Current Capacity and Future Implementation of Mental Health Services in U.S. LGBTQ Community Centers

Sexual and gender minorities (SGMs) experience disproportionately high rates of stress-sensitive mental health conditions resulting from stigma-related challenges across the life span (1, 2). SGMs are also more likely to seek mental health treatment than individuals in the general population (3–5). Despite high rates of treatment use, SGMs still experience large unmet treatment needs and barriers (6–8). Like persons in the general population, SGMs report shame about discussing emotional challenges (9, 10) and that their experiences of stigma-related stress also interfere with treatment access (11). Gender minorities, bisexual individuals, and SGMs belonging to racial-ethnic minority groups further experience disproportionate poverty (12) and financial barriers to treatment (9, 10). Mistrust of mental health professionals represents another barrier (7, 13), perhaps stemming from the historical anti-LGBTQ (lesbian, gay, bisexual, transgender, and queer) stance of the mental health professions and the continued practice of so-called conversion therapies and gatekeeping (14–16). Lack of available LGBTQ-affirmative providers presents another barrier (10, 17), and SGMs from racial-ethnic minority groups report particular dissatisfaction with treatment (18).

Since the 1970s, the SGM community has shown strong activism and organizing to address its mental health care needs (19). LGBTQ community centers were initially established to raise consciousness about the need for LGBTQ empowerment, advocate for LGBTQ rights, and provide support services unavailable in general-population settings. From the beginning, services offered at LGBTQ community centers had an explicit focus on identity-affirming mental health support (20). With even greater visibility of SGMs, the role of LGBTQ community centers in supporting LGBTQ mental health became even more imperative (21, 22).

Today, LGBTQ community centers continue to respond to the fact that the SGM mental health disparity represents a pressing contemporary challenge (23). LGBTQ community centers include any organization whose primary mission is to support the local LGBTQ community by offering formal services, ranging from centers that provide only social opportunities (e.g., support groups) to those that offer comprehensive health services (e.g., medical, mental, dental, case management) alongside social and educational services. Of the >250 LGBTQ community centers in the United States, about 40% provide mental health services free of the discrimination that many SGMs experience or anticipate experiencing in other settings (24). Most U.S. centers are located in cities and coastal states characterized by low anti-SGM structural stigma defined as the societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized (25); 13 states do not have an LGBTQ center, posing access barriers to SGMs living in many high-stigma, rural locations (19). Because LGBTQ community centers often offer free or heavily subsidized mental health services, they provide access to services for those who might not otherwise receive care, including individuals with lower incomes and LGBTQ people of color (26).

Although U.S. LGBTQ community centers provide mental health services to >30,000 SGMs each year (24), little is known about these services. One small study found that the most common mental health concerns addressed in U.S. LGBTQ community centers include those specifically related to sexual orientation and gender identity, coming out, general support, depression, and relationship issues; this finding suggests that at least some LGBTQ people are presenting to these centers with mental health needs and stressors specifically related to their sexual and gender identities (27). Yet, treatment capacity (e.g., number of providers and clients, staff training and qualifications), format of services (e.g., group, individual, medication), type of services (e.g., cognitive-behavioral therapy [CBT], supportive counseling, trauma-informed care), and perceptions of community mental health needs across centers remain relatively unknown.

LGBTQ community centers’ experience with evidence-based mental health care also remains unknown. Evidence-based mental health practice incorporates scientific findings and rational decision making into care delivery (28). However, because of limited funding, LGBTQ community centers may justifiably focus on ensuring access to any supportive mental health service to as many people as possible (e.g., peer-led support groups) (29) rather than on providing evidence-based care (e.g., CBT) (30). At the same time, questions have been raised about the cultural responsiveness of existing evidence-based treatments (31), which includes delivery of generic evidence-based treatments to SGMs (32). Furthermore, until very recently, no LGBTQ-affirmative mental health treatments had been tested in randomized controlled trials, the gold standard for establishing evidence-based practice (32–34), thereby limiting the ability of LGBTQ community centers to provide evidence-based services responsive to SGM-specific needs. Given that governmental and third-party payers increasingly attend to the evidence base of treatments in making funding decisions (35), building LGBTQ community centers’ capacity to deliver evidence-based services could help ensure their future position as a source of needed community support.

