Skip to content

Advertisement

You're viewing the new version of our site. Please leave us feedback.

Learn more

BMC Psychology

Open Access
Open Peer Review

This article has Open Peer Review reports available.

How does Open Peer Review work?

A tailored compassion-focused therapy program for sexual minority young adults with depressive symotomatology: study protocol for a randomized controlled trial

  • Christopher A. Pepping1Email author,
  • Anthony Lyons2,
  • Ruth McNair3,
  • James N. Kirby4,
  • Nicola Petrocchi5 and
  • Paul Gilbert6
BMC PsychologyBMC series – open, inclusive and trusted20175:5

https://doi.org/10.1186/s40359-017-0175-2

Received: 4 September 2016

Accepted: 22 February 2017

Published: 1 March 2017

Abstract

Background

Lesbian, gay, and bisexual (LGB) men and women represent one of the highest-risk populations for depressive symptomatology and disorders, with young LGB adults being at greatest risk. To date, there have been no randomized controlled trials (RCT) to specifically target depressive symptoms in young LGB adults. This is despite research highlighting unique predictors of depressive symptomatology in this population. Here we outline a protocol for an RCT that will test the preliminary efficacy of a tailored compassion-focused therapy (CFT) intervention for young LGB adults compared with a self-directed cognitive behavioral therapy (CBT) program with no specific tailoring for LGB individuals.

Methods

The CFT intervention consists of 8 units with self-directed reading and activities tailored to LGB young adults, and 8 x weekly 1-hour consultations with a therapist. The CBT intervention consists of 8 units with self-guided reading and activities, with 1 x 1-hour session with a therapist at the mid-point of therapy. Fifty LGB individuals with scores of 13 or above on the Beck Depression Inventory-II will be randomized to either the CFT or CBT condition. The primary outcome measure is depressive symptomatology. Secondary outcome measures are symptoms of anxiety, suicidal ideation, internalized homophobia, self-compassion, and shame and guilt proneness. Assessments will occur at pre-intervention, post-intervention, and at 3-month post-intervention.

Discussion

This study is an RCT to test the preliminary efficacy of an LGB-tailored compassion-focused intervention for young LGB adults with depressive symptomatology. If this intervention is efficacious, this could begin to address the substantial mental health disparities amongst sexual minorities.

Trial registration

ACTRN12616001018404. Prospective registration, registered 02/08/2016.

Keywords

LesbianGayBisexualDepressionCompassionSexual minority

Background

A large and coherent body of evidence reveals that LGB individuals experience poorer mental health than their heterosexual counterparts [1, 2]. Meta-analytic reviews indicate that gay men are between two and four times as likely to have attempted suicide, engaged in deliberate self-harm, or experienced depression, compared to their heterosexual counterparts [1]. Similarly, lesbian women are about twice as likely to have experienced depression or attempted suicide compared to heterosexual women [1]. Young LGB individuals are at greatest risk for depressive disorders. Specifically, LGB individuals in their teens and early 20s are more likely to suffer depression than both their heterosexual counterparts [3] and older LGB adults [4]. Suicide in this group is alarmingly high, with meta-analyses showing a 3-fold increase in the odds of suicidal ideation and attempted suicide in those aged younger than 21 years compared to their heterosexual counterparts [3].

These mental health disparities are largely accounted for by the impact of stigma, including internalized stigma or shame [5, 6]. Most LGB individuals report having experienced at least one incident of homophobic harassment, violence, or discrimination [6, 7]. Specifically, meta-analyses indicate that 44% of LGB individuals have been threatened with violence [8], 28% have been physically assaulted [9], and up to 80% have experienced verbal harassment [9]. In a large sample of heterosexuals and LGB individuals, perceived discrimination was related to lower quality of life, and increased indicators of psychiatric morbidity [6]. Importantly, when controlling for the effects of perceived discrimination, there were no differences in psychiatric morbidity between heterosexual and LGB individuals.

