sometimes occurs in high-​pressure situations (such as educating a biased person) and did not believe that it significantly interfered with their performance, or was accepting of this possible interference, it is more likely that they would be able to focus their attention on what they were saying. After a short period of time the bodily feelings would diminish of their own accord and the feelings would not have such a distressing response. This discussion on the role of bodily feelings in the emotional response provides the client with clear justification for increased exposure to these feelings and sets the stage for the interoceptive exposures (i.e., induction of bodily feelings).

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Discuss the Common Pitfall of Avoiding Bodily Feelings Avoidance of bodily feelings is common among clients suffering from panic disorder. However, in our experience, clients with other anxious and depressive symptoms also exhibit some level of avoidance of bodily feelings. More obvious avoidance includes not engaging in certain activities, such as physical exercise, arguments with friends, interactions with heterosexual/​cisgender people, and sexual relations, which elicit strong bodily feelings. Clients may avoid some substances that naturally produce bodily feelings, such as caffeinated beverages, chocolate, energy drinks, and even over-​the-​counter medications. Avoidance also includes distracting oneself from thoughts about bodily feelings. Avoidance precludes relearning and instead maintains the vigilance and reactions towards uncomfortable bodily feelings. You, as the therapist, will need to work with clients whose bodily feelings interfere with their valued behaviors to repeatedly confront bodily feelings. By repeatedly confronting bodily feelings, your client can learn to handle their bodily feelings and associated anxiety—​and learn that their bodily feelings are not harmful.

Why Practice Confronting Bodily Feelings? Through repeated exposure to bodily feelings, anxiety about those bodily feelings eventually declines. Having clients steadily and intentionally face their feared bodily feelings is very different than how they may have experienced these bodily feelings in the past, as those experiences were most likely accompanied by significant fear and avoidance. In this treatment, clients will work towards embracing, rather than avoiding, the bodily feelings that typically occur during their uncomfortable emotional experiences. In summary: Some clients avoid bodily feelings. Vigilant avoidance of bodily feelings prevents opportunities to learn new information and instead maintains a fearful reaction to bodily feelings.

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Assist Clients Who Fear Their Bodily Feelings to Practice Confronting Bodily Feelings Clients who avoid bodily feelings may benefit from interoceptive exposures. You may work with these clients to engage in symptom-​ induction exercises designed to elicit bodily feelings. Therapist Note Before conducting the interoceptive exposures, it is important to fully assess for any medical conditions that would render these exercises harmful for the client. It is also important to differentiate psychological distress from true potential for harm. For example, a client diagnosed with panic disorder who fears having a heart attack while running in place (in the absence of any physical heart condition) is different from a client who could be put at risk for cardiac arrest due to a documented medical condition. It is recommended that clients engage in their first interoceptive exposure in session with you. This in-​session practice helps demonstrate that the exposure is not dangerous and will equip the client to practice on their own in the future. These exercises will help to increase awareness of bodily feelings as part of the emotional response, increase tolerance of these feelings, and reduce patterns of avoidance. Specific exposures are listed on Worksheet 11.3: Bodily Feelings Exposure Test and discussed on page 214 in the client workbook, but you can be creative in developing exposures that will be most relevant, given the client’s presenting symptoms. This worksheet is available near the end of Chapter 11 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Try to choose exposures that are at least moderately distressing to your client and evoke similar symptoms to those that occur naturally during an emotional response. After identifying one or more exposures that elicit bodily feelings similar to your client’s naturally occurring symptoms, ask your client to

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engage in the exposures repeatedly, either in session or as home practice. The duration of exposure to bodily feelings can be gradually lengthened so that the intensity of feelings either remains the same or increases. The level of distress, however, eventually decreases as the client becomes better able to endure the feelings. The same induction exercise is conducted repeatedly, with the client only waiting long enough in between rounds of the exposure for the symptoms to mostly subside. The exercise is then repeated until the client’s distress reaches a 2 or less (on a scale of 0 to 8, as described below). Worksheet 11.4: Bodily Feelings Exposure Practice can be used to assess the client’s response to these exposures (in session and for home practice). This worksheet is available near the end of Chapter 11 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. ■ After each exposure, ask your client to rate the intensity of the bodily feelings they experienced, distress associated with the bodily feelings, and similarity of those bodily feelings to those that typically occur as part of an emotional response. Each of these items is rated on a 0-​to 8-​point scale, with 0 =​none, ■ 4 =​moderate, and 8 =​extreme. Based on the results of this assessment, several exposures can be ■ selected for additional practice in session, or given to the client as home practice. The bodily feeling exposure exercises are to be performed in a way that elicits bodily feelings as strongly as possible. Clients may only be able to engage in the exercises for a short period of time initially. However, it is important that the bodily feelings are fully induced and that the client continues the exposure beyond the point that the bodily feelings are initially experienced. This is because ending the exposure upon first noticing the bodily feelings will reinforce fear of those bodily feelings. The emotion awareness skills developed earlier in treatment (see Module 4) can also support the client’s work during the exposures: ■ Instruct your client to focus on their bodily feelings while conducting the exposures, not to distract from them.

