LGBTQ+-affirmative therapy

1. Introduction

Version followed: the minority-stress-based, transdiagnostic LGBTQ-affirmative CBT developed by John Pachankis and colleagues at Yale (ESTEEM for gay and bisexual men; EQuIP for sexual minority women and later transgender and gender-diverse adults; Therapist Guide: Pachankis, Harkness, Jackson & Safren, 2022, Oxford "Treatments That Work"). Its stance and assessment rules are taken from the APA Guidelines for Psychological Practice with Sexual Minority Persons (2021) and the APA Guidelines for Psychological Practice with Transgender and Gender Nonconforming People (2015). AFFIRM (Craig & Austin), an 8-session group CBT for LGBTQ+ youth, is noted as a variant. The 2022 Therapist Guide itself is not drawn on: session contents below are built from the papers, trial protocols and guidelines cited. [source: Proujansky & Pachankis 2014; ClinicalTrials.gov NCT02929069 and NCT06229132; APA 2021; APA 2015]

What it is. "LGBTQ+-affirmative therapy" is first a stance and framework, not one branded therapy. It means practising so that lesbian, gay, bisexual, transgender, queer and other sexual- and gender-minority identities are treated as healthy variations. It is the explicit alternative to sexual-orientation and gender-identity change efforts. That stance can sit inside any modality, including person-centred, psychodynamic, existential and family work. The only versions with published session-level protocols and trials are affirmative CBT packages (ESTEEM/EQuIP, AFFIRM). That is why this guide follows the Pachankis model for procedures and the APA guidelines for stance. [source: APA 2021, Guideline 4; CLASP AFFIRM overview]

How change happens. The model rests on minority stress theory (Meyer, 2003) and on Hatzenbuehler's (2009) account of how stigma "gets under the skin". The theory names two kinds of stressor. Distal stressors are external: discrimination, victimisation and microaggressions. Proximal stressors are internal: internalised stigma, expecting rejection, and concealing one's identity. Both feed general psychological processes such as rumination, emotion dysregulation, avoidance, hopelessness and social isolation, and these processes drive depression, anxiety, substance use and sexual-health risk. Treatment works in four steps:

• It names stigma as a cause of distress, so the client stops reading it as a personal failing.
• It builds awareness and acceptance of the emotions that stigma triggers.
• It reduces avoidance and restructures stigma-shaped thinking.
• It strengthens assertiveness, supportive relationships, community ties and the client's own strengths.

The therapy treats these shared mechanisms, not one diagnosis, which is why it is transdiagnostic. [source: Pachankis Div12 blog; Proujansky & Pachankis 2014; NCT02929069]

2. Framework

Format.

• ESTEEM: 10 individual sessions, held weekly, finished within 4 months. Two sessions in one week are allowed to catch up. It is an adaptation of the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (Barlow et al.), whose workbook served as the base manual. [source: NCT02929069]
• EQuIP, Romanian TGD adaptation: 16 weekly sessions of about 1 hour, delivered by video. It was adapted through focus groups with transgender and gender-diverse (TGD) people and providers, and guided by the gender minority stress framework. [source: NCT06229132]
• AFFIRM: 8 modules, run as a group or individually, in schools and LGBTQ+ community centres. [source: CLASP AFFIRM overview]

Phases. These are reconstructed from the published descriptions and the Unified Protocol module order. The exact session numbering in the 2022 Therapist Guide is [uncertain].

[source: Proujansky & Pachankis 2014; NCT02929069; phase mapping is synthesis] [synthesis]

Assessment at intake. Assess the following, without assuming anyone's orientation or gender identity from the other or from appearance:

• Lifetime discrimination and victimisation, including bullying, intimate partner violence and workplace discrimination.
• Proximal stressors: internalised heterosexism or binegativity, expectations of stigma, and concealment.
• Safety and social support.
• Suicide risk. Use standard risk assessment, since bi+ clients exposed to binegativity show raised suicidality, disordered eating and PTSD symptoms.

[source: APA 2021, Guidelines 2, 3, 6, 7] Consider a trauma-informed frame: discrimination can produce PTSD-like symptoms even without a single Criterion A event. [source: APA 2021, Guideline 6]

3. Guiding principles

Core treatment principles (Pachankis). The 2014 papers list eight. The later EQuIP protocol lists six, and adds intersectionality explicitly. [source: Proujansky & Pachankis 2014; Pachankis Div12 blog; NCT06229132]