Although the risks associated with “coming out” have changed from previous generations for young LGB individuals [10], they still encounter significant life stressors such as family rejection [11] and discrimination [9]. Large numbers of LGB young people also face a range of developmental challenges related to their sexual orientation, such as coming to terms with their sexuality, “coming out” to family and friends, and experiences of discrimination and rejection. Importantly, the highest risk time for suicidal ideation and suicide attempts is when LGB individuals “come out” to their families [12]. To date, there has been no randomized controlled trial specifically designed to treat depression in LGB young adults. This is problematic, as there are unique issues that predict depressive symptomatology in LGB individuals and, in particular, LGB young adults, which interventions need to address. For instance, this population is exposed to a range of stigma-related or minority stressors [13], including internalized stigma and shame related to one’s sexual orientation, which predicts high risk for depression [14].

Many LGB people who seek help for mental health problems are not successful in getting the help they need [15]. Some report barriers such as a fear of discrimination [16] and lack of LGB sensitivity of services [17] and, of those who do access treatment, many report low satisfaction with treatment [15, 16]. These barriers can be partly overcome when using internet based support [17]. Recent research from our own team demonstrates that mental health interventions need to be tailored to be appropriate for LGB people, as existing interventions are often viewed as not appropriate, relevant, or inclusive of LGB individuals [18, 19]. Our team have also identified preferences that LGB young adults have regarding delivery and content of interventions to enhance efficacy [18, 19], and recently published the world’s first set of guidelines for tailoring therapy to the needs of LGB people [18].

One promising approach to helping LGB people with depression and depressive symtomatology is compassion-focused therapy (CFT). CFT is an evidence-based psychological intervention derived from a range of psychotherapies, and research in evolutionary, social and neuropsychology, along with the comtemplativre traditions [20]. This approach focuses on helping people access and cultivate care-focused motives and emotions to address issues of shame and self-criticism and build supportive inner resources [20]. Much evidence reveals that mindful compassion-based skills lead to a range of beneficial psychosocial outcomes, including increased self-esteem [21], more positive interpersonal relationships [22], and reduced symptoms of depression [23].

Since CFT was originally developed for and with individuals with high shame and self-criticism, it is likely to be particularly beneficial for LGB individuals for at least three reasons: (1) being compassionate predicts well-being in LGB individuals [24]; (2) internalized stigma is a significant predictor of depression in LGB individuals [14], and CFT directly reduces different types of shame and harsh self-criticism [25]; and (3) compassion-based interventions have been shown to be effective in reducing depressive symptoms (d = .86) [26], with a recent meta-analysis also reporting significant moderate effect sizes [27]. As mentioned, a significant predictor of mental health among LGB people is internalized stigma, or feelings of shame and low self-worth related to their sexual orientation [14]; indeed, the emphasis on “gay pride” in LGB communities is largely related to combatting and undermining internalized stigma [10]. Coupled with the non-judgemental awareness and mindful sensitivity to distress, CFT fosters sympathy, empathy, and distress engagement with a commitment to develop the wisdom and courage to alleviate and prevent distress. CFT uses concepts from evolutionary theory and research pertaining to the nature of sexuality and other motives and emotions and provides specific practices for emotion regulation, and strategies to switch from hostile self-criticism to compassionate self-support.

Study objectives and hypotheses

The present RCT will test the preliminary efficacy of a newly developed tailored CFT intervention specifically designed to meet the needs of LGB young adults compared to a standard untailored CBT intervention. The aim is to assess whether a CFT intervention specifically tailored for LGB young adults will reduce depressive symptomatology and shame, and improve psychological functioning.

With regards to the primary outcome, it is hypothesized that, compared to the CBT condition, those in the CFT condition will demonstrate significantly lower symptoms of depression at post-intervention and 3-month follow-up compared to baseline pre-intervention levels. With regard to secondary outcomes, it is hypothesized that compared to those in the CBT condition, those in the CFT condition will demonstrate significantly lower symptoms of anxiety, suicidal ideation, internalized homophobia, and shame and guilt proneness, and significantly higher scores on a measure of self-compassion at post-intervention and 3-month follow-up compared to baseline levels.