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■ If your client notices certain thoughts occurring during the exposures, they should not engage in cognitive reappraisal at this point. Instead, they should simply recognize them as part of their experience. All emotional behaviors (e.g., distraction, minimal symptom in■ duction, the presence of safety signals) should be prevented so that clients can obtain the most benefits from the exposures. In summary: Bodily feeling exposure exercises are designed to elicit bodily feelings. Among clients who have a tendency to fear and avoid their strong emotions and bodily feelings, these exposures help to increase awareness of bodily feelings as part of the emotional response, increase tolerance to these bodily feelings, and reduce emotional behavior patterns.

Agree on Home Practice To reinforce the concepts from this module, collaboratively discuss the following home practice activities: 1. Clients will conduct one or more exposures, moving this skill into the “real world.” Begin by sharing with your client why continued practice of emotion exposures outside of session (in vivo experiments) is a critical factor in the success of treatment: First, practicing in vivo emotion exposures allows clients to di■ rectly apply the skills they have learned in treatment to the context of their daily lives. Second, practicing in vivo emotion exposures allows clients to de■ velop a sense of autonomy or self-​efficacy in their own treatment, which will help them as they transition away from the therapist and towards independence. Finally, the actual time spent in therapy represents approximately ■ 1% of the client’s waking hours; therefore, to truly learn skills presented in therapy, it is essential that the client continue to practice skills outside of session. 2. Work with the client to design emotion exposures that they will complete on their own: Your client can use Box 11.1: Guidelines for Designing and ■ Carrying Out an Effective Exposure Exercise to prepare for the

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exposure exercises that they will complete on their own. This box will help your client identify, prepare for, and objectively evaluate their engagement in the exposure exercise. ■ Again, Worksheet 11.2: Emotion Exposure Ladder can be used to identify possible emotion exposures. For example, a client struggling with fears of intimacy may set up a dating website profile; a client struggling with social phobia may purposely engage in a conversation with a heterosexual coworker; or a person with intrusive and distressing thoughts may write down their most feared thoughts and read them aloud daily. Using Worksheet 11.5: Record of Exposure Exercises, clients will ■ record their experiences with completing emotion exposures. This worksheet is available near the end of Chapter 11 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. 3. For a client who fears their bodily feelings, you may ask the client to engage in repeated interoceptive exposure exercises. This can involve repeating a practice exercise that occurred in session or beginning an unpracticed symptom-​induction exercise as home practice: Clients should continue with this exercise repeatedly. ■ In later trials, the level of distress is likely to be less than where it ■ started but may be slightly higher than it was at the end of the last exercise. This continued exposure helps increase learning and may prevent ■ any distress about these bodily feelings returning in the long term. Use Worksheet 11.3: Bodily Feelings Exposure Test to assess the ■ client’s response to the exercises.

Module 8: Additional Helpful Reference Materials Case Vignettes Case Vignette #1 Working with a 15-​year-​old cisgender asexual female client, the therapist is clarifying the intended purpose of emotion exposures—​reducing

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the negative impact of LGBTQ-​related stress—​and providing guidance on how to most effectively complete these exposures. Client:  So, about that emotion exposure we agreed on: I did it. I told my aunt that I’m asexual and I tried to explain what that means, but I was so anxious the whole time. I felt like I was going to be sick. Therapist:  That sounds really great. Want to tell me more about it? Client:  Great? I felt awful! It was really stressful, being that scared. I kept telling myself that I was going to feel better soon, but I never did. I was fumbling over my words even though I practiced them beforehand. How’s that great?! Therapist:  Well, remember, we do these emotion exposures because they cause fear, not because we expect you to suddenly be able to engage in the experience with no fear. It is really all about how you experience and react to your fear—​that is what we are trying to change, over time. More specifically, there are two goals. First, you’re trying out this particular situation to test whether your greatest fear comes true. In this case, it didn’t. Although the experience was challenging, it turned out much better than you thought it would. Second, we are trying to build up your tolerance for distress, and you showed some real promise with that here. You were scared, but you kept going and were able to accomplish your goal of coming out to your aunt. Client:  So, will it get easier? Will I feel less panicked and afraid the next time I try to come out to someone? Therapist: It’s likely that by continuing to come out to people—​ particularly those who you have reason to believe will try to understand you and your identity—​the fear will decrease, over time. There’s one catch, though: If you attempt to avoid your emotions in that situation or do something to make the situation less frightening, you might not see the progress we’re aiming for. Client:  OK. Can you remind me why that even matters again? Therapist:  Sure. That kind of avoidance blocks you from learning that coming out does not have to be dangerous. Remember, last session, you were afraid that your fear might become so intense that you wouldn’t be able to tell her, that you’d back out. Client:  Yeah, and I almost did! So, if I just allow myself to be afraid, over time I will be less afraid? 251

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Therapist:  Again, it sort of depends on you. In general, I would suggest that you focus more on reducing patterns of avoidance and changing emotional behaviors, rather than worrying so much about what happens to your fear. Now it’s important to be aware of the emotional experience, and maybe you can even do a quick three-​point check to notice your thoughts, behaviors, and bodily feelings as your emotions unfold. But then it’s just about riding the wave. I mean, actively do nothing. Just allow the emotion to be there and then notice what happens as a result. Are you losing your mind? Are you doing anything uncontrollable? If you don’t do anything to avoid or escape, then you’ll be in the best position to learn that your fear is not dangerous in this situation, and chances are the emotion will eventually diminish.

