Psychotherapy for the Spectrum of Sexual Minority Stress: Application and Technique of the ESTEEM Treatment Model
Open accessAbstract
Converging evidence points to minority stress as a risk factor that predisposes sexual minority individuals to a variety of negative psychosocial health outcomes, particularly depression and anxiety, substance use, and sexual risk-taking. This paper outlines the techniques and theoretical underpinnings for implementing an emerging empirically supported psychotherapy targeting the transdiagnostic mechanisms linking minority stress with these outcomes for sexual minority clients. We outline the essential therapeutic principles, psychoeducation content, as well as session- and homework-based activities that can be adapted for a variety of presenting problems that originate from and are exacerbated by minority stress via these transdiagnostic minority stress processes. As the development and dissemination of this therapeutic model is still within its early stages, we review the intervention's empirical support thus far and outline potential directions for future development and dissemination via individual, clinic-based, and societal channels.
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Only one randomized controlled trial has been conducted with sexual minority young people to test a CBT-based intervention targeting mental health outcomes-ESTEEM.
“To the authors’ knowledge, only one randomized controlled trial has been conducted with sexual minority young people to test a CBT-based intervention targeting mental health outcomes—ESTEEM (Effective Skills to Empower Effective Men) [31,32,33].”
From Findings from a feasibility study of an adapted cognitive behavioral therapy group intervention to reduce depression among lgbtq (Lesbian, gay, bisexual, transgender, or queer) young people (2019) · cites this paper as [31]
The Abstract identifies ESTEEM as a CBT adaptation for improving young gay and bisexual men’s mental health. “Current Support for ESTEEM” reports a completed randomized waitlist-controlled trial with mental-health outcomes, but does not establish that it was the only such trial with sexual minority young people. It also says another ESTEEM randomized trial was under way. (LLM, conf=0.86)
Experimental — accuracy not yet measuredThe first principle that "mood and anxiety symptoms are normal responses to minority stress" informs the first of a 10-module protocol designed to normalize depression and anxiety for sexual minorities.
“the first principle that “mood and anxiety symptoms are normal responses to minority stress” informs the first of a 10-module protocol”
From Minority stress theory: Application, critique, and continued relevance (2023) · cites this paper as [36]
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- Pachankis JE Hatzenbuehler ML Rendina HJ Safren SA Parsons JT 2015b LGB-affirmative cognitive-behavioral therapy for young adult gay and bisexual men: A randomized controlled trial of a transdiagnostic minority stress approach Journal of Consulting and Clinical Psychology 83 5 875 889 10.1037/ccp0000037 26147563 PMC4573250 · DOI · Paper page
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Pachankis, J. E., Chiaramonte, D. M., Scheer, J. R., Ankrum, H., Eisenstadt, B. E., Hobbs, R. J., Baldwin, H., Kidd, J. D., Witkiewitz, K. A., Esserman, D. A., et al. (2025) · BMJ Open · doi:10.1136/bmjopen-2024-086738 · Cited by 5 · see citing works
Költő, A., Gavin, A., Vaughan, E., Kelly, C. N. M., Molcho, M., & Gabhainn, S. N. (2021) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph18031118 · Cited by 5 · see citing works
Therapy and counselling experiences of queer adults in Germany
Bröning, S., & Mazziotta, A. (2024) · Counselling and Psychotherapy Research · doi:10.1002/capr.12814 · Cited by 4 · see citing works
van der Star, A. (2020) · Figshare · Cited by 4 · see citing works
Changes in the quality parameters of Cephalaria syriaca L. seed oil after the refining process