Method

Participants and recruitment

Potential participants will respond to advertisements on social media for a free depression intervention for young LGB men and women aged 18–25 years. Recruitment will be nationwide around Australia, and advertisements will direct individuals to a brief survey. The survey will provide further information about the study as well as invite potential participants to provide their contact details and complete a brief screening questionnaire to assess their eligibility. Advertisements will be targeted to meet the following criteria for gay and bisexual male participants: Gender = male; romantic interest = male or male and female; aged 18–25; residing within Australia. Advertisements will be targeted to meet the following criteria for lesbian and bisexual female participants: Gender = female; romantic interest = female or female and male; aged 18–25; residing within Australia. The brief screening questionnaire consists of the Beck Depression Inventory-II [28], the Suicide Behaviour Questionnaire [29]; and key demographic information including age, gender, sexual orientation, ethnicity, whether participants are currently taking medication for depression, and whether they are currently engaged in another form of psychological therapy for their depression.

Participants will be included in the study if they meet the following inclusion criteria: (1) aged 18–25 years; (2) currently experiencing clinically significant depressive symptomatology, as evidenced by BDI-II scores of 13 and above; (3) and identify as gay, bisexual, lesbian, or non-heterosexual. Participants will be excluded from participating if they meet the following exclusion criteria: (1) currently receiving individual psychological intervention; (2) currently at imminent risk of harm to themselves, including planning or intending to engage in suicidal and/or para-suicidal behaviors. The presence of suicidal ideation is not an exclusion criteria. No other inclusion or exclusion criteria were used to assess eligibility for participation.

Following participants’ expressions of interest and completion of the screening questionnaire, a research assistant will assess eligibility based on the above criteria, and will contact potential participants to provide further details about the project. Specifically, the research assistant will outline that participants will be randomly assigned to one of two treatment conditions, answer questions, and provide potential participants with a consent form and the pre-assessment questionnaire. Ineligible participants will be referred to other services as appropriate.

Study integrity, trial design, and procedure

The present study received ethical approval from the La Trobe University Human Research Ethics Committee (HEC016-10), and the trial was registered with the Australian New Zealand Clinical Trials Registry (ACTRN12616001018404). The present RCT adheres to the CONsolidated Standards Of Reporting Trials (CONSORT). The intervention protocol for both conditions will be manualized, and sessions with therapists for both conditions will be audio-recorded to enable quality assurance and assessment of protocol adherence.

The design will be a RCT involving 50 young adults, recruited over a five-month period (10 participants per month). This sample size was calculated using G*Power software to enable sufficient assessment of change over time in the study outcome measures. To assess change across three time points and between two conditions in a mixed-design ANOVA with both within (time) and between (condition) subjects effects, a sample of 42 is needed to detect a small-medium effect size of f = .20 at power = .80 and alpha = .05. Therefore, a sample of 50 will provide sufficient power while also accounting for possible attrition. Analyses will be conducted on an intention to treat basis.

Informed consent will be obtained prior to each participant commencing the study. Following initial screening described above, a research assistant will provide each participant with a pre-intervention questionnaire which will assess the primary and secondary outcome measures described below. Following completion of the pre-intervention questionnaire, participants will be randomly assigned to either the CFT or CBT condition with simple randomization using a computerized random number generator, and will be provided with the respective guidebooks. A therapist will contact participants approximately 1 week later to schedule session appointments. Participants will complete their respective intervention across an 8-week period. One-week post-intervention, a research assistant will provide each participant with a post-intervention questionnaire, which will again assess the primary and secondary outcome measures described below, as well as consumer satisfaction. Three-months post-intervention, the research assistant will provide participants with the follow-up questionnaire containing the primary and secondary outcome measures.

Intervention procedures and delivery

Manualized treatment protocols have been developed for both the CFT and CBT interventions. Both interventions involve self-guided reading and activities, and some contact with a therapist via Skype, which will allow for people across the country to participate in the intervention. It will also test the intervention in a flexible delivery format to potentially enhance reach to LGB young adults who face barriers accessing face-to-face services [15, 16].

