An Affirmative Mindfulness Approach for Lesbian, Gay, Bisexual, Transgender, and Queer Youth Mental Health

The purpose of this conceptual practice paper is to explore the feasibility of mindfulness-based interventions (MBIs), as a mental health approach, for lesbian, gay, bisexual, transgender, and queer (LGBTQ) youth, commonly referred as sexual and gender minority youth (SGMY) in the literature. Given the promising research evidence that youth who participate in MBIs experience positive mental health outcomes (Tan 2016; Zoogman et al. 2015), this paper proposes the use of mindfulness to help address mental health vulnerabilities experienced by SGMY. Mindfulness can help individuals “gently observe their thoughts, emotions, and physical sensations, accept them as transient inherently human experiences, and become willing to engage in meaningful activities even if doing so could elicit discomfort” (Fuchs et al. 2013, p. 3). A brief review of the mindfulness-based intervention (MBI) literature, as it applies to youth mental health, will be explored, both in the general and marginalized youth populations. Finally, adapting MBIs to address mental health issues among SGMY will be explored.

Utilizing minority stress theory (Meyer 2003) as a foundational theoretical model to inform the adaptation of mindfulness approaches for SGMY, this paper aims to integrate mindfulness theoretical insights (e.g. informed by Buddhist psychology and cognitive neuroscience) and an affirmative-based practice conceptualization (e.g. affirm LGBTQ identity, explore oppression and discrimination, use a minority stress lens) to address SGMY mental health. It is important that clinical social workers utilize an affirmative-based approach with LGBTQ populations, such as SGMY, as it can help address particular challenges related to coping with marginalization and discrimination (Alessi 2013). Drawing on the author’s clinical experience working with SGMY, this conceptual paper will build a case for the systematic investigation of culturally-appropriate affirmative MBIs for SGMY.

SGMY typically tend to exhibit poorer emotional, psychological and behavioral outcomes compared to their non-SGMY counterparts (Fisher et al. 2008; Robinson and Espelage 2011). SGMY report significantly higher rates of mental health issues, such as depression and substance use compared to their non-SGMY peers (Hatzenbuehler et al. 2012; Marshal et al. 2008). One study in the United States found that nearly one-third of SGMY (from a diverse community sample of 246 SGMY) met the criteria for a mental disorder and/or reported a suicide attempt in their lifetime, 17% met the criteria for conduct disorder, 15% for major depression, and 9% for post-traumatic stress disorder (Mustanski et al. 2010). Longitudinal studies have shown that these mental health issues continue to persist into adulthood (e.g. Fish and Pasley 2015; la Roi et al. 2016; Needham 2012).

Coming out, or being out, as a sexual and gender minority (SGM) during this adolescent developmental period may be characterized by intense peer influence (Brechwald and Prinstein 2011) that can be conducive to peer victimization (Russell and Fish 2016; Taylor et al. 2011). The mental health consequences of peer victimization have been well documented in the literature, making mental health a critical concern for SGMY (Birkett et al. 2009; Poteat and Espelage 2007; Russell and Fish 2016; Russell et al. 2014). For example, youth who endure SGMY-related peer victimization experience elevated levels of depression, suicidal ideation and attempts, as well as substance misuse (Poteat et al. 2011; Russell et al. 2012).

Additionally, many SGMY fear disclosing their SGM identities to their families (Potoczniak et al. 2009; Savin-Williams and Ream 2003), and experience familial rejection (Ryan et al. 2009). The familial rejection SGMY experience is evidenced by the disproportionate rates of homeless SGMY compared to the general population (D’Augelli 2002; Russell and Fish 2016). Durso and Gates (2012) estimate 40% of youth accessing drop-ins, street outreach and housing programs identify as SGMY. From a mental health perspective, SGMY who fear familial and peer rejection experience elevated levels of anxiety and depression as a result (D’Augelli 2002). As SGMY are significantly underserved (Dysart-Gale 2010), it is critical that these mental health disparities are addressed by utilizing culturally-relevant effective mental health approaches.