1. Normalise the mental-health impact of minority stress. Present symptoms as an understandable response to a stigmatising environment, not a personal defect.
2. Facilitate emotion awareness, regulation and acceptance. Help the client notice and allow feelings set off by stigma, rather than numb or avoid them.
3. Decrease avoidance. Approach the avoided memories, emotions and interactions, but only in situations that are actually safe.
4. Restructure minority-stress cognitions. Target rejection expectations, internalised stigma and inflexible stress-shaped beliefs with cognitive techniques.
5. Empower assertive communication. Build the skill to speak up where it is safe and healthy, for example against unfair treatment or for condom use.
6. Validate unique strengths. Name resilience such as coming out, community-building and resistance to stigma, and use it in treatment.
7. Facilitate supportive relationships. Treat authentic family, partner and community ties as a mental-health resource.
8. Affirm healthy, rewarding expressions of sexuality. Be sex-positive and fill gaps left by heteronormative sex education.
9. Recognise intersecting identities as both stressor and resource. Ask about race, religion, class, disability, age and immigration status alongside sexuality and gender. [source: NCT06229132; APA 2021, Guideline 1]

Stance principles (APA guidelines and the Pachankis commentary).

• Orientation and gender diversity are not disorders. Never attempt to change them. Inform clients, especially minors and their families, about the risks of change efforts. [source: APA 2021, Guideline 4]
• Support identity exploration without prescribing an outcome. Questioning clients get space to explore, with no destination set by you. [source: APA 2021, Guideline 4]
• Keep sexual orientation and gender identity separate. Do not infer one from the other. Do not assume a trans or nonbinary client is also a sexual minority. [source: APA 2021, Guideline 2; APA 2015, Guideline 2]
• Gender is not binary, and identity may differ from the sex assigned at birth. Ask; do not assume. [source: APA 2015, Guideline 1]
• Address orientation and gender only as far as they are relevant. Ignoring them is non-affirmative, but so is treating them as the client's only issue. [source: Proujansky & Pachankis 2014]
• Keep the formulation open to the client's correction. Ask for feedback on the minority-stress formulation, and drop parts that do not fit. [source: Proujansky & Pachankis 2014]
• Stay alert to minority stress throughout treatment, even when it is not obvious at intake. [source: Proujansky & Pachankis 2014]
• Affirm bi+ identities and check your own monosexism. Do not treat bisexuality as a phase or a step toward a "real" identity. [source: APA 2021, Guideline 3]
• Do not push disclosure. Coming out is the client's decision, made situation by situation, because it can increase risk. [source: APA 2021, Guideline 3]
• Make the link to institutional barriers when the client does not. Do not minimise harms the client reports from institutions. [source: APA 2021, Guideline 5]
• Practise cultural humility. That means self-examination, repairing ruptures and working through value differences. [source: APA 2021, Guideline 6; APA 2015, Guideline 4]
• Not every problem is about gender or orientation. For TGD clients, mental-health concerns may or may not relate to gender identity. [source: APA 2015, Guideline 10]
• Treat affirmation and social support as active ingredients. [source: APA 2015, Guideline 11]
• Notice stigma inside LGBTQ+ communities, such as rejection based on race, age, body size, effeminacy or HIV status. [source: Proujansky & Pachankis 2014]
• Vet referrals. Many "LGBT" services centre gay and lesbian, white or cisgender people, so check that a referral actually fits this client. [source: APA 2021, Guidelines 2, 6]
• Make the environment affirming. Use inclusive intake forms (for example "parent or guardian") and collaborate across disciplines, for instance in medical transition care. [source: APA 2021, Guideline 5; APA 2015, Guidelines 6, 14]

4. Intervention inventory

The inventory is listed roughly in treatment order. The Unified Protocol (UP) base techniques are described from the published UP (Barlow et al., 2011/2018). That manual and the 2022 LGBTQ-affirmative Therapist Guide are not drawn on, so the UP-derived steps are marked [uncertain] where detail goes beyond the published descriptions. All example language is illustrative.

4.1 Affirming opening and permission to discuss identity

• Purpose: Signal safety and invite, but never force, discussion of sexuality or gender. Use it in the first session, and again whenever identity comes up.
• Steps:
  1. Ask the client what name and pronouns they use, and what words they use for their orientation and gender. Use those terms from then on. [synthesis]
  2. Ask permission before exploring sexual orientation or gender identity.
  3. If the client discloses, affirm the disclosure explicitly.
  4. Explore where any hesitation to talk about it came from, such as upbringing, family or religion.
  5. Do not assume a partner's gender, or anything about orientation from gender, or about gender from appearance. [source: Proujansky & Pachankis 2014, describing Mandel's case; APA 2021, Guideline 2]
• Example language (illustrative): "Would it be OK if we talked about how your sexuality fits into what's been going on? You decide how much." / "Thank you for telling me that. I'm glad you did."
• Watch for: Over-focusing on identity when the client came for something else. Fewer hedges and euphemisms over time suggests safety is growing.

