Beyond the individual: Sexual minority help-seeking and the consequences of structural barriers

Sexual minorities report more psychological distress, unmet mental health needs, and barriers to mental health care compared with heterosexuals, yet little is known about their barriers to seeking out mental health care. The present study reports the factors that influence intentions to seek out mental health care of a national survey of 398 sexual minorities. Structural equation modeling identified structural barriers, such as cost, time, and knowing how to access services, as the strongest predictor of sexual minorities' help-seeking intentions. Latent moderators indicated sexual minorities' help-seeking intentions varied depending upon their degree of psychological distress. This revealed a pattern where the most vulnerable participants (i.e., those with high structural barriers and negative help-seeking attitudes) were willing to pursue mental health care only when they were experiencing significant distress. Furthermore, nearly 40% of participants reported unmet mental health needs, and structural barriers were the primary reasons for this deficit. Findings from this study contrast with previous mental health help-seeking research by emphasizing the importance of structural vulnerability, which refers to the external forces that frame and constrain choices, thereby impeding decision-making and limiting life options for those who are in systemically disadvantaged social positions. These findings are discussed in terms of counseling psychology training, practice, social justice advocacy, and future health care research. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sexual Orientation Beliefs and Identity Development: A Person-Centered Analysis among Sexual Minorities

We conducted person-centered analysis of sexual orientation beliefs among sexual minorities to explore potential relationships between these beliefs and sexual orientation, developmental milestones, race and ethnicity, and attitudes about sexual orientation. We recruited participants (N = 416) via Amazon Mechanical Turk who completed measures of beliefs about sexual orientation and attitudes about their own sexuality, as well as assessments of mental health and age of sexual identity development milestones. We conducted a latent profile analysis and found three distinct sexual orientation belief profiles, similar to those previously observed in predominantly straight samples. We found that sexual orientation and race-ethnicity predicted belief profile membership, with the latter exhibiting the most substantial effect. Of the four identity developmental milestones tested, only the age of first same-sex attraction predicted belief profile membership. Across profiles, members differed significantly in their mean endorsement of both positive and negative attitudes regarding sexual orientation and psychological distress. Thus, the current research suggests that sexual orientation beliefs are powerful constructs in the lives of sexual minorities, with relationships to sexual orientation, other social identities, and mental health.

What Does "Couple" Mean in Couple Therapy Outcome Research? A Systematic Review of the Implicit and Explicit, Inclusion and Exclusion of Gender and Sexual Minority Individuals and Identities

This study systematically reviewed extant couple therapy outcome studies (k = 111) through December 2018 to evaluate for implicit or explicit, inclusion or exclusion of gender and/or sexual minority individuals and identities. We evaluated sampling, participant demographic reporting, and language used in each manuscript for any reference or consideration given to participants' sexual and/or gender identity. Results indicate that couples have been historically presumed to be heterosexual and cisgender male or female without reported assessment. More recent inclusion and consideration of sexual minority individuals is limited and absent for nonmonosexual and gender minority individuals. These findings are contextualized in supplementary analyses of other sociocultural characteristics (e.g., race, age, length together). Suggestions are provided for affirmative consideration of the plurality of individuals' sexual and gender identities. Implications are discussed for research, training and practice of couple therapy with sexual and/or gender minority couples.

“Sincerely Held Principles” or Prejudice? The Tennessee Counseling Discrimination Law

In 2016, Tennessee became the first state to allow counselors and therapists in private practice to deny services to any client based on the therapist’s sincerely held principles. The law’s proponents framed mental health care ethics as infringing on counselors’ religious liberties; its critics denounced the bill because it apparently targeted LGBT+ individuals. This exploratory study is the first statewide assessment of LGBT+ Tennesseans’ ( N = 346) perceptions of the law and how it may affect their help-seeking attitudes and behaviors. Evidence suggests widespread awareness of the law among our respondents and deep skepticism toward mental health care. Further, most respondents view the law as cover for discrimination. We stress the need for broader research on conscience clauses and call for advocacy against these laws, which have the potential to engender widespread harm to multiple minority groups.