Case Vignette #2 In this vignette, the therapist is working with a 42-​year-​old cisgender bisexual male client to generate solutions for his tendency to escape an emotion exposure by using alcohol. Client:  I tried hooking up with a guy without being drunk, but eventually I had to have a drink. Therapist:  And why was that? Client:  Well, I started feeling really upset. My vision got blurry and I was getting really annoyed with him for being so affectionate. Therapist:  So then what happened? Client: Well, I excused myself from the bedroom and went to the kitchen to make us drinks. I really tried to stay in the moment, but I was just so agitated. I knew that if I let it go a bit longer, I probably would have had to ask him to leave. Therapist: Why did you feel the need to protect yourself against those feelings? What are your thoughts about what could have happened if you didn’t have a drink? Client:  I don’t know. I was just concerned that I might not be able to stay into him because I couldn’t really focus properly . . . on account of the feelings I was having. Therapist:  It looks like maybe we should take some time to look a little more closely at these thoughts you have about your emotions in those situations. 252

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Navigating Challenges in Module 8 Avoidance Versus Emotional Behaviors Some clients may struggle with understanding the distinction between emotional avoidance and emotional behaviors. Theoretically, we view the difference between emotional avoidance and emotional behaviors as an issue of temporality—​sometimes one works hard to prevent negative emotions; other times one engages in behaviors to decrease or suppress negative emotions once they are activated. Even still, the therapist may sometimes find it difficult to help clients distinguish between the two. Again, it is more important for clients to recognize maladaptive patterns of responding with regards to their emotions, rather than become 100% accurate in classifying avoidance versus emotional behaviors. You may choose to help the client gain a broader understanding of why both avoidance and emotional behaviors can be problematic, and how altering these response patterns is essential to therapeutic change.

Effectively Tracking Emotional Behaviors Emotional behaviors can sometimes be difficult for clients to identify. Worksheet 9.1: List of Emotional Behaviors and Worksheet 9.2: Alternative Action have been included to assist clients in becoming better at identifying emotional behaviors. In addition, you may want to revisit some of the emotional tracking exercises the client completed in prior weeks to generate examples, or help the client identify common emotional behaviors associated with their emotions.

Consistency Is Key Once clients have identified the emotional behaviors they would like to change, they may still find it difficult to consistently adopt an alternative behavior, particularly in the beginning. As the client continually tracks emotional behaviors, they are likely to improve their ability to engage in the alternative action. However, as the therapist, you may find the motivation enhancement techniques described in Module 1 helpful as well.

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CHAPTER 14

Module 9: Recognizing Accomplishments and Looking to the Future

(Corresponds to Chapter 12 of the client workbook) This treatment ends with a module that focuses on consolidating treatment gains and planning for the future, including long-​term goal setting and planning for coping with LGBTQ-​related stress. Accordingly, you will: ■ Start the module by reviewing the client’s home practice, which involved an emotion exposure, as well as the client’s overall experience with home practice throughout treatment. Review overall treatment progress. ■ Review treatment skills for coping with negative emotions in the ■ context of LGBTQ-​related stress. Help the client identify and troubleshoot common or potential ■ triggers. Promote skill generalization and set goals for continued progress. ■

Module Agenda Evaluate treatment progress with the Progress Record ■ Review home practice from the prior module and general treatment ■ progress Anticipate future challenges ■ Review skills learned in this treatment ■ Make a plan for continued practice ■ Establish long-​term goals ■ Share resilience ■ End treatment ■

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Recommended Number of Sessions This module is intended to be delivered across one or two sessions. If you choose to complete this module in two sessions, you might divide the module content as follows: ■ Session 1: Review general treatment progress and skills learned and make a plan for continued practice, including long-​term goals. Session 2: Explain the self-​affirmation exercise, and formally end ■ treatment by consolidating treatment gains, reviewing the client’s resilience, and exploring feelings about ending the client–​therapist relationship.

Materials Needed Progress monitoring assessments (i.e., ODSIS, OASIS) ■ Progress Record ■ Worksheet 12.1: Assessing Changes During the Treatment Program, ■ located in client workbook Chapter 12 Worksheet 12.2: Practice Plan, located in client workbook ■ Chapter 12 Worksheet 12.3: Long-​ ■ Term Goals, located in client workbook Chapter 12 Worksheet 12.4: Sharing Your Resilience, located in client work■ book Chapter 12 Therapist Notes ■ The ODSIS and OASIS assessments are located at the end of the client workbook chapters starting with Chapter 3 and can be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. The Progress Record is located at the end of Chapter 3 in the client ■ workbook; the client should continue to use the same Progress Record throughout treatment so they can track progress over time. Additional copies of worksheets can be downloaded by searching for this ■ book’s title on the Oxford Academic platform at academic.oup.com.