To identify the mental health services and needs of LGBTQ community centers, with a particular focus on evidence-based practice, we conducted a mixed-methods survey of executive directors and chief executive officers of LGBTQ community centers across the United States. Survey questions regarding LGBTQ community centers’ treatment capacity, format, and type as well as perceived future needs were supplemented with qualitative responses regarding perceived barriers to and facilitators of strengthening mental health service capacity. We also assessed the centers’ current facilitators of and barriers to providing evidence-based mental health care specifically.

Methods

We developed a mixed-methods survey assessing mental health services offered by U.S. LGBTQ community centers. Survey items assessed the following variables: mental health service capacity (e.g., number of mental health staff, staff qualifications, number of people receiving services); format of mental health services (e.g., one-on-one counseling, support groups); types of mental health services (e.g., CBT, trauma-informed therapy); and perceived training needs, including questions regarding the perceived utility, acceptability, and feasibility of staff training in evidence-based, LGBTQ-affirmative mental health care. Following an open-ended question, respondents provided qualitative feedback regarding their LGBTQ community center’s mental health services and their staff’s training needs.

Between February and March 2020, the survey was distributed by e-mail to the executive directors and chief executive officers of 165 U.S. LGBTQ community centers. LGBTQ centers without paid staff were not sent this e-mail because these centers do not provide mental health services. The recruitment e-mail asked respondents to complete a 10-minute survey to “better understand the needs of our centers who provide mental health services.” Sixty-seven respondents representing 67 community centers began the survey; 60 respondents completed more than half of the survey items, and their responses were included in analyses. Descriptive statistics included means and SDs for continuous variables and proportions for categorical variables. A trained research assistant reviewed the qualitative data, and emergent codes were categorized into larger themes following core tenets of thematic analysis (36). Two senior researchers experienced in qualitative research reviewed these emergent themes and garnered salient quotes to contextualize findings. The Yale Human Subjects Committee deemed this study exempt from review.

Results

The 60 survey respondents represented 26 states and Puerto Rico, somewhat evenly across the four U.S. Census regions: Northeast (N=15; 25%), Midwest (N=8; 13%), South (N=18; 30%), and West (N=19; 32%).

Table 1 details mental health service capacity and type currently offered by the LGBTQ community centers. Most centers reported having five or fewer professional or volunteer mental health staff (52%) and providing mental health services to ≤250 individuals annually (59%). The most common types of mental health services offered included support groups (98%) and one-on-one counseling (85%); the least common types included medication management (12%) and prayer or other spiritual practices (8%). Social workers were the most common provider type (70%), followed by mental health counselors (62%). Psychiatrists (8%) and a category including nurses, occupational therapists, or other health care providers (5%) were the least common types of mental health service providers.

A large majority of LGBTQ community centers reported providing evidence-based mental health treatment (88%), and most provided trauma-informed therapy (68%), CBT (62%), and supportive therapy (62%). Most centers (61%) reported collecting client mental health data (e.g., depression, anxiety, substance use) (Table 1).

Table 2 presents the perceived mental health training needs of LGBTQ community centers. Nearly one-third of the centers (32%) reported being well equipped to meet the mental health needs of all people seeking mental health services at their center, whereas one-quarter of the centers (25%) reported being well equipped to meet the estimated mental health needs of their local LGBTQ community. Most centers characterized their mental health staff as having previously received training in evidence-based mental health practice (75%). Similarly, most respondents perceived their staff to be well prepared to deliver evidence-based treatment (75%), including CBT (70%). Nonetheless, most respondents felt that their mental health staff would desire further training in evidence-based treatment “a lot” or “very much” (85%) and that they would benefit from such training “a lot” or “very much” (83%). All respondents (100%) indicated that they would provide administrative support for their staff to receive training in evidence-based mental health treatment.