Conscience clauses and sexual and gender minority mental health care: A case study

Tennessee is one of the first states in the United States to have a law that enables counselors and therapists in independent practice to deny services to any client based on the practitioner's "sincerely held principles." This so-called "conscience clause" represents a critical moment in professional psychology, in which mental health care providers are on the frontlines of cultural and legal debates about religious freedom. Though the law's language is ambiguous, it was widely perceived to target sexual and gender minority (SGM) individuals. We interviewed 20 SGM people living in Tennessee to understand their experiences with mental health care in the state and their perceptions of the law. Our participants perceive the law as fundamentally discriminatory, though they overwhelmingly conceptualize the conscience clause as legalizing discrimination toward members of all stigmatized groups-not just SGM individuals. They described individual and societal consequences for the law, including an understanding of the conscience clause as harmful above and beyond any individual discrimination event it may engender. We situate these findings amid the research on structural stigma and suggest that counseling psychologists become actively engaged in combatting conscience clauses, which appear to have profound consequences on mental health care engagement, particularly for populations vulnerable to discrimination. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

What Happens When Trained Graduate Student Instructors Switch to an Open Textbook? A Controlled Study of the Impact on Student Learning Outcomes

Open educational resources (OER) are increasingly attractive options for reducing educational costs, yet controlled studies of their efficacy are lacking. The current study addressed many criticisms of past research by accounting for course and instructor characteristics in comparing objective student learning outcomes across multiple sections of General Psychology taught by trained graduate student instructors at a large research-intensive university. We found no evidence that use of the OER text impeded students' critical thinking compared to use of a traditional textbook, even after accounting for instructor characteristics. To the contrary, we found evidence of a slight increase in content knowledge when using an OER text. Importantly, this effect was driven by improvements from both our lowest-performing students and our highest-performing students. Moreover, student learning outcomes were not influenced by instructor experience, suggesting even novice instructors fared well with OER materials. Finally, students from traditionally underserved populations reported the lower cost of the book had a significantly higher impact on their decision to enroll in and remain enrolled in the course.

Microaggressions: Clinical errors with sexual minority clients

Sexual minority (SM) individuals live in a heterosexist society that denigrates their sexual orientation identity. The stigma and prejudice they regularly encounter is hypothesized to lead to their significantly increased risk for developing mental health disorders. Because of these factors, therapists should be diligent to create an affirming and supportive therapeutic environment but this is often not the case. SM clients frequently report experiencing sexual orientation microaggressions in therapy, such as heteronormative statements, a disregard for their sexual orientation identity, and an assumption that their presenting issues are rooted in their sexual orientation identity. These microaggressions should be viewed as bias manifested as clinical errors because of how they weaken therapeutic alliance, decrease the effectiveness of treatment, decrease utilization intent, and cultivate feelings of shame, anger, and misunderstanding. This article provides empirically supported findings regarding common SM clinical errors and microaggressions, a clinical example of such biases with corrective examples along with the author's personal reactions, and more general strategies for avoiding microaggressive errors with SM clients. Implications for practice, training, and research are discussed. (PsycINFO Database Record

Psychological masquerade embedded in a cluster of related clinical errors: Real practice, real solutions, and their scientific underpinnings

In this paper, we discuss the need for medical rule outs in over 50% of DSM–5 diagnoses and the risk for mental health practitioners to engage in a clinical judgment error called psychological masquerade (Taylor, 2007). We use the specific example of thyroid dysfunction as a relevant rule out when a client presents with symptoms consistent with an affective disorder. A real clinical example is provided and discussed to illustrate how the first author invoked psychological masquerade resulting in clinical decision-making errors during the treatment of a mother participating in family therapy. Solutions for this specific case and more generally for psychological masquerade are provided and discussed in the context of theory and research on mental health clinical decision-making.

A meta-analysis of confidence and judgment accuracy in clinical decision making

The overconfidence bias occurs when clinicians overestimate the accuracy of their clinical judgments. This bias is thought to be robust leading to an almost universal recommendation by clinical judgment scholars for clinicians to temper their confidence in clinical decision making. An extension of the Meta-Analysis of Clinical Judgment (Spengler et al., 2009) project, the authors synthesized over 40 years of research from 36 studies, from 1970 to 2011, in which the confidence ratings of 1,485 clinicians were assessed in relation to the accuracy of their judgments about mental health (e.g., diagnostic decision making, violence risk assessment, prediction of treatment failure) or psychological issues (e.g., personality assessment). Using a random effects model a small but statistically significant effect (r = .15; CI = .06, .24) was found showing that confidence is better calibrated with accuracy than previously assumed. Approximately 50% of the total variance between studies was due to heterogeneity and not to chance. Mixed effects and meta-regression moderator analyses revealed that confidence is calibrated with accuracy least when there are repeated judgments, and more when there are higher base rate problems, when decisions are made with written materials, and for earlier published studies. Sensitivity analyses indicate a bias toward publishing smaller sample studies with smaller or negative confidence-accuracy effects. Implications for clinical judgment research and for counseling psychology training and practice are discussed.