Queer-Affirming Training for Therapists

Psychology of Sexual Orientation and Gender Diversity | 2021, Vol. 8, No. 3, p. 365-377

Training Mental Health Providers in Queer-Affirming Care: A Systematic Review

Jay Bettergarcia; Department of Psychology and Child Development, California Polytechnic State University

Em Matsuno; Department of Psychology, Palo Alto University

Kristin J. Conover; Clinical Psychology PhD Program, Alliant International University

The effectiveness of training for mental health professionals to increase queer-affirming (e.g., lesbian, gay, bisexual, pansexual) cultural competencies has not been well established. Though there is an assumption that training generally works to increase or improve knowledge, attitudes, and skills, it is unclear what training format, content, and pedagogical approaches are effective. To explore the effectiveness of cultural competency training interventions for mental health professionals, a systematic review of peer-reviewed empirical articles in English published between 2000 and 2020 was conducted. Studies were selected for inclusion if the article was empirical, evaluated a training or education related to working with queer clients, and participants were mental health providers or graduate level trainees. Independent data extraction was conducted by using predefined thematic content areas, including information about the research method, training content, training format, measures, outcomes, and recommendations. Data was reviewed for 13 studies and training duration varied from 1 hr to 1 year. Most studies measured knowledge, and some measured attitudes, skills, and self-efficacy. There is some evidence that queer cultural competency training helps to improve self-reported knowledge, attitudes, and skills for mental health professionals. However, given several limitations, including a lack of studies and various methodological challenges, clear conclusions cannot be made about the effectiveness of queer cultural competency training for mental health professionals, more broadly.

Sexual minority; LGB; cultural competence; systematic review; training

"It is well-documented that queer people (e.g., lesbian, gay, bisexual, pansexual, queer) face disproportionate mental health concerns, including higher rates of psychological distress, depression, anxiety, substance use, and suicide compared to their heterosexual counterparts due to external and interpersonal stressors such as discrimination, victimization, and rejection. Due to these increased mental health risks, queer individuals are more likely to seek out therapy and other psychological services compared to heterosexual individuals. Many mental health providers (MHPs), however, have not been adequately trained in providing affirming psychological services or advocacy for queer individuals; and therefore may cause additional harm rather than alleviating mental health risks" (p. 365)​​.

“To evaluate the research questions, a systematic review was conducted using the PRIMSA guidelines. The 13 included articles were all empirical, and included both qualitative and quantitative approaches. Several research designs were utilized across the 13 included articles, including between subject’s design (n = 3), within subject’s design (n = 6), cross sectional posttest-only design (n = 2), and qualitative analysis (n = 2)... Most studies conducted tests of mean differences with either independent or dependent samples (e.g., t-tests, ANOVAS, ANCOVAS) as their primary form of analyses (n = 7). One study used regression analyses and one study used chi-square tests. The cross-sectional posttest-only designs only reported descriptive statistics. The qualitative studies used Consensual Qualitative Research (CQR) methods and ethnographic methods to analyze their results​​. Participants represented a range of mental health professional fields including counseling and clinical psychology, social work, and school counseling. There are vast differences in the number of training hours delivered across the 13 studies, from a one-hour training to a year-long intensive fellowship. All 13 studies were delivered in person and each reported utilizing a combination of didactic lecture and experiential or interactive components"​​ (p. 366 - 368).

"The primary outcomes were measures of cultural competency, including knowledge, attitudes or awareness of biases, and behavioral skills. All of the studies that measured subjective or objective knowledge showed an increase in knowledge post-training (n = 11); the remaining two studies did not measure knowledge. Attitudes toward queer people were measured in 9 of the 13 studies. Nearly all of the studies that measured attitudes showed an increase in positive attitudes or decrease in negative attitudes (n = 7). One study found a decrease in positive attitudes posttraining (n = 1); and one study did not find a significant difference in attitudes (n = 1). A total of seven studies included behavior-related measures, such as clinical skills, self-efficacy, behavioral intentions or behavioral change. All seven studies found that training significantly increased affirming clinical skills or related measures" (p. 370).

"Results across most training indicated an increase in knowledge, though we questioned the quality of subjective increases in knowledge, as opposed to those studies that measured knowledge change with objective measures. Attitude change tended to improve, though one study found more negative attitudes. Most articles provided recommendations for training and research, though there was minimal consensus. Broadly, training should allow an opportunity for first-hand accounts, difficult dialogues, and skill rehearsal. Interestingly, these recommendations map on to common training objectives with respect to knowledge, attitudes, and skills"​​ (p. 371).