Twenty-seven (45%) respondents provided qualitative replies to an open-ended question about their center’s mental health services provision and training needs, and three key themes emerged: LGBTQ-affirmative mental health care is limited, and training is needed; centers are eager to expand their mental health services but have limited time, resources, and funding to do so; and training should be sensitive to the intersection of diverse identities (e.g., race and gender identities).

Respondents expressed a high need for LGBTQ-affirmative mental health care in their communities. Some highlighted the negative mental health impact of the multiple societal marginalizations faced by their local LGBTQ populations. One respondent stated, “Our community faces unique challenges. Specifically, around the medical process of transitioning, being safe to live authentically, living in poverty, job insecurity, housing insecurity, and food insecurity. All of which has a tremendous impact on mental health.” Another respondent explained, “Mental health needs in the LGBT community are an undisputed need and so are the disparities.” Several respondents noted that limited LGBTQ-affirmative mental health services in their region overwhelmed their center’s ability to meet local LGBTQ community needs. One respondent from a large metropolitan area said, “Need for these services remains high and waitlists abound in [city name] for LGBTQ-affirming mental health clinical services. Our short-term services provide needed support but are not enough.” Another respondent from a smaller municipality echoed such difficulties in meeting community needs, stating, “The need in our community far outweighs our capacity.”

Overall, respondents articulated great desire for additional mental health training to provide high-quality care to their local LGBTQ community. For instance, one respondent said, “More training is always something that the staff at [center name] is looking to do to ensure we are providing the best services to participants.” Another respondent echoed the belief that centers wish to meet the mental health needs of the LGBTQ community with high-quality services based on contemporary best practices, stating, “Having affordable, ongoing training to provide the best services—evidence-based and trauma-informed care—available is essential for our community. They deserve the best practices available.” Some respondents specifically stated that LGBTQ-affirmative mental health training should go beyond introductory material, with one respondent explaining, “We would be seeking more advanced training rather than ‘101’ type training. We continually seek and also provide training for working with the LGBTQ community.”

Limited access to resources, including time and funding, represents a key barrier to adequate provision of mental health services and ability to pursue training. One respondent said, “We support [mental health] training, but the time is a big financial drain on the billable hours used to support the staff costs.” A common theme across qualitative feedback was that limited funding meant relying on volunteers who often had little or no professional mental health training. Indeed, one respondent stated, “We are unable to pay a licensed therapist; therefore, we rely on interns and volunteers, but the turnover is quick. Ongoing training will benefit us.” Other respondents also highlighted that without adequate funding, centers relied on volunteers or peer facilitators who would benefit from evidence-based mental health training. One respondent stated, “Our main program is a weekly youth support group run by volunteer facilitators . . . there is a real lack of therapists trained to meet our needs.” Another respondent also expressed desire for additional training to augment current peer-led services: “At this time, the vast majority of mental health services we provide are peer-support models and are staffed by volunteers, not professionals. Our community would benefit greatly from having more professional staff and training in our center.”

Finally, respondents were adamant that mental health services and LGBTQ-affirmative mental health training must be sensitive to the diverse intersectional identities of LGBTQ community members. Along those lines, one respondent stated, “We are very supportive of any research that is being done around our LGBTQ community as long as there is an acknowledgment around QTBIPoC [queer and trans Black, Indigenous, people of color] folx. There is a void in the research around this specific community.” Another respondent said, “We value the impact of intersecting identities.”

Discussion

LGBTQ community centers provide essential mental health support services, as they have done since the beginning of the LGBTQ rights movement (19). Responses from 60 executive directors and chief executive officers of LGBTQ community centers show that these centers perceive a high need for mental health care in their communities and strive to meet that need; for most centers, however, existing needs outweigh their resources. Most centers reported having few mental health staff; still, most of these centers provide support groups and individual psychotherapy through social workers and mental health counselors. Furthermore, most centers reported providing general evidence-based care, such as CBT, and indicated that their mental health staff have received training in evidence-based practice. Most centers also reported high interest in their staff receiving training in new types of evidence-based, LGBTQ-affirmative approaches (34). All respondents indicated that their centers would provide the resources necessary for their staff to receive training in such approaches. Some respondents suggested that this training be sophisticated and attend to the intersectional needs of their community members, including gender minorities and people of color.

