What Are the Mechanisms through Which Therapist Affirmative Practices Influence Sexual Minority Clients' Psychological Well-Being?

Background and Purpose: Lesbian, gay, and bisexual (LGB)-affirmative psychotherapy is now considered the preferred practice approach for working with sexual minority clients (Craig & Austin, 2016). However, few empirical studies have examined whether affirmative practice actually improves psychological functioning among LGB clients. Furthermore, little information exists about how psychotherapeutic processes influence client outcomes in affirmative practice. This study investigates whether the working alliance (i.e., goals/tasks for psychotherapy as well as the bond between client/therapist) and real relationship (i.e., personal connection between client/therapist) mediate hypothesized positive associations between LGB-affirmative practice and psychological well-being among LGB clients.

Methods:  We recruited a nationwide sample of 362 LGB individuals through the Internet. Eligibility criteria included: identifying as LGB, being 18 years old or older, and attending at least one session of psychotherapy 1 year prior to study participation. The majority of participants identified as White/non-Latino/a (64%) and women (54%). The mean age was 28 years old (SD=9.64), and the mean number of counseling sessions was 2.58 (SD=1.78). Participants completed an online survey that assessed: perceptions of pre-counseling distress (Owen et al., 2011); the working alliance (Hatcher & Gillaspy, 2006); the real relationship; and therapist affirmative practices (Crisp, 2006).

Results: Preliminary analyses showed differences according to age. Older participants reported: having more affirmative therapists (r = .20, p < .01); better working alliance (r = .19, p =.01); more real relationship (r = .23, p <.01); and higher levels of psychological well-being (r = .15, p = .02). In comparison to females, males reported more affirmative therapists (M = 1.97, SD = .71 vs. M = 2.29, SD =. 81; p = .02) and more real relationship (M = 4.09, SD = .57 vs. M = 3.79, SD = .68; p = .01). We used structural path analysis to test our research questions. Covariates included pre-counseling distress, age, race/ethnicity, number of therapy sessions, and therapist gender. The direct path between therapist LGB-affirmative practices and client psychological well-being was significant (β = .25, p < .01). Both the working alliance (β = .25, p < .01; 95% CI [.08, .31]) and real relationship (β = .37, p< .01; 95% CI [.19, .56]) mediated the relationship between LGB-affirmative practice and psychological well-being.

Conclusions and Implications: This study provides empirical support for the underlying mechanisms through which LGB-affirmative practices relate with psychological well-being among sexual minority clients. Training social workers to practice affirmatively may positively influence the working alliance and real relationship, which in turn contributes to LGB clients’ psychological well-being. Findings contribute to the evidence-base for LGB-affirmative psychotherapy and improving the affirmative training experiences of social workers.