The CFT program is an 8-week compassionate mind training intervention (compassion-focused therapy) adapted to be appropriate for LGB young adults, and tailored to their unique life experiences. It consists of 8-units, each incorporating self-directed reading and experiential activities, coupled with weekly Skype sessions with a trained therapist to ensure compliance and to assist with tailoring skills to the specific individual’s situation. The eight units cover 1) psychoeducation pertaining to compassion, evolution, life challenges, brain functioning, and emotion systems to enhance understanding of the evolved functions that underpin emotions and behavior, and to facilitate de-shaming; 2) body-focused interventions (e.g., body posture, soothing rhythm breathing, voice tone exercises) to facilitate affiliative processing and the activation of the parasympathetic system, a core process in emotion regulation and mentalization (empathy/perspective taking); 3) cultivation of mindful attention, including non-judgmental awareness of experiences; 4) cultivation of the compassionate self as the persons motivational system through imagery practices. This also includes addressing the fears, blocks and resistances to compassion. Each of the units are tailored to cultivate the compassionate self, which is an orientation of the mind aimed at creating an inner secure base/safe haven for the individual to address and reduce shame and internalized stigma, and alleviate depression.

The units involve evidence-based step-by-step training founded on mindfulness and compassion-focused principles [20] and include examples relating to the lives of young LGB adults. For instance, included within the protocol is content pertaining to stigma and discrimination, significant life events such as coming out, and the effects of internalized homophobia and shame. These experiences of shame and internalized stigma are discussed in the context of negative societal attitudes to facilitate de-blaming and reduce shame. Specific exercises are included for participants to apply compassion-focused strategies to their own situation, with audio recordings of each exercise to facilitate practice between sessions.

Participants assigned to the CBT condition will receive a hard copy of an evidence-based cognitive-behavioral self-help book Feeling Good: The New Mood Therapy [30]. This cognitive behavioral bibliotherapy program guides the reader through a series of sections that provide psychoeducation about their symptoms of depression, and a series of self-directed cognitive and behavioral exercises to complete. This book has been established as beneficial for depression [31]. Participants will be provided with a guide to which sections of the book to read across the eight-week program. At the mid-point of this program (week 4), each participant will have a 1-hour telephone or Skype session with a therapist to monitor compliance, assist with any questions, and troubleshoot any difficulties with the exercises.

Measures

Primary outcome

The primary outcomes will be depressive symptomatology, assessed by the Beck Depression Inventory-II (BDI-II) [28]. The BDI-II is a widely used 21-item self-report measure of depressive symptomatology which requires participants to respond to statements describing symptoms of depression on a scale from 0 (never) to 3 (always). The BDI-II specifies symptom severity from non-clinical to clinical ranges, and has demonstrated sound reliability and validity [32, 33].

Secondary outcomes

We also included several secondary outcome measures to assess whether the intervention is associated with a reduction in symptoms commonly associated with depression, including anxiety [34] and suicidal ideation [29]. In addition, we included secondary outcome measures associated with the targets of the CFT intervention described earlier, including internalized stigma [35], self-compassion [36] and shame [37].

The Beck Anxiety Inventory (BAI) [34] will be used to measure symptoms of anxiety. The BAI is a 21-item self-report measure of symptoms of anxiety, and demonstrates excellent validity, internal consistency, and test-retest reliability [34, 38]. The BAI asks participants to respond to a series of questions pertaining to symptoms of anxiety on a 4-point scale, ranging from 0 (never) to 3 (always).

The Suicide Behaviors Questionnaire-Revised [29] is a widely used 4-item self-report measure to assess suicidal ideation. The SBQ-R is a valid and reliable measure of suicidal ideation [29, 39], and effectively discriminates between non-suicidal and suicidal individuals [29].

The Lesbian, Gay, and Bisexual Identity Scale (LGBIS) [35] is a 27-item self-report measure that assesses eight minority stress-related constructs that each form eight subscales. Three subscales will be used in this research, which assess internalized stigma (Internalized Homonegativity subscale), motivations to conceal one’s sexual identity (Concealment Motivation subscale), and feeling positive about being LGB (Identity Affirmation subscale). The scale is measured on a 6-point Likert scale, ranging from 1 (disagree strongly) to 6 (agree strongly). The measure has demonstrable construct validity and internal consistency [35, 40].