4.2 Affirming intake materials and setting

• Purpose: Remove signals of heteronormativity and cisnormativity before therapy starts. This is a practice-level intervention.
• Steps:
  1. Audit your forms. Use "parent or guardian" and "partner". Give open fields for gender, pronouns and orientation, and record names as used. [source: APA 2021, Guideline 5; pronoun and name fields are synthesis]
  2. Use inclusive case examples and readings in your service and in training. [source: APA 2021, Guideline 5]
  3. Check that referral lists and groups you recommend actually welcome bi+, TGD and racialised clients. [source: APA 2021, Guidelines 2, 6]
• Watch for: Clients correcting the forms, or leaving fields blank, which tells you an option is missing.

4.3 Minority-stress assessment

• Purpose: Map the distal and proximal stressors, the client's strengths and safety, so you can build the formulation. Use it at intake and update it throughout.
• Steps:
  1. Ask about lifetime discrimination, victimisation, bullying, microaggressions, workplace discrimination and intimate partner violence. Validate the pain these caused. [source: APA 2021, Guidelines 3, 6]
  2. Ask about proximal stressors [source: APA 2021, Guideline 7]:
     • internalised heterosexism, binegativity or transnegativity
     • expecting rejection
     • vigilance
     • concealment: who knows and who doesn't, and what hiding costs
  3. Ask about stigma within LGBTQ+ spaces and about intersecting identities. [source: Proujansky & Pachankis 2014; APA 2021, Guideline 1]
  4. Assess suicide risk and current safety at home, school and work using standard practice. [source: APA 2021, Guideline 3; NCT02929069 safety procedures]
  5. Note resilience: support, community, coming-out experiences and activism. [source: APA 2021, Guideline 8]
  6. Optional idea: a brief free association to identity words (see 4.10) can reveal internalised stigma. In research, ESTEEM also used an Implicit Association Test reviewed against norms. That is a research measure, not a required clinical step. [source: Proujansky & Pachankis 2014] [uncertain]
• Example language (illustrative): "Some people have experienced unfair treatment because of who they are, at school, at work, in their family or even in queer spaces. What has that looked like for you?"
• Watch for: Clients minimising discrimination ("it wasn't that bad"). Note it, don't argue, and revisit later.

4.4 Shared minority-stress case conceptualisation

• Purpose: Link the client's symptoms to stigma-related stressors and the processes they set off. This is the organising frame for treatment, used in sessions 1 and 2 and revisited later.
• Steps:
  1. Sketch the formulation with the client, from left to right:
     • distal stressors
     • proximal stressors
     • general processes (rumination, avoidance, isolation, substance use, perfectionism)
     • current symptoms
  2. Add strengths and sources of support as protective arrows.
  3. Ask explicitly for feedback: what fits and what doesn't. Revise, or drop parts that don't fit.
  4. Pick the treatment targets from the processes, not from identity. [source: Proujansky & Pachankis 2014; Hatzenbuehler 2009 as cited]
• Example language (illustrative): "Here's one way of putting it together: years of expecting rejection might keep you on guard and avoiding people, which feeds the low mood. Does that match your experience, or am I off?"
• Watch for: Clients who reject a stigma explanation, sometimes at first. Leave it as a hypothesis, because clients often come to accept minority-stress explanations over time. [source: Proujansky & Pachankis 2014]

4.5 Motivation enhancement

• Purpose: Build commitment to change and connect it to the client's values. This is UP Module 1, kept in ESTEEM. [source: NCT02929069 lists "motivation enhancement"]
• Steps (UP-derived) [uncertain]:
  1. Weigh the pros and cons of changing against staying the same.
  2. Elicit concrete goals and break them into small steps.
  3. Use motivational interviewing reflections to resolve ambivalence, for example about drinking or sexual-risk behaviour.
• Example language (illustrative): "What would be different in a year if this went well? And what might you lose by changing?"
• Watch for: Goals set by others, such as family, partner or a religious community, instead of by the client. Check whose goal it is.

4.6 Minority-stress psychoeducation (normalising)

• Purpose: Help the client attribute distress to stigma rather than personal failure (Principle 1). Use it early, and repeat it whenever self-blame appears.
• Steps:
  1. Explain the minority stress model in plain terms: stress from stigma is extra to ordinary stress, and it is chronic and socially caused.
  2. Explain how stigma can shape thoughts, feelings and behaviour.
  3. Connect the model to the client's own examples.
  4. Explain that high rates of depression, anxiety and substance use in LGBTQ+ groups reflect the environment, not identity. [source: Proujansky & Pachankis 2014; Pachankis Div12 blog; NCT02929069]
• Example language (illustrative): "Feeling on edge in a new job where you don't know if it's safe to mention your partner isn't a flaw in you. It's a reasonable response to an uncertain environment."
• Watch for: Normalising tipping into fatalism ("the world is hostile, nothing can change"). Balance it with agency and strengths.