“Although we tend to believe that cultural competency training works to increase knowledge, attitudes, and skills so that mental health providers can deliver queer-affirming care, there is not enough supporting evidence to suggest that this is always the case. These findings echo the training and education guidelines set forth via APA’s (2021) Guidelines for Psychological Practice with Sexual Minority Clients and the ACA ALGBTIC’s Competencies for Counseling Lesbian, Gay, Bisexual, Queer, Questioning, Intersex and Ally Individuals. Yet, as queer clients continue to experience harmful microaggressions in therapy, it is clear that cultural competency training about queer clients is critical to effectively serve this vulnerable population and prevent additional harm. There is an obvious discrepancy, however, in our belief that training is working and data about the continued current mistreatment of queer clients in clinical settings. This review leaves the field with more questions than it answers, such as, are current training methods actually working? Do we just need more training? Or, do we need to change our training components and approaches?” (p. 372). 

“As is true for the multicultural training literature overall, the existing empirical findings on queer-focused training do not provide clear guidance for the most effective length of training or training activities. The most commonly recommended training component was an opportunity for difficult dialogue, yet, there was almost no focus on the ability of trainers to effectively facilitate these discussions. In addition to training activities, it is crucial to focus on the trainer skills necessary to successfully facilitate difficult dialogues and create a safe learning environment. Weeks et al. (2018) addressed the challenges experienced by the trainers, but did not speak to the impact of trainer abilities on the overall effectiveness of the training. Finally, one article pointed out the need to train more established clinicians in addition to students and recent graduates. As the majority of the studies in this review focused on training graduate students (n = 7), our findings support that call. Training for later career MHPs is important because they may be less likely to have received training in their graduate programs. In addition, queer terminology and cultural norms are constantly and often rapidly evolving, requiring ongoing education for all clinicians” (p. 372). 

"Based on existing literature and what we think we know, training components should map onto competency objectives; and incorporate activities that focus on knowledge, self-awareness and attitudes, and skills. However, more recently, the literature has called for a focus on cultural humility as well. Similar to this literature and the new APA Guidelines for Psychological Practice with Sexual Minority Persons; we encourage clinicians to take a standpoint of cultural humility. Given that none of the articles in this review mentioned training in cultural humility, it appears that this relational component of queer-affirming therapy may be overlooked in our current approaches. In order to meet these calls, future training would benefit from providing readings and discussions on cultural humility, as well as examples of clinical interactions that demonstrate a cultural humility approach” (p. 372). 

“It is beyond time for trainers to not only integrate intersectionality in training, but to centralize queer people of color, queer transgender people, queer disabled people, the queer poor, and queer women when discussing issues faced by queer people. The literature on supporting queer clients has historically and continues to be dominated by a White perspective on issues such as coming out, identity development, pride, and other clinical issues. Perpetuating such perspectives in training not only excludes experiences of people of color, but can contribute to continued harm for queer clients with multiple marginalized identities. To centralize intersectional queer experiences, White queer trainers may need to decentralize their own experiences. This can be done using critical race and feminist theories to inform pedagogy, showing videos that give voice to multiply marginalized groups, inviting panelists who reflect diversity within queer communities, and assigning readings on intersectionality” (p. 373).

“Further, psychologists should also be poised to protect and defend all forms of diversity training as they face attacks like the recent Executive Order on Combating Race and Sex Stereotyping. This may be a critical moment in the future of diversity training, and it underscores the importance of knowing how to use our power and expertise as psychologists to advocate for social justice. Future training curriculum would benefit by focusing on increasing cultural humility, cultivating an intersectional approach, teaching advocacy skills, and future research is needed to evaluate the impact of training on these areas” (p. 373).

“This systematic review explores and synthesizes findings across studies to help elucidate the current state of the research on queer-affirming cultural competency training for mental health providers. The main limitations of this systematic review, as with many reviews, is that the quality of the studies included for analysis varied substantially. Methodological rigor was highly variable across the quantitative studies, which made analysis challenging and the conclusions drawn from this data are weak. Further, the training format, content, length, and delivery varied across the studies and were often not easily ascertained from the training descriptions provided. Though some of these challenges may be due, in part, to the nature of training programs and the challenges associated with assessing training, more is desperately needed to bolster this research and propel the field forward” (p. 374).