Promoting Resilience to Improve Disordered Eating (PRIDE): A case series of an eating disorder treatment for sexual minority individuals

OBJECTIVE

Despite the increased risk for eating disorders (EDs) among sexual minority (SM) individuals, no ED treatments exist specifically for this population. SM stress and appearance-based pressures may initiate and/or maintain ED symptoms in SM individuals; thus, incorporating strategies to reduce SM stressors into existing treatments may help address SM individuals' increased ED risk. This mixed-methods study evaluated the feasibility, acceptability, and preliminary efficacy of Promoting Resilience to Improve Disordered Eating (PRIDE)-a novel ED treatment for SM individuals.

METHODS

N = 14 SM individuals with an ED diagnosis received 14 weekly sessions integrating Enhanced Cognitive Behavioral Therapy for EDs (CBT-E) with techniques and principles of SM-affirmative CBT developed to address SM stressors. Participants completed qualitative interviews and assessments of ED symptoms and SM stress reactions at baseline (pretreatment), posttreatment, and 1-month follow-up.

RESULTS

Supporting feasibility, 12 of the 14 (85.7%) enrolled participants completed treatment, and qualitative and quantitative data supported PRIDE's acceptability (quantitative rating = 3.73/4). By 1-month follow-up, 75% of the sample was fully remitted from an ED diagnosis. Preliminary efficacy results suggested large and significant improvements in ED symptoms, clinical impairment, and body dissatisfaction, significant medium-large improvements in internalized stigma and nonsignificant small-medium effects of sexual orientation concealment.

DISCUSSION

Initial results support the feasibility, acceptability, and initial efficacy of PRIDE, an ED treatment developed to address SM stressors. Future research should evaluate PRIDE in a larger sample, compare it to an active control condition, and explore whether reductions in SM stress reactions explain reductions in ED symptoms.

PUBLIC SIGNIFICANCE

This study evaluated a treatment for SM individuals with EDs that integrated empirically supported ED treatment with SM-affirmative treatment in a case series. Results support that this treatment was well-accepted by participants and was associated with improvements in ED symptoms and minority stress outcomes.

Expressive writing treatments to reduce PTSD symptom severity and negative alcohol-related outcomes among trauma-exposed sexual minority women and transgender/nonbinary people: Study protocol for a mixed-method pilot trial

Background

Sexual minority women (SMW) and transgender and/or nonbinary (TNB) individuals report an elevated prevalence of posttraumatic stress disorder (PTSD) symptoms and negative alcohol-related outcomes compared to heterosexual women and cisgender people. SMW and TNB individuals also face barriers to utilizing treatment, which can result in delayed or missed appointments. Accessible, feasible, and effective treatment approaches, such as web-based expressive writing (EW) treatments, are needed to address PTSD and negative alcohol-related outcomes in these populations.

Method

We describe the design of a mixed-method pilot randomized controlled trial which will compare an EW treatment adapted for SMW and TNB people (stigma-adapted EW) and trauma (i.e., non-adapted) EW with an active (neutral-event) control to determine acceptability and feasibility of a future fully powered randomized controlled trial. The sample will include 150 trauma-exposed SMW and TNB individuals from across the United States who will be randomly assigned to stigma-adapted EW (n = 50), trauma EW (n = 50), or control (n = 50). Participants will be assessed before treatment, one-week after the first writing session, and three-months after the first writing session. This paper identifies steps for evaluating the acceptability and feasibility of the proposed study and determining changes in outcomes resulting from adapted and non-adapted EW treatments to inform refinements. This paper also highlights our strategy for testing theory-driven mediators and moderators of treatment outcomes.

Conclusions

This mixed-method pilot trial will inform the first fully powered, self-administered, brief web-based treatment to reduce PTSD symptom severity and negative alcohol-related outcomes among trauma-exposed SMW and TNB individuals.

Guided LGBTQ-affirmative internet cognitive-behavioral therapy for sexual minority youth's mental health: A randomized controlled trial of a minority stress treatment approach

OBJECTIVE

LGBTQ-affirmative cognitive-behavioral therapy (CBT) addresses the adverse impacts of minority stress. However, this treatment has rarely been tested in randomized controlled trials with LGBTQ youth and never using an asynchronous online platform for broad reach. This study examined the feasibility, acceptability, preliminary efficacy, and multi-level stigma moderators of LGBTQ-affirmative internet-based CBT (ICBT).