4.7 Self-monitoring and emotion tracking

• Purpose: Teach the sequence of trigger, emotion and response. Make reactions to minority stress visible, especially avoidance such as substance use or condomless sex. Start in phase 2 and continue throughout.
• Steps:
  1. Introduce a tracking form with columns for antecedent, thoughts, feelings, body sensations, behaviour, and short- and long-term consequences. [UP-derived; uncertain]
  2. Ask the client to log events between sessions, flagging any linked to stigma: a slur, a family comment, hiding at work.
  3. Review the logs together and look for patterns, such as avoidance bringing short-term relief and long-term cost. [source: NCT02929069, "identify minority stress experiences; track unhealthy reactions"]
• Example language (illustrative): "Let's look at Thursday. What happened right before you started drinking, and what did it do for you that night and the next day?"
• Watch for: Logs that are incomplete. Shrink the form, or do it in session.

4.8 Mindful emotion awareness and mood labelling

• Purpose: Build present-focused, non-judgemental awareness of emotions set off by minority stress (Principle 2). Use it in phase 2, and before exposures.
• Steps:
  1. Teach the client to notice and name emotions and body sensations as they arise, with no judgement.
  2. Practise with a brief in-session exercise. Then repeat it during a recalled minority-stress trigger, with the client describing the feeling rather than acting on it.
  3. Use a short anchoring practice between sessions, such as breath or the senses, especially at known trigger points. [UP-derived; uncertain] [source: Proujansky & Pachankis 2014, "mood labeling and mindfulness"; NCT02929069]
• Example language (illustrative): "As you remember your father's comment, what do you notice in your body right now? Just name it. You don't need to change it."
• Watch for: Mindfulness used to suppress feeling. It is working when the client can name an emotion and stay with it for a few seconds longer than before.

4.9 Urge surfing for substance use or compulsive behaviour

• Purpose: Let cravings that serve to numb stigma-related shame or loneliness rise and fall without acting on them.
• Steps:
  1. When an urge appears, notice it, rate its intensity, and observe its physical sensations without acting.
  2. Track the urge as it peaks and subsides, like a wave.
  3. Plan an alternative action for afterwards, such as contacting a supportive person (see 4.16). [source: Proujansky & Pachankis 2014, describing Mandel's use of mindfulness and urge surfing]
• Example language (illustrative): "Notice the urge to smoke. Where is it? How strong, from 0 to 10? Let's watch what it does over the next few minutes."
• Watch for: Repeated urges at the same trigger, such as loneliness at night. Address that trigger directly.

4.10 Free association to identity words

• Purpose: Bring internalised stigma into view so it can be restructured. Use it when you suspect internalised stigma that the client has not put into words.
• Steps:
  1. Ask permission first.
  2. Ask the client to say whatever words come to mind about being gay, bi, trans, queer, or whatever term they use.
  3. Write the words down without commenting.
  4. Explore where each word came from: family, religion, school or the media.
  5. Mark the stigmatising words as targets for cognitive work (4.11). [source: Proujansky & Pachankis 2014, describing Mandel's case, in which the client produced condemning and lonely words]
• Example language (illustrative): "When you hear the word 'gay', what words pop up? Don't filter. We'll look at where they came from afterwards."
• Watch for: Shame spiking. Slow down, validate the feeling, and make clear these are learned messages, not facts.

4.11 Cognitive restructuring of minority-stress cognitions

• Purpose: Loosen rigid appraisals that stigma has shaped, such as:
  • expecting rejection ("everyone will reject me if they know")
  • internalised stigma ("being bi means I'm confused")
  • conditional worth and perfectionism ("I must be the perfect child to be loved") Use it in phase 3, and whenever these thoughts drive avoidance. (Principle 4)
• Steps:
  1. Catch the automatic thought from the tracking forms.
  2. Identify the thinking trap. UP names two: overestimating how likely a bad outcome is, and catastrophising about how bad it would be. [UP-derived; uncertain]
  3. Examine the evidence. Tell apart realistic threat, where discrimination really is likely, from overgeneralised threat. Do not dispute accurate perceptions of discrimination.
  4. Generate balanced alternatives, including attributing the cause to stigma: "they rejected me because of their prejudice, not because I'm defective".
  5. Test alternatives through behavioural experiments (4.13). [source: Proujansky & Pachankis 2014; Pachankis Div12 blog; NCT02929069]
• Example language (illustrative): "How likely, from 0 to 100, is it that your team would treat you badly if they knew? What's that estimate based on? And if one person did react badly, how would you cope?"
• Watch for: Debating whether the client's experience of discrimination was "real". That is invalidating and can rupture the alliance. The method is working when the client spontaneously generates flexible appraisals and acts on them.