Duman, E. (2023) · Grasas y Aceites · doi:10.3989/gya.1123212 · Cited by 4 · see citing works
Hilgeman, M. M., Cramer, R. J., Kaniuka, A. R., Robertson, R. A., Bishop, T. K., Wilson, S. M., Sperry, H. A., & Lange, T. M. (2024) · PLoS ONE · doi:10.1371/journal.pone.0282376 · Cited by 3 · see citing works
Scheer, J. R., Breslow, A. S., Esposito, J., Price, M. A., & Katz, J. (2020) · Springer eBooks · doi:10.1007/978-3-030-52612-2_10 · Cited by 3 · see citing works
Cascalheira, C. J., Pugh, T. H., Hong, C., Birkett, M. A., Macapagal, K. R., & Holloway, I. W. (2023) · Frontiers in Reproductive Health · doi:10.3389/frph.2023.1303218 · Cited by 3 · see citing works
Luxon, A. M., Chasson, G. S., Williams, M. T., Skinta, M. D., & Galupo, M. P. (2021) · Journal of Cognitive Psychotherapy · doi:10.1891/jcpsy-d-20-00013 · Cited by 3 · see citing works
Strifler, Y., & Diamond, G. M. (2024) · Psychotherapy Research · doi:10.1080/10503307.2024.2309285 · Cited by 2 · see citing works
Caceres, B. A., Sharma, Y., Doan, D., Ravindranath, R., Nguyen, V., Ensari, I., Belloir, J. A., Lim, Y. R., & Cook, S. (2025) · Annals of Behavioral Medicine · doi:10.1093/abm/kaaf032 · Cited by 2 · see citing works
Presenting a strengths-based ecological model for promoting well-being among LGBTQ+ adults
Cowand, A., Bresin, K., Todd, N. R., & Mekawi, Y. (2025) · New Ideas in Psychology · doi:10.1016/j.newideapsych.2025.101178 · Cited by 2 · see citing works
Fox, S. D., Orozco‐Poore, C., & Pachanki, J. E. (2025) · The Journal of LGBTQ+ Mental Health · doi:10.1080/19359705.2025.2473344 · Cited by 2 · see citing works
Martell, C. R., & Williams, M. E. (2018) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2018.12.001 · Cited by 2 · see citing works
Mijas, M. E. (2021) · Psychiatria Polska · doi:10.12740/pp/onlinefirst/127468 · Cited by 2 · see citing works
McMahon, K. M. (2025) · Journal of Aggression Maltreatment & Trauma · doi:10.1080/10926771.2025.2539829 · Cited by 1 · see citing works
van Dyk, I. S., Rutherford, C. G., Pachankis, J. E., Bränström, R., & Hatzenbuehler, M. L. (2025) · Social Psychiatry and Psychiatric Epidemiology · doi:10.1007/s00127-025-02974-5 · Cited by 1 · see citing works
Jaramillo, J., Kalra, N. R., Reyes, N., Rodriguez-Seijas, C. A., Rogers, B. G., Morris, F., Jackson, S. D., Safren, S. A., Pachankis, J. E., & Harkness, A. (2025) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2025.09.001 · Cited by 1 · see citing works
Warren, M., Smith, L. J., Pridgen, S., & Held, P. (2026) · Journal of Traumatic Stress · doi:10.1002/jts.70043 · Cited by 1 · see citing works
Treatment Goals of Sexual Minority Men in LGBTQ-Affirmative CBT
Brisbin, C. D., Soulliard, Z. A., Puccinelli, M. J., Harkness, A., Fetzner, B. K., Safren, S. A., & Pachankis, J. E. (2023) · Cognitive and Behavioral Practice · doi:10.1016/j.cbpra.2023.12.002 · Cited by 1 · see citing works
Distress as a Function of Social Exclusion and Assertiveness among Homosexual/Bisexual People
Cheung, C., & Tsang, E. Y.-H. (2024) · International Journal of Environmental Research and Public Health · doi:10.3390/ijerph21050633 · Cited by 1 · see citing works
Introduction to LGBTQ-Affirmative Cognitive-Behavioral Therapy
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0001 · Cited by 1 · see citing works
(2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.002.0004
Module 5: Increasing Cognitive Flexibility
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0010
Module 8: Emotion Exposures for Countering LGBTQ-Related Stress
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0013
Module 9: Recognizing Accomplishments and Looking to the Future
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0014
History, Basic Principles, and Outline of LGBTQ-Affirmative Cognitive-Behavioral Therapy
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0002
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.005.0001
Additional Information for Therapists
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0003