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Evaluate Treatment Progress with the Progress Record Continue using the Progress Record from Session 1 to see how your client’s symptoms are changing from session to session based on the assessments that they complete before the session (i.e., ODSIS, OASIS): ■ Use the Progress Record to review your client’s overall changes in symptoms across the entire treatment process. Encourage your client to use the Progress Record to review their ■ overall changes in symptoms, not just how they feel now. Show your client the overall graph of treatment progress to help ■ them see their treatment progress overall. Emphasize that treatment progress is a continuing process, and that ■ with continued practice of the skills learned in treatment, clients can expect to see continued changes in their symptoms over time. Sometimes, clients will see a Progress Record that they may view as “unsuccessful,” for example if they have not seen a steady decline in symptoms throughout treatment. There are many reasons for a lack of progress, none of which should be considered a “hopeless” outcome. Potential reasons for lack of progress include: ■ An inaccurate case conceptualization and functional analysis at the start of treatment A lack of understanding of the treatment principles ■ Goals that are unrealistic for time-​limited treatment ■ Lack of motivation or opportunity for home practice ■ The weekly assessments do not capture all aspects of personal change; ■ it may be that the client did in fact change but the Progress Record does not accurately capture these changes. Sometimes, it takes continued engagement in emotion exposure ■ exercises in order to see optimal reduction in symptoms. Therefore, the client can expect to see continued growth with continued practice after treatment ends. Explore with your client any potential reasons for lack of progress, which will help to determine the best next steps. In summary: The end of treatment is, in many ways, a new “phase” of treatment, where the client can continue practicing the skills learned in

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treatment to see further treatment gains and/​or troubleshoot challenges to treatment progress to determine appropriate next steps.

Review Home Practice from the Prior Module and General Treatment Progress For this final module, it will be important to discuss your client’s home practice from the prior week, as well as their overall experience with home practice throughout treatment. Review the prior week’s home practice, as recorded on Worksheet 11.5: Record of Exposure Exercises and, if applicable, Worksheet 11.3: Bodily Feelings Exposure Test and Worksheet 11.4: Bodily Feelings Exposure Practice. Provide positive reinforcement for any attempt the client made to approach previously uncomfortable emotional experiences. If the client reports that their emotional experience did not change during the emotion exposure: ■ Normalize that the reduction of distressing emotions through emotion exposures can take time and practice, and encourage the client to continue performing emotion exposures. Explore whether the client may have engaged in any emotional ■ behaviors (e.g., subtle avoidance strategies) during the emotion exposure; if so, encourage them to re-​attempt the experiment without using emotional behaviors. Explore where the experiment fell on their emotion exposure ladder; ■ if the experiment was too high on the ladder, encourage them to try an experiment lower on the ladder and build up to this more challenging experiment successively. Conversely, also ensure that the experiment was challenging enough. ■ Therapist Note If your client was not able to complete the home practice, and you are able to spend extra sessions on the prior module, we recommend considering revisiting the prior module to ensure that the client completes at least some emotion exposures prior to ending treatment. Emotion exposures are critical to treatment and can be difficult to conduct while also trying to complete a final “relapse prevention” session.

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Review your client’s overall experience and engagement with home practice throughout treatment: ■ Ask your client what changes or treatment gains they have experienced as a result of completing the home practices. To help your client observe their treatment gains, invite your ■ client to compare changes on more recent home practice activities to changes they noticed as a result of earlier home practice activities. Talk with your client about their ability to complete their home ■ practice exercises during treatment, emphasizing their success in completing home practices, to increase the likelihood that the client will continue to intentionally practice these skills after treatment ends.

Anticipate Future Challenges It is important, before ending treatment, to prepare clients for future challenges they may experience and the ongoing relevance of the skills that they gained in treatment to face these challenges. Below are key points related to addressing future challenges.

Intense, Uncomfortable Emotions Will Undoubtedly Arise in the Future All clients will experience intense or uncomfortable emotions in the future, which may occur in response to LGBTQ-​related stress or other life stressors. Anxiety, depression, and other uncomfortable emotions are normal responses to LGBTQ-​related stress.

A Resurgence of Intense, Uncomfortable Emotions Is Not Equivalent to a Relapse Clients who have completed this treatment program may find it unsettling if, in the future, they experience strong emotions that remind them of their pre-​treatment functioning, without any clear “trigger,” and might be quick 259

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to conclude that the treatment did not work. Remind your client that fluctuations in the types of emotions and the intensity of one’s emotions are a normal part of life, especially for LGBTQ people who face early and ongoing experiences with LGBTQ-​related stress; such fluctuations are not necessarily an indicator of a relapse or any failing on the client’s part. Encourage your client to use the skills developed through treatment, including mindful, nonjudgmental awareness of their emotional experiences, to understand the ups and downs of their emotions after treatment ends.