4.12 Examining internalised gender norms

• Purpose: Address devaluing of gender nonconformity in oneself or others, for example disgust at "flamboyant" men or at masculine women. Use it when this devaluing feeds shame or intra-community prejudice.
• Steps:
  1. Notice judgements the client makes about gender expression.
  2. Ask curious questions about where the standard comes from.
  3. Give psychoeducation on how gender scripts devalue gender diversity.
  4. Link it back to the client's own self-criticism. [source: Proujansky & Pachankis 2014, describing Mandel's case]
• Example language (illustrative): "You said you'd never want to be 'one of those' guys. What would it mean about you if you were?"
• Watch for: Lecturing. Keep it exploratory.

4.13 Avoidance hierarchy and graded exposure, including emotion and interoceptive exposure

• Purpose: Reduce avoidance of memories, emotions, sensations and social situations linked to minority stress (Principle 3). Use it in phase 4.
• Consent and safety first:
  1. Explain the rationale. Agree on each step together. The client sets the pace and can stop at any point.
  2. Include only situations that are realistically safe. Never set exposure to genuinely dangerous settings, such as coming out to a violent family member or to an unsafe employer.
  3. Screen for acute suicidality, current victimisation, unstable housing and active substance dependence. These need stabilisation first.
  4. For trauma memories from victimisation, consider a trauma-focused protocol. [source: Pachankis Div12 blog, "in safe settings"; APA 2021, Guidelines 3, 6] [synthesis for screening list]
• Steps:
  1. Together, list avoided behaviours, such as:
     • holding a partner's hand in a safe area
     • going to an LGBTQ+ event
     • mentioning one's partner at work
     • recalling a bullying memory
     • having sex sober
  2. Rate each item for expected distress from 0 to 10, and order them into a hierarchy.
  3. Plan in-session exposures first, such as imaginal recall, role-play or interoceptive exercises, then between-session ones.
  4. During each exposure, ask the client to stay with the feeling and drop subtle avoidance or safety behaviours.
  5. Afterwards, review what happened compared with what they predicted. [source: Proujansky & Pachankis 2014; NCT02929069, "interoceptive and situational exposure"]
• Example language (illustrative): "Next on your list is going to the queer book club for 20 minutes. What do you predict will happen? Let's write it down, and check it next week."
• Watch for: Hidden safety behaviours, such as staying on the phone or drinking first. The method is working when distress ratings fall across repetitions and the client climbs the hierarchy.

4.14 Assertiveness hierarchy with in-session role-play

• Purpose: Build the skill and self-efficacy to assert oneself against unfair treatment, and to state needs, including sexual-health needs, where this is safe (Principle 5). Use it in phase 4.
• Steps:
  1. List situations needing assertion, from easier to harder. Examples:
     • correcting a misgendering colleague
     • asking a partner to use condoms or discuss PrEP
     • challenging a homophobic joke
     • setting a boundary with a relative
  2. Teach clear, direct and respectful statements.
  3. Role-play in session. The therapist plays the other person, then swaps roles. Give feedback, then rehearse again.
  4. Assign real-world practice only in situations judged safe enough. [source: Proujansky & Pachankis 2014; NCT02929069, "assert themselves against unjust minority stress in safe situations"]
• Example language (illustrative): "I'll be your coworker. Try telling me, plainly, that your pronoun is 'they' and you'd like me to use it."
• Watch for: Aggressive or over-apologetic delivery. Also weigh the risk of retaliation; safety outranks assertion.

4.15 Disclosure (coming-out) decision-making

• Purpose: Help the client make situation-specific choices about disclosure, without pushing disclosure as a goal. Use it when concealment is costly or the client is considering coming out.
• Steps:
  1. For each person or setting, list the pros and cons of disclosing and of not disclosing. Include safety, financial dependence, cultural or religious context and the strain of concealment.
  2. Rate the risk.
  3. If the client chooses to disclose, plan when, where and how, along with supports and a fallback if it goes badly. Rehearse it by role-play (4.14).
  4. If the client chooses not to, respect that. Work on reducing the strain of concealment and finding at least some contexts where they can be authentic. [source: APA 2021, Guideline 3; Proujansky & Pachankis 2014, suggesting cost-benefit work about disclosure to parents]
• Example language (illustrative): "There's no right answer here. Let's look at what telling your sister might give you, what it might cost, and what you'd need in place either way."
• Watch for: Your own wish for the client to be "out". Concealment can be adaptive. Where the client is a minor, or is dependent on someone who might reject them, plan housing and safety first. [synthesis]

4.16 Building supportive relationships and community connection

• Purpose: Counter isolation and rejection by building authentic ties: chosen family, LGBTQ+ peers, affirming relatives and partners (Principle 7). Use it throughout, with a heavier focus in phase 5.
• Steps:
  1. Map the client's current supports and gaps.
  2. Use loneliness or urges as a cue to reach out rather than to use substances or withdraw.
  3. Schedule concrete contact, such as old friends, a campus LGBTQ+ centre, an LGBTQ+ recovery meeting or a sponsor.
  4. Check that the groups chosen fit the client's intersecting identities. [source: Proujansky & Pachankis 2014, describing homework in Mandel's case; APA 2021, Guidelines 6, 11]
• Example language (illustrative): "When the loneliness hits on Sunday night, who is one person you could message instead?"
• Watch for: Rejection in community spaces, for example because of race, body, age or HIV status. Process it, and look for alternatives.