The Self-Compassion Scale – Short Form [36] is a widely used 12-item measure of an individual’s capacity to experience feelings of kindness towards themselves, and to hold difficult feelings with warmth and concern as opposed to self-criticism. The 12 items are rated on a 5-point scale ranging from 1 (almost never) to 5 (almost always), and the measure has excellent psychometric properties, including validity and reliability [36].

The Guilt and Shame Proneness Scale [37] is a 16-item self-report measure of an individual’s feelings of shame and guilt. This will be included to assess shame and guilt proneness at a broad level, beyond sexual orientation. Participants respond to the items on a 7-point scale ranging from 0 (unlikely) to 4 (very likely). The measure is a valid and reliable measure of guilt and shame proneness, and demonstrates high test-retest reliability [37].

Finally, three measures to examine consumer satisfaction and acceptability will be included. The Consumer Satisfaction Questionnaire [41] is a widely used measure that assesses the helpfulness of an intervention or service. The LGBT Appropriateness Scale [18] is a 12-item measure of the extent to which LGB individuals perceive an intervention inclusive and relevant to them. Participants indicate whether they agree or disagree with the 12 statements pertaining to the suitability of the program for LGB individuals. Finally, participants in the CFT condition will rate the extent to which each of the eight core compassion-focused skills were helpful on a 5-point scale, ranging from 1 (not at all helpful) to 5 (extremely helpful).

Statistical analyses

This RCT is a mixed-model repeated measures design involving between- and within-participants factors. The between-participants factor, or independent variable, is condition (CFT vs CBT). The within-participants factor is assessment time, with each participant assessed on relevant primary and secondary outcome measures at three time points (pre- and post-intervention, plus 3-month follow-up). A mixed-model repeated measures analysis of variance (ANOVA) will assess main and interaction effects across the three time points and between the two conditions. Participants in both conditions will also complete the BDI at each session with the therapist (sessions 1–8 for those in the CFT condition, at session 4 for those in the control). Should any participant not complete the post-questionnaire, their most recent BDI score will be used in order to maximize all available data. The effect size (Cohen’s d) and its precision will be calculated with 95% CI for the mean differences between pre-, post-, and follow-up for each condition.

Discussion

LGB individuals experience poorer mental health than their heterosexual counterparts [1, 2], and young LGB individuals are at greatest risk for poor mental health, including depressive disorders [3, 4] and depression-related suicide [3]. Many LGB people who seek help for mental health problems are not successful in getting the treatment they need [15], and many face additional barriers to accessing effective treatment such as fears of discrimination about their sexual orientation. A recent RCT of a transdiagnostic, gay-affirmative intervention for gay and bisexual men aged 18–35 years (M age = 25.94) engaging in HIV-risk behavior was found to reduce symptoms of anxiety and depression [42], suggesting that tailored, gay-affirmative interventions hold considerable promise to enhance mental health. To date there has been no RCT to specifically target depressive symptomatology in LGB young adults. The present study therefore represents an important step toward addressing the disproportionate burden of depressive symptomatology in this population. In addition to the lack of research investigating interventions for LGB young adults, the extent to which current evidence-based interventions generalize to LGB individuals remains unclear. Specifically, the majority of studies invesitgating treatment for depression and depressive symptomatology do not report the sexual orientation of participants when describing their sample [43], which makes generalization to sexual minorities difficult. Finally, testing the intervention delivered via video-conferencing technology may have important clinical implications for enhancing reach to young LGB individuals who often face significant barriers to accessing mental health services.

It is important to note some limitations of the current study. First, although the inclusion of a self-directed active control condition is a clear strength of the current trial, it will not be possible to definitively establish whether any effects found are due to CFT, the LGB-tailoring, or to common factors such as therapist contact. Should the current CFT intervention show promise in the current trial, future randomized controlled trials should conduct a component analysis with a range of alternative control conditions to examine which specific components of the intervention are producing change. It is also important to note that there may be a range of potential moderators of treatment outcome, including social support and ‘outness’ to family and friends, and future research should examine whether these and other factors moderate outcome.