Use Treatment Skills to Address a Recurrence of Symptoms Remind your client that if they do experience a recurrence of symptoms (e.g., anxiety, depression, emotional behaviors), this is not a sign that they have “lost control” or that treatment was ineffective: ■ Recurrences are a temporary experience of symptoms that can be addressed using the same skills that clients learned during the treatment program. Let your client know that in times of future distress, they can re■ member the unique strengths and resiliencies that LGBTQ people have shown across history and, indeed, those that your client has shown in their own personal history of being an LGBTQ person able to navigate emotional challenges. It may be useful to show your client Figure 3.1: Progress in Treatment Is Not Linear (see p. 27 in the client workbook) as a reminder that progress in (and after) treatment is not linear; there will always be ups and downs. Even if the client feels like they have relapsed to pre-​treatment levels of distress, the difference is that now they have the skills to address this distress. In summary: Clients are likely to experience triggers for intense, uncomfortable emotions in the future, as well as the normal emotional ups and downs of daily life, after they complete treatment; the skills learned in treatment can be used to address these.

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Review Skills Learned in This Treatment As part of this treatment, your client learned a variety of treatment skills. Using Worksheet 12.1: Assessing Changes During the Treatment Program, located near the end of client workbook Chapter 12, reinforce your client’s learning throughout the treatment by inviting your client to discuss the skills they have learned along the way. This worksheet can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. What skills have you found most helpful? ■ What skills come most easily to you? ■ What skills do you feel like you could use more practice with? ■ Try an example scenario: As part of this discussion, it may be helpful to present a scenario that you imagine could be an ongoing challenge for your client, based on what they have discussed in treatment. Invite your client to talk through what skills they could use in that scenario, now that they have learned an array of treatment skills. Emphasize the client’s effective handling of this or similar situations during treatment using the treatment skills so as to promote ongoing use of these skills. In summary: Invite your client to recall the primary treatment skills learned and discuss how they will continue using them after treatment ends.

Make a Plan for Continued Practice Continuing to practice the skills learned in treatment, after treatment ends, is a useful way to maintain treatment gains and generalize the skills to new situations. Discuss the following points related to continued skills practice. Progress can continue after treatment ends. It is typical for clients to experience continued treatment gains even after completing treatment with continued practice of the treatment skills.

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Help your client select skills they would like to continue practicing. Take out Worksheet 12.2: Practice Plan, and invite your client to generate a list of specific areas that they would like to practice in the coming weeks, as they relate to the treatment skills learned. This worksheet is available near the end of Chapter 12 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Discuss strategies for continued practice after treatment ends. Clients may be concerned that if they do not have the structure of a weekly session, they may not continue to practice the skills they learned. We recommend helping clients consider setting aside a weekly time, perhaps the same time that their sessions have been occurring, to: ■ Review progress—​take stock of what they have accomplished, even after completing treatment, which can motivate continued practice. Observe any recurrence in symptoms—​if symptoms or old, maladap■ tive patterns of emotional responding begin to emerge again, having a weekly check-​in time is a great chance to observe them and make a plan for using the treatment skills to address them. Set goals—​it may be that, with continued practice of the skills ■ and improvements in functioning, your client will want to pursue new goals. Setting aside a weekly time to check in with oneself is especially helpful for the few weeks that immediately follow the end of treatment; still, clients might continue setting aside a weekly time for as long as they find it to be helpful. In summary: Clients can continue to practice all of the skills learned in treatment; it is helpful to make a concrete plan for doing so before treatment ends.

Establish Long-​Term Goals With treatment ending, one strategy for promoting post-​treatment gains is to help your client set long-​term goals. Below are some discussion points related to setting long-​term goals.

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Discuss the Purpose of Setting Long-​Term Goals Now that your client is likely experiencing an improvement in their functioning, they may be ready to begin planning next steps towards goals that they are now better equipped to pursue. Setting long-​term goals at the end of treatment can create a sense of empowerment towards confronting the ongoing challenges of LGBTQ-​ related stress and other triggers.

Set Long-​Term Goals Take out Worksheet 12.3: Long-​Term Goals, and discuss with your client the goals that they would like to pursue following the completion of treatment. This worksheet is available near the end of Chapter 12 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Use a similar process to Module 1, in which clients broke their goals down into actionable steps towards achieving these long-​term goals. (For a review of effective goal-​setting strategies, see Module 1.) Remind your client that all the skills learned in treatment will continue to be relevant as they pursue their long-​term goals. In summary: Provide your client with a rationale for long-​term goal setting. Then, help your client to identify the long-​term goals that they would like to pursue following the completion of treatment.

Sharing Resilience In preparation for the end of treatment, we recommend having clients complete a self-​affirmation exercise to consolidate their treatment gains and reinforce their self-​efficacy regarding their ability to respond to LGBTQ-​related stress. Box 14.1 provides some background information that you as the therapist may find helpful to know regarding the rationale for this exercise in treatment; this background information does not need to be presented to the client.