4.17 Validating unique strengths and resilience

• Purpose: Make strengths an explicit resource, such as coming out, survival, creativity, community and resistance (Principle 6). Use it throughout.
• Steps:
  1. Ask about times the client coped with stigma.
  2. Reflect back the skills involved: courage, discernment, building chosen family.
  3. Bring those skills into current problems.
  4. In the final sessions, review accomplishments. [source: Proujansky & Pachankis 2014; APA 2021, Guideline 8; NCT06229132]
• Example language (illustrative): "You worked out at 15 who was safe to tell and who wasn't. That's the same judgement you can use now with your new manager."
• Watch for: Strengths talk that feels hollow because it is offered before the client feels understood. Validate the pain first.

4.18 Affirming healthy sexuality and sexual health

• Purpose: Address sexual shame, compulsivity, and sexual-risk behaviour driven by avoidance. Fill the information gaps left by sex education that is not inclusive (Principle 8). Use it when sex or relationships are part of the presenting picture.
• Steps:
  1. Take a matter-of-fact, sex-positive history. Ask about fantasies and shame, and whether substances are used to manage shame about sex.
  2. Identify avoidance, such as using substances during sex or not raising condom or PrEP use.
  3. Combine this with assertiveness (4.14) and exposure (4.13), for example having sex sober.
  4. Discuss relationship structures without assuming any norm. Explore monogamy and consensual non-monogamy as options.
  5. Refer to sexual-health services as needed. [source: Proujansky & Pachankis 2014; NCT02929069; APA 2021, Guidelines 9, 10]
• Example language (illustrative): "What would a sex life that feels good and safe look like for you?"
• Watch for: Your own discomfort, or moralising. Leaving sexuality unaddressed is itself a gap the authors flag. [source: Proujansky & Pachankis 2014]

4.19 Affirmative work on religion–identity conflict

• Purpose: Help clients whose faith and sexual or gender identity feel incompatible find their own resolution. The goal is resolving the conflict, not changing orientation or gender.
• Steps:
  1. Explore what the faith means to the client, and what the conflict costs them.
  2. Give accurate information: orientation is not a disorder, and change efforts carry risks of harm.
  3. Map out possible paths. Examples:
     • affirming congregations or traditions
     • reinterpreting teachings
     • separating spirituality from institutions
     • stepping back from religion
  4. Support whichever path the client chooses, as long as it does not involve trying to change identity. [source: APA 2021, Guideline 4; steps 3 and 4 are synthesis]
• Example language (illustrative): "Your faith matters to you, and so does who you are. Let's look at how others have held both, and what might fit you."
• Watch for: Requests for help to "become straight" or to stop being trans. Explain plainly that you will not do change work and why, then offer to explore the underlying distress. [source: APA 2021, Guideline 4]

4.20 Families of origin and chosen family

• Purpose: Address family rejection, ambivalence or acceptance, and strengthen chosen family. Use it when family is a stressor or a resource.
• Steps:
  1. Map both the family of origin and the chosen family.
  2. Explore unmet needs from family members, such as acceptance or being seen.
  3. Where safe and wanted, plan conversations or joint sessions.
  4. Give families psychoeducation on orientation and gender, and on how distinct the two are.
  5. Grieve losses where acceptance is unlikely. [source: APA 2021, Guidelines 2, 11; APA 2015, Guideline 13; steps 2 and 5 are synthesis]
• Optional, proposed by the authors but not used in the case: Empty-chair work to voice unmet needs toward parents the client has not come out to. If you use it, apply standard emotion-focused chair-work procedure. [source: Proujansky & Pachankis 2014, offered as a suggestion] [uncertain]
• Example language (illustrative): "If your mum could really hear you, what would you most need her to understand?"
• Watch for: Pressure to reconcile with a family that is still harmful. The client's safety and autonomy come first.

