LGBTQ+ affirmative CBT: A hierarchical linear model of longitudinal outcomes and mechanisms of change

Craig, S. L., Leung, V. W. Y., Hui, J. A., Austin, A., Iacono, G., Pascoe, R. V., Pang, N., Dobinson, C., Dillon, F., & Brooks, A. S. (2025). LGBTQ+ affirmative CBT: A hierarchical linear model of longitudinal outcomes and mechanisms of change. BMC Psychology. Advance Online Publication. DOI: 10.1186/s40359-025-03314-7.

Background 

• Sexual and gender diverse adolescents and young adults (SGDAYA) face disproportionately high rates of depression, anxiety, and suicidality compared to cisgender heterosexual peers. 

• Minority stress theory explains these disparities as stemming from stigma, discrimination, rejection, and internalized oppression. 

• Affirmative psychotherapies that explicitly validate SGD identities are under-researched, especially regarding long-term effects and mechanisms of change. 

• AFFIRM is an 8-session, manualized, group-based affirmative cognitive-behavioral therapy (CBT) intervention designed to address minority stress, build adaptive coping, and foster hope in SGDAYA. 

Study Description 

• A longitudinal clinical trial evaluated the AFFIRM program, an 8-session manualized LGBTQ+ affirmative cognitive-behavioral therapy (CBT) group intervention. 

• 202 SGDAYA (aged 14–29) recruited between 2018 and 2020 through social media, partner organizations, and a project website participated in AFFIRM. Participants reflected diverse gender identities, sexual orientations, and racial/ethnic backgrounds. 

• Participants were organized into 29 groups stratified by developmental stage (ages 14–18, 19–24, and 25–29). Groups ranged from 4 to 14 members and were co-facilitated by two graduate-level clinicians with at least two years of experience and specialized AFFIRM training. 

• The AFFIRM curriculum combined core CBT skills with LGBTQ+ affirmative practices, and included: 

• Introduction to CBT and minority stress. 

• Stress appraisal and thought restructuring.  

• Development of adaptive coping strategies.  

• Hope-building, goal setting, and future planning. 

• Identity-affirming social support, self-compassion, and self-care planning.

• Data were collected at four points: pre-test, post-test, 6-month follow-up, and 1-year follow-up. Participants received e-gift cards at each stage for survey completion. 

• Primary outcomes included measures of depression and anxiety; mechanisms of change examined included stress appraisal (threat, challenge, resources), coping strategies (engagement, disengagement, social support), and hope (agency, pathways). 

Unique Findings 

• Overall outcomes: 

• Significant decreases in depression and anxiety sustained at 1-year follow-up. 

• Significant increases in engagement coping, social support, appraising stress as a challenge and having the resources to deal with stress, and hope (agency and pathways) sustained at 1-year follow-up. 

• Significant decreases in disengagement coping and appraising stress as a threat sustained at 1-year follow-up. 

• Baseline predictors: 

• Youth with higher appraisal of stress as a threat, and lower hope at baseline showed the greatest improvements in depression and anxiety. 

• Youth scoring higher in disengagement coping at baseline also showed the greatest improvements in depression. 

• Mechanisms of change: 

• Long-term reductions in depression were most strongly predicted by: 

• Increased perception of resources to manage stress. 

• Greater uptake of engagement coping strategies. 

• Increased hope pathways (belief in multiple ways to reach goals). 

• Anxiety reduction was less directly tied to these mechanisms, suggesting distinct processes. 

• Small-to-medium (0.26–0.79) effect sizes that are clinically meaningful given chronic minority stress faced by participants. 

Conclusions 

• AFFIRM is the first empirically tested affirmative CBT group intervention for SGDAYA to show long-term reductions in depression and anxiety. 

• Mechanisms of positive change include targeting engagement coping, hope, social support, and reappraisal of stress. 

• Findings highlight the importance of tailored, affirmative interventions that explicitly address minority stress and validate LGBTQ+ identities. 

• SGDAYA experiencing greater initial distress may particularly benefit from AFFIRM, underscoring its potential for addressing inequities in mental health. 

• Future research should refine anxiety-focused components, expand diverse outcome measures, and explore booster or follow-up programming.