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Box 14.1. Background Information About Sharing Resilience Exercise for Therapists

■ This exercise, in which you ask your client to share their resilience with a (fictional) other LGBTQ person who is struggling with LGBTQ-​related stress, has been shown to have enduring benefits for individuals who face ongoing challenges associated with LGBTQ-​related stress (Cohen & Sherman, 2014). This type of exercise alone has been shown in randomized controlled trials to lead to ■ reductions in depression and suicidal ideation, especially for LGBTQ young people who experience high degrees of LGBTQ-​related stress. Delivered at the end of treatment, this exercise is designed to remind clients of the ■ strength and resilience they have developed during treatment and foster confidence in their ability to maintain treatment gains over time. This sharing resilience exercise involves having your client write a letter to an LGBTQ ■ individual who is struggling. In this letter, your client will share their own experiences and coping. This type of “saying is believing” exercise can help LGBTQ clients recognize the resil■ ience and skills they themselves have developed during treatment. Writing about these strengths may activate your client’s sense of themselves as effica■ cious agents capable of navigating LGBTQ-​related stress, in all forms.

Explain the sharing resilience exercise to your client. Feel free to introduce the exercise in your own words; we present the following script in order to highlight key points to discuss: ■ Before we finish our work together, I’d like you to try a short writing exercise in which you’ll be giving some advice to another LGBTQ person dealing with LGBTQ-​related stress. To start us off, you’ll need to read a short story about an LGBTQ person. ■ All you need to do is read about what the person in the story is going through, and after that I’ll walk you through a short exercise. [Show a story—​see Box 14.2 for potential stories of LGBTQ people’s ■ exposure to LGBTQ-​related stress; similar stories are provided in the client workbook as well.] What I’d like you to do is write a letter to the person in the story for ■ 20 minutes. In the letter, try to describe your own experiences with LGBTQ-​related stress, how you have handled it, and what skills from treatment you have found most helpful. No need to worry about spelling

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Box 14.2. Finding and Choosing a Story for the Sharing Resilience Exercise

The purpose of this exercise is to show an example of an LGBTQ person who is actively struggling with an LGBTQ-​related stress experience so that the client can provide the person with guidance and thereby come to see themselves as efficacious in coping with LGBTQ-​related stress. Therefore, the story should focus on the struggle of its main character (as opposed to the resolution of this struggle). Some example stories include: Story 1: Alex is a non-​binary student at a local high school. Alex recently came out to their dad, who responded by saying, “You’re not gonna be non-​binary under my roof!” He kicked them out and they have been couch-​surfing since. That was several months ago, and they’re still feeling really hopeless. They knew he wouldn’t take the news well, but Alex never expected him to freak out this badly. Now Alex is worried about being homeless forever and how they will pay for college. And they’re terrified that their dad will never speak to them again. Story 2: Micah is a devout bisexual Christian man in his mid-​20s. He has belonged to his church for his whole life and loves playing in the church band each Sunday. However, things have changed since he came out. His band members told him he’s going to hell and kicked him out. His pastor asked him to meet so they could “pray it away.” And everyone else at church gives him dirty looks like he’s an abomination. So, he’s stopped going. But now there’s a big hole in Micah’s life where his church life used to be, and he’s worried that he’ll never find a church community again. Story 3: Natalie is a high school student. A few months back, some students found out that she is lesbian, and she has been bullied and teased ever since, and her friends constantly tell jokes about gay people. Although several teachers see what’s going on, they never intervene, and none are openly LGBTQ. She can’t transfer schools and is feeling hopeless about ever being accepted for who she is. NOTE: Tailor the scenario to match the client’s own sexual and gender identity. ■ You may also wish to use other brief stories or even videos or to make up your own stories to use with clients. As long as the story depicts an LGBTQ person navigating a current LGBTQ-​related stress experience, it will work for this exercise. The story doesn’t have to match your client’s experience exactly, although it should at ■ least be relatable to them.

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or anything like that—​the important thing is just to get your message to the person. What you share in your letter might be able to help other LGBTQ people, such as the person in the story. Worksheet 12.4: Sharing Your Resilience provides space for your client to complete this exercise. This worksheet is available near the end of Chapter 12 in the client workbook and can also be downloaded by searching for this book’s title on the Oxford Academic platform at academic.oup.com. Once your client has finished writing, you can ask them to review their writing and reflect on the strength and resilience they have shown in the writing and throughout treatment: Tell me what you think about what you wrote in your letter. ■ What new strengths and resilience do you see in yourself now compared ■ to when you started treatment? How can you use this new competence you’ve shown going forward in ■ your life?

Ending Treatment As you end this final treatment session, we recommend emphasizing the following: ■ Your client has new knowledge and new skills to manage and respond to their emotions and LGBTQ-​related stress. Many clients feel concerned about ending treatment; this is a normal experience. It may be helpful to emphasize to your client that they now have the knowledge and skills to manage and respond to their emotions independently, even in very stressful situations. Your client, and the LGBTQ community, are resilient. Your client has ■ substantial personal capabilities and has worked hard to complete treatment. They have also shown significant resilience and unique strengths during and before treatment, which is a quality shared by the LGBTQ community as a whole. Acknowledge your client’s work and progress. All clients who have ■ reached the end of this treatment program have engaged in substantial personal work and, even if they have not met their personal

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treatment goals, have likely made tangible progress and engaged in the vulnerable process of being in treatment. ■ If terminating with this client, acknowledge and process the end of your therapeutic relationship. We encourage you to use this termination to process the end of treatment in a way that works for you, while also acknowledging the deep, personal, and vulnerable work that the client has completed. For example, you might comment on what the work has meant to you, as a therapist, and any genuine feelings you may have toward your client (e.g., feeling honored to have witnessed their treatment process). Exploring their feelings about the end of your client–​therapist relationship may also be beneficial.