In the past decade, the U.S. Department of Health and Human Services has called for implementation science to bolster the translation of research into practice. Using an implementation science perspective (37), here we propose ways to incorporate evidence-based, LGBTQ-affirmative practice within LGBTQ community centers. Specifically, we found evidence of high need for training in such approaches and eagerness to accommodate this training, including by devoting staff time to training. We also identified several barriers to providing care, including lack of funding and heavy reliance on volunteer mental health staff who are not necessarily trained in evidence-based approaches. Together, these facilitators (e.g., center readiness for training) and barriers (e.g., lack of funding for service delivery) suggest several opportunities for building these centers’ capacity to deliver evidence-based, LGBTQ-affirmative care.

In terms of implementation facilitators, LGBTQ community centers’ high interest in receiving training in evidence-based, LGBTQ-affirmative mental health care suggests a timely opportunity to implement these new approaches. Although both funders (35) and consumers (38) of mental health services frequently seek evidence-based practice, evidence-based LGBTQ-affirmative mental health treatment has historically been unavailable because of a lack of randomized controlled trials of such treatment. Now that several trials have established the efficacy of LGBTQ-affirmative treatments (34), which have been developed in close consultation with SGMs in the community and treatment providers (39), such treatment is ready for implementation.

In general, LGBTQ-affirmative practice promotes insight into how stigma-related stress can compromise mental health; helps SGMs reduce feelings, such as shame and guilt, and negative cognitive styles, such as hopelessness and low self-worth, that often emerge from stigma-related stress; promotes resilience, pride, and community building as an antidote to stigma-related stress; and provides SGM-specific resources and advocacy against societal injustice (32). Evidence-based, LGBTQ-affirmative practice infuses existing evidence-based treatments, such as CBT, with these LGBTQ-affirmative principles (34, 40). More recent evidence-based, LGBTQ-affirmative mental health approaches now also show the benefit of addressing the intersectional experiences of LGBTQ gender minorities (34) and people of color (Jackson S.D., Wagner K.R., Yepes M., et al., 2021, unpublished manuscript), an approach that has been relatively lacking until now (41).

Our results suggest that training in these approaches, a necessary initial step toward treatment implementation, can capitalize on the fact that providers at most LGBTQ community centers have already been trained in general evidence-based approaches, such as CBT. Therefore, training in delivering more specific evidence-based, LGBTQ-affirmative treatments could incorporate the LGBTQ-specific principles and techniques derived from the recent clinical trials described above with providers’ existing knowledge. Training in evidence-based, LGBTQ-affirmative mental health care has shown efficacy for increasing provider competence in high-stigma, low-resource countries (42), supporting the promise of related training for diverse SGM communities in the United States. The more advanced focus of such training (e.g., on principles and practice of LGBTQ-affirmative CBT) also adheres to respondents’ request that any mental health training should go beyond reviewing introductory material.

Such training, for instance, would focus on the LGBTQ-affirmative delivery of skills such as cognitive restructuring, building emotion awareness, and designing effective exposure exercises specifically adapted to promote coping with the mental health sequelae of stigma-related stress (39). Respondents also noted that training should take an intersectionality approach, which can be accomplished by highlighting the interlocking structural systems of inequity that can compromise the mental health of individuals who occupy identities and lived experiences at multiple sites of social oppression. Such training would go beyond a focus on cultural competence to also promote structural competence in recognizing and addressing the impact of interlocking structural forms of oppression on the mental health of SGMs who also occupy racialized positions and those based on ethnicity, class, gender, citizenship, disability, and any other marginalized status (43).