The present CFT intervention is designed to target the largest and well-established causes of depression in LGB individuals, such as shame and internalized homophobia. By doing so, we expect that the psychological impact of stigma will be reduced by this intervention. Nonetheless, it is important to note that there are some additional mediators that link stigma and discrimination with poor mental health. Specifically, a range of psychological, emotional, interpersonal, and behavioral processes have been established as mechanisms underlying the association between stigma and poor mental health [5]. Future researchers may therefore wish to explore the development and testing of additional interventions that target other specific mediators and to develop or refine interventions as new mediators are identified.

The present RCT will test the utility and preliminary efficacy of a newly developed CFT intervention specifically tailored to meet the needs of LGB young adults, compared to a standard CBT intervention that has not been tailored for LGB individuals. The aim is to assess whether a CFT intervention specifically targeted to address known causes of depression in LGB young adults will reduce depressive symptomatology and improve psychological functioning. Results of this research will have great potential to inform clinical practice and future research by examining the utility and preliminary efficacy of the first ever LGB affirmative treatment for depression in LGB young adults. This research will also help advance the fields of mindfulness, compassion, and LGB mental health by translating research into clinical practice, as well as delivering a much-needed intervention designed specifically to address a major mental health inequity.

Abbreviations

CBT: 

Cognitive behavioral therapy

CFT: 

Compassion focused therapy

LGB: 

Lesbian, gay, and bisexual

Declarations

Acknowledgements

We would like to thank Timothy J. Cronin and Sophie Marsland for their invaluable research assistance.

Funding

The proposed study is funded by the Building Healthy Communities Research Focus Area, La Trobe University, following peer-review. The funding body did not play any role in the study design, and will not play a role in data collection, analysis, interpretation of data, or in writing the manuscript.

Availability of data and materials

Deidentified data will be made available once collected.

Authors’ contributions

CP and AL developed the design of the study and drafted the manuscript. CP, AL, RM, JK, NP and PG developed and refined the CFT protocol. CP, AL, RM, JK, NP and PG contributed to and approved the final manuscript.

Competing interests

The authors declare that they have no competing interests.

Consent for publication

Not Applicable.

Ethics approval and consent to participate

This study has been approved by the ethics committee of La Trobe University. The study will be conducted in accordance with APA ethical guidelines. All participants will be asked to provide informed consent to participate in the study and for anonymized publication of their data.

Trial status

Recruitment for the present study commenced in August 2016.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
School of Psychology and Public Health, La Trobe University
(2)
Australian Research Centre in Sex, Health, and Society, La Trobe University
(3)
Department of General Practice, University of Melbourne
(4)
School of Psychology, University of Queensland
(5)
Department of Economics and Social Sciences, John Cabot University
(6)
Department of Psychology, University of Derby