Minority stress theory (Meyer 2003) has given us a compelling framework for understanding mental health disparities among sexual minority groups (e.g. lesbian, gay, bisexual) (Inst. Med. 2011; Russell and Fish 2016), and more recently among gender minority groups (e.g. transgender, genderqueer) (Craig and Austin 2016). Minority stress theory proposes that SGM mental health disparities can be explained in large part by unique and distinct stressors induced by hostile homo/bi/transphobic cultural, social and institutional structures (Marshal et al. 2008; Russell and Fish 2016). This theory posits that LGBTQ-specific forms of discrimination and microaggressions disproportionately impact the mental health of SGM. The literature suggests that there is a connection between coping with LGBTQ-specific forms of marginalization and SGM mental health issues (Cochran et al. 2006; Ross et al. 2008).

Furthermore, SGMY may not have the necessary coping skills to cope with minority stress and a stigmatized identity (Berghe et al. 2010); this may lead to maladaptive and risky coping approaches such as high-risk sexual behaviors and substance misuse (Hatzenbuehler 2009). The work of Hatzenbuehler and colleagues (2008), in utilizing minority stress theory, has focused on the deleterious effects of minority stress on mental health, such as the difficulty in coping with and regulating emotions. For example, lesbian, gay, and bisexual youth were found to be more likely to ruminate and suppress emotional responses when experiencing minority stressors (e.g. prejudice, microagressions), which led to greater psychological distress (Hatzenbuehler et al. 2008). Furthermore, same-sex attracted youth experienced diminished emotional awareness and emotional regulation compared to their opposite-sex attracted peers, a challenge which was related to symptoms of anxiety and depression (Hatzenbuehler et al. 2008; Russell and Fish 2016). Therefore, attending to psychological processes and the emotional needs of SGMY, in tandem with community and policy-level interventions, is crucial to address mental health risks and to promote resilience.

It is also critical to incorporate a minority stress theoretical lens to inform clinical practice with SGMY (Alessi 2014; Craig et al. 2013). For instance, in articulating how to incorporate minority stress theory into clinical social work practice, Alessi (2014) describes a framework that incorporates clinical assessment, one that draws on Meyer’s (2003) and Hatzenbuehler’s (2009) work, to aid in exploring various factors (e.g. stigma, internalized homophobia, coping, emotional regulation) that are impacted by minority stress. In line with connecting minority stress theory with affirmative practice, Alessi also suggests an affirmative treatment approach to work with LGBTQ populations. Similarly, it is useful to utilize minority stress theory when taking an affirmative approach with SGMY because this theoretical orientation emphasizes protective features against marginalization and stigma, such as minority group identification and support (DiPlacido 1998). Thus, incorporating minority stress and affirmative practice perspectives can help inform and focus work with SGMY that facilitates increased coping, resilience and social support.

Mindfulness is a concept adopted from Buddhist psychology and philosophy (Brito 2013). Traditionally fostered in Buddhist meditation (Goldstein and Kornfield 1987), mindfulness as a mental health approach has become tremendously popular in many professional disciplines such as medicine, psychology, business and education (Meiklejohn et al. 2012). Considerable efforts have been made to achieve consensus in operationally defining and understanding mindfulness as a construct (Bishop et al. 2004; Burke 2010; Shapiro et al. 2006). Despite inconsistent definitions of mindfulness in the literature, a general understanding of mindfulness is that it is as a way of bringing attention and awareness to the present moment. It also comprises an attitude of non-judgment, acceptance, patience and letting go (Kabat-Zinn 1991). Kabat-Zinn (1994), the founder of the popular mindfulness-based stress reduction (MBSR) program, states that mindfulness is a “way of being,” a dynamic process that is fundamental to all parts of our lives and in the way we relate to ourselves and others.