Module 9: Additional Helpful Reference Materials Case Vignettes Case Vignette #1 In this vignette, the therapist is working with Rene, a 50-​year-​old gay man who has been exploring his gender expression and what feels most authentic to him. He has felt obligated to express himself in stereotypically “masculine” ways in terms of dress, grooming, and behavior, and has for a long time wanted to experiment with more “feminine” apparel and grooming. When his therapist asks how his emotion exposure went this past week, Rene initially says that he was not successful because he did not complete the planned experiment, but on further exploration, the therapist learns that he has engaged in an organic experiment through which he learned the key take-​home messages intended by the emotion exposure exercise. This is an opportunity to highlight Rene’s gains through this home practice, as well as his overall treatment gains. Therapist:  So, tell me how it went with your emotion exposure activity that you planned for this week. Client:  Well, I actually didn’t do it. I know we made a plan, but I just had a really busy week and I didn’t get to it. Then, last night I remembered and I was going to do it, but then I forgot again.

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Therapist:  It sounds like it was a busy week. Client: Yeah, well, actually I did do something else that we had talked about before, that I know I was avoiding. Can I tell you about that? Therapist:  Of course, I’d like to hear. Client:  Well, you know how I’ve been wanting to experiment going out without having to dress super-​masculine? Like wanting to experiment with different kinds of clothes, but I’ve been scared that people will make fun of me or treat me differently. Therapist:  Yes, we’ve talked a lot about that, as well as the anxiety you feel both when you think about trying it and when you don’t get to be your authentic self in social situations. Client:  Yeah, so this last weekend I went to this house party and I actually wore clothes that better represent who I really am. I was really nervous before I went, but it was funny: No one said anything and it was totally fine. When I got there my heart was racing and then the longer I stayed there, I honestly felt really comfortable, and then when I left, I didn’t have that old feeling of being a fake. Therapist:  Wow, so you initially said you didn’t do an emotion exposure, but this sounds like a pretty substantial exposure, even if you didn’t plan it as one. What did you take away from it? Client:  Just that it might actually be better for me, in the long run, to do the things that I want to do and be myself around other people, even if it’s scary. For the most part, I’m in situations where I know it’s safe to do those things, it just scares me. But it’s been really nice being able to be myself and feel what that’s like these last couple of days. Therapist:  Let’s just pause there for a minute. This sounds really different than the person who came to see me 4 months ago. What do you think has changed? Client:  I am different. I think it’s because I’ve been using the skills and practicing a lot. I’ve really been trying to push myself as much as I can. I haven’t always been doing the exact home practice activities we’ve planned on, but I’ve always been pushing myself in between sessions. Therapist:  That’s huge. You’ve committed to putting the skills into action, and you’ve seen changes in yourself because of it. Client:  Yeah, I really have.

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Case Vignette #2 In this vignette, the therapist is working with Shanti, a 19-​year-​old non-​ binary pansexual client who presented to treatment very depressed and with their mother’s encouragement. When treatment began, Shanti was not getting out of bed at all, and their mother was dropping them off for treatment sessions. Now, they take public transportation on their own to come to treatment, and they have made significant progress to reconnect with old friends and build new, affirming social networks. However, Shanti is very worried about their depression coming back after treatment ends. Notice how the therapist encourages the client to consider the skills they have gained through treatment, thereby consolidating treatment gains, and to modify their long-​term goals to be focused on using these skills. Therapist:  One thing that we like to do before ending treatment is to think about what your long-​term goals are from here. It seems like you’re in a pretty different place now than where you were when we first started—​you now have a set of skills that you can use to respond to intense emotions, whether they are triggered by LGBTQ-​ related stress or something else. Where do you want to go from here? Client:  When I started here, I definitely was in a different place. I was so depressed that I wasn’t doing any of the things that I really valued or wanted. Since coming here I’ve really opened my world up and connected with people, made friends—​including some pansexual, non-​binary people. I’ve finally felt normal for the first time in a while. Therapist:  You’ve seen a lot of changes during treatment. Client:  Absolutely. I think that the most important long-​term goal for me is to just make sure that I never go back to that place. Therapist:  Tell me what you mean by that. Client:  I just never want to get depressed like that again. I haven’t felt really sad in a while, and I just really don’t want to go back to that again. Therapist:  To feeling depressed? Or feeling sad? Client: Both. I know we’ve learned here that I can handle my emotions, but I feel like if I slipped back into a lot of sadness or, even worse, depression, I would feel like this was all for nothing. Why did I even do all this work if it all comes back again? 269