References

  1. King M, Semlyen J, Tai SS, Killaspy H, Osborn D, Popelyuk D, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC psychiatry. 2008;8:70.View ArticlePubMedPubMed CentralGoogle Scholar
  2. Cochran SD, Mays VM. Burden of psychiatric morbidity among lesbian, gay, and bisexual individuals in the California quality of life survey. J Abnorm Psychol. 2009;118:647.View ArticlePubMedPubMed CentralGoogle Scholar
  3. Marshal MP, Dietz LJ, Friedman MS, Stall R, Smith HA, McGinley J, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: a meta-analytic review. J Adolesc Health. 2011;49:115–23.View ArticlePubMedPubMed CentralGoogle Scholar
  4. Leonard W, Lyons A, Bariola E. A closer look at private lives 2: addressing the mental health and wellbeing of lesbian, gay, bisexual, and transgender (LGBT) Australians. Melbourne: La Trobe University; 2015.Google Scholar
  5. Hatzenbuehler ML, Phelan JC, Link BG. Stigma as a fundamental cause of population health inequalities. Am J Public Health. 2013;103:813–21.View ArticlePubMedPubMed CentralGoogle Scholar
  6. Mays VM, Cochran SD. Mental health correlates of perceived discrimination among lesbian, gay, and bisexual adults in the United States. Am J Public Health. 2001;91:1869–76.View ArticlePubMedPubMed CentralGoogle Scholar
  7. Herek GM, Gillis JR, Cogan JC. Psychological sequelae of hate-crime victimization among lesbian, gay, and bisexual adults. J Consult Clin Psychol. 1999;67:945.View ArticlePubMedGoogle Scholar
  8. Berrill KT. Anti-gay violence and victimization in the United States: an overview. In: Herek GM, Berrill KT, editors. Hate crimes: confronting violence against lesbians and gay men. Newbury Park CA: Sage; 1992. p. 289–305.Google Scholar
  9. Katz-Wise SL, Hyde JS. Victimization experiences of lesbian, gay, and bisexual individuals: a meta-analysis. J Sex Res. 2012;49:142–67.View ArticlePubMedGoogle Scholar
  10. Lyons A, Croy S, Barrett C, Whyte C. Growing old as a gay man: how life has changed for the gay liberation generation. Ageing Soc. 2014;35:2229–50.View ArticleGoogle Scholar
  11. Ryan C, Russell ST, Huebner D, Diaz R, Sanchez J. Family acceptance in adolescence and the health of LGBT young adults. J Child Adolesc Psychiatr Nurs. 2010;23:205–13.View ArticlePubMedGoogle Scholar
  12. Igartua KJ, Gill K, Montoro R. Internalized homophobia: a factor in depression, anxiety, and suicide in the gay and lesbian population. Can J Commun Ment Health. 2009;22:15–30.View ArticleGoogle Scholar
  13. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychol Bull. 2003;129:674–97.View ArticlePubMedPubMed CentralGoogle Scholar
  14. Newcomb ME, Mustanski B. Internalized homophobia and internalizing mental health problems: a meta-analytic review. Clin Psychol Rev. 2010;30:1019–29.View ArticlePubMedGoogle Scholar
  15. Guasp A, Taylor J. Experiences of healthcare: stonewall health briefing. London: Stonewall Publishing; 2012Google Scholar
  16. Leonard W, Pitts M, Mitchell A, Lyons A, Smith A, Patel S, et al. Private Lives 2: the second national survey of the health and wellbeing of gay, lesbian, bisexual and transgender (GLBT) Australians. The Australian Research Centre in Sex, Health & Society. Melbourne: La Trobe University; 2012Google Scholar
  17. McNair R, Bush R. Mental health help seeking patterns and associations among a diverse group of Australian same sex attracted women: a survey-based study. BMC Psychiatry. 2016;16:209.View ArticlePubMedPubMed CentralGoogle Scholar
  18. Lyons A, Rozbroj T, Pitts M, Mitchell A, Christensen H. Improving E-therapy for mood disorders among lesbians and Gay Men: a practical toolkit for developing tailored web and mobile phone-based depression and anxiety interventions. 2015. Available: http://arrow.latrobe.edu.au:8080/vital/access/manager/Repository/latrobe:37676.Google Scholar
  19. Rozbroj T, Lyons A, Pitts M, Mitchell A, Christensen H. Improving self-help e-therapy for depression and anxiety among sexual minorities: an analysis of focus groups with lesbians and gay men. J Med Internet Res. 2015;17:e66.View ArticlePubMedPubMed CentralGoogle Scholar
  20. Gilbert P. Introducing compassion-focused therapy. Adv Psychiatr Treat. 2009;15:199–208.View ArticleGoogle Scholar
  21. Pepping CA, O’Donovan A, Davis PJ. The positive effects of mindfulness on self-esteem. J Posit Psychol. 2013;8:376–86.View ArticleGoogle Scholar