Module 7: Experimenting with New Reactions to LGBTQ-Related Stress
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0012
Module 6: Countering Emotional Behaviors
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0011
(2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.002.0007
Session 1: Functional Analysis and Introduction to Treatment
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0005
Module 1: Setting Goals and Building Motivation for LGBTQ-Affirmative Cognitive-Behavioral Therapy
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0006
Module 3: Understanding and Tracking LGBTQ-Related Stress and Emotional Experiences
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0008
Module 2: Understanding the Nature and Emotional Impact of LGBTQ-Related Stress
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0007
Overview of General Treatment Format and Procedures
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0004
(2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.002.0008
Module 4: Increasing Mindful Awareness of LGBTQ-Related Stress Reactions
Pachankis, J. E., Harkness, A., Jackson, S. D., & Safren, S. A. (2022) · Oxford University Press eBooks · doi:10.1093/med-psych/9780197643303.003.0009
Perceptions of a Cardiovascular Risk Reduction Intervention for Sexual Minority Adults
Pepe, V. M., Sharma, Y., Doan, D., George, M., Cortés, Y. I., Lelutiu‐Weinberger, C., & Caceres, B. A. (2024) · Annals of LGBTQ Public and Population Health · doi:10.1891/lgbtq-2023-0010
Considerations for Sexual Minority and Gender Diverse Individuals Living in Specific Countries
Randall, A. K., & Lannutti, P. J. (2025) · Cambridge University Press eBooks · doi:10.1017/9781009345774.004
Pehar, A., & Meuwly, N. (2025) · Cambridge University Press eBooks · doi:10.1017/9781009345774.012
Tatnell, R., Constanti, A., Johansen, S. W. F., & Demmer, D. H. (2025) · Australian Psychologist · doi:10.1080/00050067.2025.2484001
Karcher, S., Gertzen, M., Rosenberger, C., Schwarz, J., Villa, P.-I., Strasburger, M., Rabenstein, A., Pogarell, O., Martl, P., Hentschel, H., et al. (2025) · Sexuality Research & Social Policy · doi:10.1007/s13178-025-01137-0 · Cited by 1 · see citing works
A psychometric evaluation of the coping self-efficacy scale among LGBTQ+ Veterans
Prowten, S. D., Cacace, S. C., Bishop, T. K., Sperry, H. A., Wilcox, M. C., Phillips, S., Cramer, R. J., & Hilgeman, M. M. (2025) · Military Psychology · doi:10.1080/08995605.2025.2586984
Hall, C. D. X., Bao, A., Sabuncu, B. C., Wang, L., Luu, M. N., Mills, J. C., Trang, K., Millender, E., Lane, B. L., Cheung, D. H., et al. (2025) · AIDS Care · doi:10.1080/09540121.2025.2578652
Coping When the Struggle Is Real: Cognitive Behavioral Therapy Strategies for Youth Anxiety
Chu, B. C., Badin, E., & Pimentel, S. S. (2026) · Neuromethods · doi:10.1007/978-1-0716-5134-6_6
- Authors
- Burton, C. L., Wang, K., & Pachankis, J. E.
- Affiliations
- Yale University (US)
- Corresponding author
- Burton, Charles L.
- Venue
- Cognitive and Behavioral Practice
- Publisher
- Elsevier BV
- Published
- 2019-05
- Volume
- 26
- Issue
- 2
- Pages
- 285-299
- ISSN
- 1077-7229 (ISSN-L)
- PMC
- PMC6779338
- OpenAlex
- W2620794797
- Cited by
- 105
- References
- 55
- Citations by year
- 2026: 7 · 2025: 13 · 2024: 15 · 2023: 8 · 2022: 31 · 2021: 11 · 2020: 9 · 2019: 9 · 2018: 2
- FWCI
- 7.83
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Cognitive and Behavioral Practice (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- National Institute of Mental Health
- Topics
- Social Sciences › Psychology › Social Psychology › LGBTQ Health, Identity, and Policy
- Social Sciences › Psychology › Clinical Psychology › Psychotherapy Techniques and Applications
- Social Sciences › Psychology › Social Psychology › Counseling Practices and Supervision
- Keywords
- sexual minority stress, depression, anxiety, substance use, sexual risk behavior, psychoeducation, transdiagnostic mechanisms, intervention dissemination
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