METHOD

Participants were 120 LGBTQ youth (ages 16-25; 37.5% transgender or non-binary; 75.8% assigned female at birth; 49.2% non-Latino White) living across 38 U.S. states and reporting depression and/or anxiety symptoms. Participants were randomized to receive 10 sessions of LGBTQ-affirmative ICBT or only complete 10 weekly assessments of mental and behavioral health and minority stress; all completed measures of psychological distress, depression, anxiety, suicidal thoughts, alcohol use, and HIV-transmission-risk behavior at baseline and 4 and 8 months post-baseline; 20 LGBTQ-affirmative ICBT participants completed a qualitative interview regarding intervention acceptability.

RESULTS

Participants randomized to LGBTQ-affirmative ICBT completed, on average, 6.08 (SD = 3.80) sessions. Participants reported that LGBTQ-affirmative ICBT was helpful and engaging and provided suggestions for enhancing engagement. Although most outcomes decreased over time, between-group comparisons were small and non-significant. LGBTQ-affirmative ICBT was more efficacious in reducing psychological distress than assessment-only for participants in counties high in anti-LGBTQ bias (b = -1.73, p = 0.001, 95% CI [-2.75, -0.70]). Session dosage also significantly predicted reduced depression and anxiety symptoms.

CONCLUSIONS

LGBTQ-affirmative ICBT represents a feasible and acceptable treatment. Future research can identify more efficacious approaches and modalities for engaging LGBTQ youth, especially those living under stigmatizing conditions, who might benefit most.

Future Directions in Mental Health Treatment with Stigmatized Youth

Stigma refers to societally-deemed inferiority associated with a circumstance, behavior, status, or identity. It manifests internally, interpersonally, and structurally. Decades of research indicate that all forms of stigma are associated with heightened risk for mental health problems (e.g., depression, PTSD, suicidality) in stigmatized youth (i.e., children, adolescents, and young adults with one or more stigmatized identities, such as youth of Color and transgender youth). Notably, studies find that stigmatized youth living in places with high structural stigma - defined as laws/policies and norms/attitudes that hurt stigmatized people - have a harder time accessing mental health treatment and are less able to benefit from it. In order to reduce youth mental health inequities, it is imperative for our field to better understand, and ultimately address, stigma at each of these levels. To facilitate this endeavor, we briefly review research on stigma and youth mental health treatment, with an emphasis on structural stigma, and present three future directions for research in this area: (1) directly addressing stigma in treatment, (2) training therapists in culturally responsive care, and (3) structural interventions. We conclude with recommendations for best practices in broader mental health treatment research.

Exposure to interpersonal stigma enhances the effectiveness of a culturally adapted personalized normative feedback alcohol intervention for sexual minority women

Stigma-related stress and inflated perceptions of substance use norms are positioned in the literature as theoretically distinct explanations for disproportionate substance use among sexual minorities. As research has yet to examine how these variables may interact in an intervention context, this study examined the impact of recent experiences with violence and harassment due to sexual minority status (i.e., interpersonal stigma exposure) on the effectiveness of a culturally adapted personalized normative feedback intervention for lesbian, bisexual, and queer (LBQ) women. A sub-sample of 499 moderate-to-heavy drinking LBQ women were randomized to receive personalized normative feedback (PNF) on alcohol use or control topics within a broader digital competition designed to challenge negative LBQ stereotypes. At baseline, recent interpersonal stigma exposure strengthened the relationship between perceived LBQ alcohol-related norms and participants' own alcohol-related behaviors (i.e., consumption and consequences). At follow-up, 3 months later, recent interpersonal stigma exposure moderated the effectiveness of alcohol PNF with substantially less drinking and consequences among participants in the treatment condition reporting recent violence or harassment due to sexual minority status, relative to those reporting no such experiences. Underscoring the utility of PNF for LBQ women and potentially other heavy drinking stigmatized populations, findings suggest that a greater tendency to conform to over-estimated ingroup drinking norms may be another way in which minority status-based violence and harassment contributes to alcohol consumption in stigmatized populations.