  22. Pepping CA, Halford WK. Mindfulness and Couple Relationships. In Mindfulness and Buddhist-Derived Approaches in Mental Health and Addiction. Switzerland: Springer; 2016: 391–411.Google Scholar
  23. Keng S-L, Smoski MJ, Robins CJ. Effects of mindfulness on psychological health: a review of empirical studies. Clin Psychol Rev. 2011;31:1041–56.View ArticlePubMedPubMed CentralGoogle Scholar
  24. Greene DC, Britton PJ. Predicting adult LGBTQ happiness: impact of childhood affirmation, self-compassion, and personal mastery. J LGBT Issues Couns. 2015;9:158–79.View ArticleGoogle Scholar
  25. Gilbert P, Procter S. Compassionate mind training for people with high shame and self‐criticism: overview and pilot study of a group therapy approach. Clin Psychol Psychother. 2006;13:353–79.View ArticleGoogle Scholar
  26. Neff KD, Germer CK. A pilot study and randomized controlled trial of the mindful self‐compassion program. J Clin Psychol. 2013;69:28–44.View ArticlePubMedGoogle Scholar
  27. Kirby JN. Compassion Interventions: The programs, the evidence, and implications for research and practice. Psychol. Psychother. 2016. doi:10.1111/papt.12104.
  28. Beck AT, Steer RA, Brown GK. Beck depression inventory-II. San Antonio: TX. The psychological corporation; 1996.Google Scholar
  29. Osman A, Bagge CL, Gutierrez PM, Konick LC, Kopper BA, Barrios FX. The suicidal behaviors questionnaire-revised (SBQ-R): validation with clinical and nonclinical samples. Assessment. 2001;8:443–54.View ArticlePubMedGoogle Scholar
  30. Burns DD. The feeling good handbook (rev). NY: Harper Collins Publishers; 1999.Google Scholar
  31. Anderson L, Lewis G, Araya R, Elgie R, Harrison G, Proudfoot J, et al. Self-help books for depression: how can practitioners and patients make the right choice? Br J Gen Pract. 2005;55:387–92.PubMedPubMed CentralGoogle Scholar
  32. Storch EA, Roberti JW, Roth DA. Factor structure, concurrent validity, and internal consistency of the beck depression inventory—second edition in a sample of college students. Depress Anxiety. 2004;19:187–9.View ArticlePubMedGoogle Scholar
  33. Wiebe JS, Penley JA. A psychometric comparison of the beck depression inventory-II in English and Spanish. Psychol Assess. 2005;17:481.View ArticlePubMedGoogle Scholar
  34. Beck A, Steer R. Beck anxiety inventory manual. San Antonio: TX. The psychological corporation; 1993.Google Scholar
  35. Mohr JJ, Kendra MS. Revision and extension of a multidimensional measure of sexual minority identity: the lesbian, Gay, and bisexual identity scale. J Couns Psychol. 2011;58:234.View ArticlePubMedGoogle Scholar
  36. Raes F, Pommier E, Neff KD, Van Gucht D. Construction and factorial validation of a short form of the self‐compassion scale. Clin Psychol Psychother. 2011;18:250–5.View ArticlePubMedGoogle Scholar
  37. Cohen TR, Wolf ST, Panter AT, Insko CA. Introducing the GASP scale: a new measure of guilt and shame proneness. J Pers Soc Psychol. 2011;100:947.View ArticlePubMedGoogle Scholar
  38. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol. 1988;56:893.View ArticlePubMedGoogle Scholar
  39. Osman A, Barrios FX, Gutierrez PM, Wrangham JJ, Kopper BA, Truelove RS, et al. The positive and negative suicide ideation (PANSI) inventory: psychometric evaluation with adolescent psychiatric inpatient samples. J Pers Assess. 2002;79:512–30.View ArticlePubMedGoogle Scholar
  40. Denton FN, Rostosky SS, Danner F. Stigma-related stressors, coping self-efficacy, and physical health in lesbian, gay, and bisexual individuals. J Couns Psychol. 2014;61:383.View ArticlePubMedGoogle Scholar
  41. Nguyen TD, Attkisson CC, Stegner BL. Assessment of patient satisfaction: development and refinement of a service evaluation questionnaire. Eval Program Plann. 1983;6:299–313.View ArticlePubMedGoogle Scholar
  42. Pachankis JE, Hatzenbuehler ML, Rendina HJ, Safren SA, Parsons JT. LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: a randomized controlled trial of a transdiagnostic minority stress approach. J Consult Clin Psychol. 2015;83:875–89.View ArticlePubMedPubMed CentralGoogle Scholar
  43. Heck NC, Mirabito LA, LeMaire K, Livingston NA, Flentje A. Omitted data in randomized controlled trials for anxiety and depression: A systematic review of the inclusion of sexual orientation and gender identity. J. Consult. Clin. Psychol. In press.Google Scholar

Copyright

© The Author(s). 2017

Advertisement