4.21 Gender-affirming exploration and care coordination (TGD clients)

• Purpose: Support TGD clients' exploration and affirmation of their gender without assuming any binary or medical outcome, and coordinate with medical providers. Use it whenever gender is relevant.
• Steps:
  1. Treat gender as non-binary and self-defined. Use the client's name and pronouns. [source: APA 2015, Guideline 1]
  2. Explore what kinds of affirmation the client wants. These may be social (name, pronouns, expression), legal, medical, or none. Do not presume a pathway. [source: APA 2015, Guidelines 1, 11; specific domains are synthesis]
  3. Assess gender minority stress, such as misgendering, rejection, discrimination and violence. Also assess how gender change affects romantic, sexual and family relationships. [source: APA 2015, Guidelines 5, 12; NCT06229132]
  4. Do not assume every mental-health concern is about gender. [source: APA 2015, Guideline 10]
  5. Collaborate with medical and other providers when the client wants that. Any assessment or letter-writing follows current WPATH Standards of Care, which are not drawn on here. [source: APA 2015, Guideline 14] [uncertain]
  6. With youth, attend to developmental stage. The 2015 guideline notes that not all gender-questioning young people keep a TGD identity into adulthood, so support exploration without steering in either direction. [source: APA 2015, Guideline 8]
• Example language (illustrative): "What would help you feel more like yourself day to day? That could be anything from clothes to a name to nothing in particular yet."
• Watch for: Gatekeeping, which makes therapy feel like an exam. Also check your own assumptions about binary outcomes.

4.22 Linking distress to institutional barriers, and advocacy

• Purpose: Validate the impact of policies and institutions, and act on them where you can. Use it when systems contribute to distress, for example school, work, healthcare, legal documents or housing.
• Steps:
  1. Name the institutional contribution when the client does not.
  2. Don't minimise harm the client reports.
  3. Help the client problem-solve their rights and resources.
  4. With consent, advocate, for example through letters or by liaising with a school. [source: APA 2021, Guideline 5; APA 2015, Guidelines 6, 7]
• Example language (illustrative): "Part of what's wearing you down is a system that keeps asking you to explain yourself. That's not a personal weakness."
• Watch for: Advocacy that overrides what the client wants, or exposes them to risk.

4.23 Relapse prevention and looking ahead

• Purpose: Consolidate skills, and plan for predictable future minority stressors, such as a new job, moving, family events, transition milestones or political climate.
• Steps:
  1. Review progress against goals. [UP-derived; uncertain]
  2. List the skills that helped most.
  3. Identify upcoming high-risk situations, and write a coping plan for each, including support contacts.
  4. Agree how to tell an ordinary lapse from a relapse. [source: UP final module (Barlow et al.); detail is synthesis]
• Example language (illustrative): "Christmas with your extended family is coming up. What's your plan before, during and after?"
• Watch for: Treating termination as an abrupt loss of a rare affirming relationship. Taper sessions if needed.

4.24 Delivering the model to youth in groups (AFFIRM variant)

• Purpose: Deliver affirmative CBT to LGBTQ+ adolescents in schools and community centres.
• Structure: AFFIRM is 8 modules, run as a group or individually. It is CBT based and centred on building coping skills for both internal and external stress. It targets negative thinking, feeling and behaviour patterns that develop from exposure to homophobia and transphobia, such as bullying and family rejection. It was co-developed with LGBTQ+ youth and providers. [source: CLASP AFFIRM overview]
• Steps: Module titles and session scripts are [uncertain]. Use the AFFIRM manual from the developers. In the meantime, apply 4.6, 4.7, 4.11, 4.16 and 4.17 in a group format with youth-relevant examples. [synthesis]
• Watch for: Outing risk inside groups. Agree confidentiality rules, and how members will interact outside the group. [synthesis]

5. Handling problems

The sources give little explicit problem-handling guidance. Items tagged [source] come from the sources; everything else is [synthesis].