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Therapist:  That’s a common feeling, the idea that if sadness, or even depression, comes back again after treatment, that it means treatment didn’t work. What could you do if you did start feeling sad or depressed again? Client:  Well, I guess I could try using the same skills I learned here? Therapist:  Absolutely. These skills, which worked to help you navigate the depression that you started treatment with, will continue to be helpful if you practice them after you end treatment. How likely do you think it is that you’ll never face another stressor again? Client:  [laughs] Not likely. Therapist:  Exactly. Unfortunately, stressors will continue to happen. You might face other types of LGBTQ-​related stress in the future, or more general types of stress in the future. But what I’ve seen from you during this treatment is that you are able to use the skills, on your own, and apply them to many different stressful situations to be able to respond to your emotions in ways that benefit you in the long run. Client:  That’s true. If I get sad or depressed again, I could use the skills again and they could help again. Therapist:  So, what do you think might be your long-​term goal then? Client:  With that in mind, my long-​term goal is probably to keep practicing these skills, especially if I start feeling sad or depressed again.

Navigating Challenges in Module 9 Managing Client Discouragement Sometimes, at the end of treatment, clients can feel discouraged if they feel that they have not made as much treatment progress as they would have liked to. There are several possible explanations for this, all of which merit exploration: ■ First, it is possible that your client is minimizing the very real treatment gains that they have made. In this case, it may be useful to use the “challenging automatic thinking” skill from Module 5 to

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help your client identify the unhelpful thought (i.e., minimization or discounting the positive) and challenging it (e.g., “Actually, I did make substantial gains. I can see it right there on my Progress Record”). ■ Another possibility is that your client may have set unrealistic goals for themselves at the beginning of treatment. In this case, it may be helpful to invite your client to re-​examine their initial goals and, using the skills learned in treatment, assess whether these goals were realistic. This may facilitate your client focusing on the gains that they did make during treatment, instead of those gains that they were not able to make. Finally, it is possible that your client may have set realistic goals that ■ were not able to be fully realized during treatment. If this is the case, it may be helpful to emphasize the notion that treatment is a starting point, and that in this type of treatment, the skills gained are generalizable to new situations. With practice, clients can expect to continue to see growth and change even after treatment ends. Such growth is facilitated by all of the components of this final module (e.g., reviewing skills, making a practice plan, and setting long-​term goals).

Responding to Final Session Crises Inevitably, there are times when immediately before the final treatment session, a major life crisis occurs, which understandably can be destabilizing for clients. When this happens, it is common for clients to feel particularly discouraged, thinking that they are now back to where they started before they began treatment. It is important to acknowledge the real impact of this crisis on your client, while also emphasizing that they are not, in fact, in the same place as when they started treatment: They now have the experience and knowledge of a variety of skills to more effectively respond to and cope with their emotions. Another strategy that may be helpful is to return to other crises that may have occurred during the course of treatment and discuss how the client was able to use the treatment skills to navigate those prior events, then emphasize that they have the skills to do the same in response to the current crisis.

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Client Readiness to End Treatment Upon being faced with the end of treatment, clients often feel worried that they are not ready to end treatment or express uncertainty about their ability to use the treatment skills on their own, without the therapist. One unique aspect of this cognitive-​behavioral–​focused treatment that can be emphasized in response to this concern is that clients actually learn all of the treatment skills (and practice them) before treatment ends. Another important point is that many of the treatment gains that the client has experienced are a result of their own, independent actions. You were not present when the client completed any of their home practice, which suggests that the client has the ability to engage in all of the skills learned in treatment by themselves. That said, these concerns are very common, and it is important to validate them as a normal response to ending treatment.

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About the Authors

John E. Pachankis, PhD, is the Susan Dwight Bliss Professor of Public Health and Psychiatry at Yale and Director of Yale’s LGBTQ Mental Health Initiative. His research examines the mental health of LGBTQ populations globally and the efficacy of LGBTQ-affirmative mental health interventions. He has published 150+ scientific papers on LGBTQ mental health and stigma and recently co-edited the Handbook of Evidence-Based Mental Health Practice with Sexual and Gender Minorities, published by Oxford University Press. Audrey R. Harkness, PhD, is Assistant Professor of Public Health Sciences at the University of Miami. Her research focuses on mental health of LGBTQ populations, including mental health in the context of HIV prevention and treatment, mental health disparities and equity, and Latino/a/x LGBTQ communities in particular. Skyler D. Jackson, PhD, is an Associate Research Scientist at Yale School of Public Health. As an award-winning researcher and psychologist, his work examines how experiences of stigma—if not adequately coped with—interfere with psychological functioning and contribute to health disparities. In particular, much of his published work helps illuminate the complex role of intersectional stigma in shaping the everyday lives and health outcomes of LGBTQ people of color. Steven A. Safren, PhD, is a Professor of Psychology and Cooper Fellow at the University of Miami (UM) in the Department of Psychology. He is also Director of the UM Center for HIV and Research in Mental Health (CHARM). For over 20 years, Dr. Safren has studied behavioral health related to sexual and gender minorities, much of which in the context of HIV prevention and treatment, both domestically and globally. He is a leading expert in cognitive behavioral therapy, has been the editor of the journal Cognitive and Behavioral Practice, and has published over 400 peer-reviewed papers in his field.

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