Mental health providers can learn to deliver evidence-based LGBTQ-affirmative cognitive therapy through low-cost online training, which would help deliver more evidence-based mental health care to LGBTQ people and support its implementation across practice settings, according to a new study by Yale School of Public Health (YSPH) researchers.
The study, published July 28 in the American Psychological Association’s Journal of Consulting and Clinical Psychology, was led by John Pachankis, the Susan Dwight Bliss Professor of Public Health in the Department of Social and Behavioral Sciences and director of Yale’s LGBTQ Mental Health Initiative.
This randomized controlled trial examined whether an 11-week, real-time, online training in LGBTQ-affirmative cognitive behavioral therapy (CBT) could lead to increased uptake of this practice at LGBTQ community centers across 20 U.S. states and internationally. It comes at a time when there’s an urgent need for more mental health professionals who can work with LGBTQ clients, the researchers said.
“LGBTQ people represent one of the highest-risk populations for depression, anxiety, suicide, and substance use problems,” said Pachankis, “However, LGBTQ people have not had access to evidence-based mental health treatments created by and for LGBTQ people.”
A 2022-23 Fulbright Scholar, Pachankis will spend the coming school year as a visiting scholar at the Karolinska Institute in Stockholm, Sweden. There, he’ll study why LGBTQ people in Sweden, one of the world’s most tolerant countries, face mental health disparities similar to people elsewhere.
“Our team at Yale recently created a treatment called LGBTQ-affirmative cognitive behavioral therapy (CBT), which is the first mental health treatment specifically for LGBTQ people to have been tested in randomized controlled trials,” Pachankis said. “When we found that LGBTQ-affirmative CBT could help improve LGBTQ people’s mental health, we then wanted to make sure that LGBTQ people could access this treatment in their local communities.”
As part of the research, Pachankis and colleagues trained mental health providers at 50 LGBTQ community centers to deliver the treatment. They also tested whether the training worked – namely, whether the newly trained providers actually learned to implement the therapeutic principles and skills taught to them.
To line up the community centers used in the study, Pachankis enlisted the help of an organization called CenterLink based in Fort Lauderdale, Florida. CenterLink serves as the coordinating hub of the US’s LGBTQ community centers, providing resources, support, and programming.
LGBTQ people represent one of the highest-risk populations for depression, anxiety, suicide, and substance use problems. However, LGBTQ people have not had access to evidence-based mental health treatments created by and for LGBTQ people.
Professor John Pachankis
In all, 121 mental health providers were randomized to receive the 11-week training either immediately or after a 4-month wait. The staggered start, Pachankis said, “allowed us to compare differences in treatment knowledge and demonstration of treatment skill between those providers who were trained and those who were not.”
At baseline and at four and eight months after baseline, participants self-reported their LGBTQ-affirmative competency, cultural humility, and knowledge of the minority stress theory and practice skills underlying LGBTQ-affirmative CBT. To objectively assess uptake of LGBTQ-affirmative CBT, providers demonstrated, through simulated practice, how they would respond to two video-based clinical vignettes played by LGBTQ actors. One factor that made the study unique, Pachankis said, was the use of video vignettes to add more objectivity to the study outcomes.
“We faced a challenge of how to assess the training’s impact on providers,” he said. “Most studies of training effectiveness rely on providers’ self-reported treatment knowledge and skills. To bypass the limitations of only relying on providers’ reports of their abilities, we hired LGBTQ actors to create videos of typical LGBTQ clients seeking mental health services.”
The trainees were asked both before and several months after the training sessions to describe the therapeutic approaches and specific techniques they would use to help the people in the videos. Two research assistants coded the trainees’ responses, not knowing whether they were submitted before or after the training.
“Using this novel assessment approach, we found that trainees indeed demonstrated more LGBTQ-affirmative CBT skills in their treatment approaches after, compared to before, the training,” Pachankis said. “Not only did this show that our training worked, but it also shows how future studies can overcome the limitations of relying on providers’ self-report to determine the effectiveness of any training.”
Also, he said, “Compared to waitlisted participants, those who were trained immediately reported greater improvements in self-reported cultural competence, minority stress knowledge, LGBTQ-affirmative CBT knowledge, and LGBTQ-affirmative CBT skills familiarity and use. They also retained that knowledge, showing CBT competency eight months after completing the training program.
YSPH Assistant Professor Skyler Jackson is a co-author of the study. Zachary Soulliard, Ilana Seager van Dyk, Eric Layland, and Kirsty Clark were postdoctoral fellows at YSPH at the time the study was conducted. The study was funded by the David R. Kessler, MD ’55, Fund for LGBTQ Mental Health Research at Yale, with financial support also provided by the Fund for Gay and Lesbian Studies at Yale.