In terms of barriers to treatment implementation, our findings suggest that LGBTQ community centers might wish to consider time- and cost-efficient ways of delivering mental health care to the largest number of clients with the fewest resources. For example, Internet-based mental health treatments have received strong research support for efficiently effecting mental health improvements among treatment-seeking individuals in general populations. Internet-based treatments come in many forms, including one-on-one synchronous approaches (e.g., telehealth) to even more efficient online platforms that are relatively self-guided with some asynchronous therapist support (44). This latter approach can require only a few minutes of provider time per patient per week, without sacrificing efficacy (45), making it particularly suited to the resource-constrained environment of many LGBTQ community centers. Such treatments, frequently based on cognitive-behavioral approaches, often show effects that are equal to those of in-person treatments for conditions such as depression and substance use problems (45–47).

Although LGBTQ-affirmative approaches have not been tested with efficient Internet-based platforms, such an approach can help LGBTQ community centers respond to unmet needs while also circumventing geographic access barriers (26). The extent to which such treatment approaches are billable and reimbursable by insurance companies might further determine their ultimate implementation, given that most LGBTQ community center funding comes from program revenue (24). Future implementation research can capitalize on the fact that most centers currently collect client mental health outcomes, thereby allowing implementation researchers to assess the effectiveness of new approaches, such as evidence-based, LGBTQ-affirmative treatments, that might be implemented therein.

Communities of practice (i.e., networks of practitioners who support knowledge exchange, develop members’ clinical capabilities, and work to bring evidence-based research into practice) represent a promising model for facilitating the implementation of evidence-based, LGBTQ-affirmative mental health treatments across LGBTQ community centers (48). Examples of successful mental health care communities of practice models often seek to foster interdisciplinary communication and teamwork, deploy psychoeducational training programs for providers, and engage mental health stakeholders (e.g., psychologists, social workers, and psychiatric nurses) across professions (49). An online community of practice for mental health providers housed within LGBTQ centers across the United States has particular promise as a low-burden, cost-effective way to support the implementation of evidence-based, LGBTQ-affirmative mental health treatment that also fosters community connectedness and collective learning among providers (50).

These study findings must be interpreted in light of some limitations. First, our survey was constructed to be brief to minimize burdens on potentially already burdened executive directors and chief executive officers of the centers. This brevity likely yielded an incomplete picture of the current capacities and needs of these centers. Future research of additional implementation factors may offer a more comprehensive assessment of LGBTQ community centers’ readiness and needs to adopt evidence-based, LGBTQ-affirmative practice. For instance, future research could explore whether centers currently deliver online mental health services and consider treatment implementation involving online practice. Similarly, although we assessed whether center executive directors and chief executive officers would be willing to provide administrative resources for training their mental health staff in LGBTQ-affirmative CBT, we did not assess whether capacities exist to support ongoing supervision in such approaches, an important implementation consideration for future research.

Second, SGMs seek mental health care in many settings, ranging from federally qualified health clinics to general medical and mental health care settings in the local community. Future research should assess the current state of practice and unmet needs in those settings specific to SGMs (51–53). Future research might also assess the interface between LGBTQ community centers and more general health care settings, including referral pathways between the two; shared care; and training opportunities in LGBTQ-affirmative practice offered by LGBTQ community centers for providers in general practice settings. Third, 60 of 165 invited centers responded, which may underrepresent the perspectives of some centers.

Conclusions

The results of this study suggest that LGBTQ community centers present a significant opportunity to address the substantial unmet mental health needs of the LGBTQ population by implementing evidence-based, LGBTQ-affirmative practices. The executive directors and chief executive officers of LGBTQ community centers reported a high degree of openness to their mental health staff being trained in such approaches; moreover, the staff at most centers possessed a foundation in more general evidence-based practice into which recent LGBTQ-affirmative innovations could be incorporated. Potential implementation barriers, including cost concerns, could be overcome with Internet-based approaches or other cost-efficient means of reaching large numbers of community members with state-of-the-art practice. Overall, these findings may help LGBTQ community centers continue to lead the way in providing needed support for this segment of the U.S. population.