• Client rejects the minority-stress explanation ("this has nothing to do with being gay"):
  • Keep the formulation as a hypothesis and invite the client's feedback.
  • Drop the parts that don't fit, and work on the general processes, such as avoidance and rumination.
  • Stay alert for stigma links that emerge later. Acceptance often comes over time. [source: Proujansky & Pachankis 2014]
• Reluctance to discuss sexuality or gender:
  • Ask permission, and affirm any disclosure.
  • Explore where the reticence comes from, such as family, religion or past clinicians.
  • Don't force it; return to it when it is relevant. [source: Proujansky & Pachankis 2014]
• Over-focus on identity:
  • If the client feels reduced to their identity ("why do you keep bringing up that I'm trans?"), acknowledge it, re-center their stated goals, and address identity only as relevant. [source: Proujansky & Pachankis 2014; APA 2015, Guideline 10]
• Microaggression by the therapist or a rupture (misgendering, assuming a partner's gender, a binegative remark):
  • Name it promptly and apologise briefly, without asking the client to comfort you.
  • Correct it, invite their reaction, and repair.
  • Take it to supervision. [source: APA 2021, Guideline 6 on cultural humility and repairing ruptures; steps are synthesis]
• Stuck in avoidance, or not doing homework:
  • Find hidden avoidance and safety behaviours.
  • Move down the hierarchy, or do the exposure in session first.
  • Shrink the monitoring forms.
  • Check whether the feared outcome is actually likely. If it is, switch from exposure to problem-solving or safety planning. [synthesis]
• Real danger versus distorted threat:
  • Do not restructure accurate threat appraisals, for example a hostile family or a dangerous neighbourhood.
  • Separate "realistic and manageable" from "overgeneralised".
  • Use safety planning for real risks. [source: Pachankis Div12 blog, "where safe"; synthesis for the distinction]
• Overwhelm during exposure or trauma recall:
  • Pause, ground the client, and lower the hierarchy step.
  • For extensive victimisation histories, stabilise first and consider a trauma-focused protocol. [source: APA 2021, Guideline 6 on trauma-informed care; synthesis]
• Suicidality:
  • Use standard structured risk assessment and safety planning. Include identity-specific risk factors: recent rejection, outing, victimisation, family rejection.
  • For lethal-means counselling, cover only safe storage and removal.
  • Escalate to emergency services if risk is imminent. [source: NCT02929069 safety procedures; APA 2021, Guideline 3; synthesis]
• Requests for change efforts (from the client, a parent or a religious leader):
  • Decline to do them, and explain the evidence of harm.
  • Explore the distress underneath.
  • Offer affirmative alternatives, such as identity exploration with no outcome set, and resolving religious conflict.
  • Check local law on change efforts with minors. [source: APA 2021, Guideline 4]
• Parents or guardians pushing in opposing directions (youth work):
  • Clarify who the client is. Give psychoeducation, and support exploration without a preset outcome.
  • Keep the young person's safety central, including home safety and risk of losing housing. [source: APA 2015, Guideline 8; synthesis]
• Intersectional and within-community stigma:
  • If a recommended LGBTQ+ group or service rejects the client (racism, biphobia, transphobia, ageism, HIV stigma), validate it and find better-fitting alternatives.
  • Vet referrals in advance. [source: APA 2021, Guidelines 1, 6; Proujansky & Pachankis 2014]
• Substance use as emotion regulation:
  • Combine urge surfing, mindfulness and emotion tracking with peer support, such as LGBTQ+ recovery meetings or a sponsor. [source: Proujansky & Pachankis 2014]
• Therapist bias or limits of competence:
  • Seek bi- and trans-affirmative training, supervision and consultation.
  • Refer if you cannot provide affirmative care. [source: APA 2021, Guideline 3; APA 2015, Guideline 4]
• Client from a context where same-sex behaviour or gender variance is criminalised or highly dangerous:
  • Prioritise safety, confidentiality, digital security, and record-keeping that cannot out the client.
  • Avoid exporting Western coming-out norms. [source: APA 2021, Guideline 1 on non-Western models; specifics are synthesis]

Sources

Sources

• Toward Formulating Evidence-Based Principles of LGB-Affirmative Psychotherapy (Proujansky & Pachankis, 2014, Pragmatic Case Studies in Psychotherapy)
• A Unified Intervention for Young Gay and Bisexual Men's Minority Stress, Mental Health, and HIV Risk: ESTEEM trial protocol, NCT02929069
• Mental Health Support for Transgender and Gender-expansive Individuals: EQuIP adaptation protocol, NCT06229132
• Pachankis, Division 12 blog post on a transdiagnostic LGB-affirmative CBT approach
• APA (2021) Guidelines for Psychological Practice with Sexual Minority Persons (copy hosted by Aristotle University of Thessaloniki). Only Guidelines 1 to 7 were read in full; 8 to 16 by title only.
• APA's new guidelines for psychological practice with transgender and gender nonconforming people: a brief summary (Portland Psychotherapy, 2015). This is a secondary summary.
• AFFIRM overview (Craig & Austin), CLASP 2019 mental health convening
• Transdiagnostic LGBTQ-Affirmative Cognitive-Behavioral Therapy: Therapist Guide, OUP book page. Metadata only; contents not drawn on.

Further reading (not drawn on): books and papers cited

• Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022). Transdiagnostic LGBTQ-Affirmative Cognitive-Behavioral Therapy: Therapist Guide. Oxford University Press.
• 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., Hatzenbuehler, M. L., Rendina, H. J., Safren, S. A., & Parsons, J. T. (2015). LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. Journal of Consulting and Clinical Psychology, 83(5), 875–889.
• Barlow, D. H., et al. (2011; 2nd ed. 2018). Unified Protocol for Transdiagnostic Treatment of Emotional Disorders: Therapist Guide. Oxford University Press.
• Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations. Psychological Bulletin, 129(5), 674–697.
• Hatzenbuehler, M. L. (2009). How does sexual minority stigma "get under the skin"? Psychological Bulletin, 135(5), 707–730.
• American Psychological Association (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70(9), 832–864.
• Craig, S. L., & Austin, A. (2016). The AFFIRM open pilot feasibility study: a brief affirmative cognitive behavioral coping skills group intervention for sexual and gender minority youth. Children and Youth Services Review, 64, 136–144.
• Austin, A., & Craig, S. L. (2015). Transgender affirmative cognitive behavioral therapy: clinical considerations and applications. Professional Psychology: Research and Practice, 46(1), 21–29.