Generally speaking, mindfulness is cultivated through specific awareness and concentrative practices such as meditation and yoga, but can be nurtured in the everyday through informal practices (Neff and Tirch 2013). Cultivating mindfulness involves emphasizing our internal experience and observing bodily sensations, emotions, and thoughts in a self-compassionate manner as they arise (Germer 2009). Shapiro and colleagues (2006) posit that mindfulness is comprised of three main components: intention (purposefulness and vision), attention (awareness of the present moment), and attitude (open and nonjudgmental stance). They argue that “intention, attention, and attitude are not separate processes or stages—they are interwoven aspects of a single cyclic process and occur simultaneously…mindfulness is this moment-to-moment process” (Shapiro et al. 2006, p. 375). The attitude of mindfulness, the way one pays attention, is critical and involves “an affectionate, compassionate quality…a sense of openhearted, friendly presence and interest” toward oneself (Kabat-Zinn 2003, p. 145), as opposed to a cold and self-critical quality (Shapiro et al. 2006).

MBIs focus on altering our relationship to challenging and difficult unwanted mental experiences (Roemer and Orsillo 2009) instead of changing the thought content, thus offering a different way of being with psychological distress (Omidi et al. 2013). As the cultivation of mindfulness involves an experiential approach, it must be practiced to be fully understood (Kabat-Zinn 1991). The pioneering and successful evidence-based MBSR program (Kabat-Zinn 1991) has led to the generation of several variations and off-shoots of this MBI. Many MBIs make use of MBSR’s essential components and practices, which include:

…mindful movement (gentle hatha yoga with an emphasis on mindful awareness of the body); the body scan (designed to systematically, region by region, cultivate awareness of the body…without the tensing and relaxing of muscle groups associated with progressive relaxation); and sitting meditation (awareness of the breath and systematic widening the field of awareness to include all four foundations of mindfulness: awareness of the body, feeling tone, mental states and mental contents… (Cullen 2011, p. 224).

MBSR, like other MBIs, assumes that humans can gradually develop sustained attention to mental content through regular practice of mindful awareness (formally and informally), and that this moment-to-moment awareness can generate a more vibrant sense of living and less mental reactivity (Grossman et al. 2004).

Mindfulness is also a psychological resource that aids in managing uncomfortable physiological arousal that often accompanies psychological trauma (van der Kolk 2006, 2015). People who have experienced significant and complex trauma, as is often the case for LGBTQ populations, need to develop the capacity to undo trauma-specific physiological sensations that are connected to trauma-related emotions and cognitions. Dr. Bessel van der Kolk (2015), a leader in the research and treatment of trauma, posits that becoming mindful (i.e. observing internal experiences such as bodily sensations, emotions and thoughts) is necessary to work with trauma. Based on extensive empirical research, he argues that a person who has experienced trauma needs to learn to experience safety in their bodies, and that mindfulness helps make it possible to achieve this due to the compassionate and curious stance taken in mindfulness practices. In light of the research evidence, SGMY may benefit from a culturally-specific practice approach that teaches practical skills, such as mindfulness, and affirms SGM identities to better cope with stressors.

A growing body of literature strongly suggests that empirically supported MBIs for youth—including marginalized youth (e.g. racial and ethnic minority youth; those with low-income backgrounds; those involved with mental health systems or child protection) (Fuchs et al. 2013)—provide solid mental health coping skills (Burke 2010; Semple et al. 2005; Tan 2016; Zoogman et al. 2015). At this writing, no research studies with youth have compared MBIs with other active treatment interventions. However, randomized controlled-trials of standardized MBIs (e.g. MBSR, MBCT) with adults have found moderate effect sizes with respect to a range of mental health problems, when compared with other active treatments such as cognitive behavioral therapy (CBT) (De Vibe et al. 2012; Khoury et al. 2013; Tan 2016). What we do know about MBI studies is that participating youth have derived positive mental health outcomes from mindfulness practices (Tan 2016). For example, one study found that a school MBI called Learning to Breathe resulted in significant improvements in emotion regulation and psychosomatic complaints, as well as lowered perceived stress in a large sample of youth (n = 216) (Metz et al. 2013). However, the study relied only on self-report measures and did not use randomization. A study in the United Kingdom by Kuyken and colleagues (2013) explored the feasibility of a MBI (based on MBSR and MBCT) delivered in British schools to promote mental health, and social and emotional competence (n = 522). The authors found that there was a significant reduction in depression scores at post-intervention, after adjusting for gender, age and ethnicity. Results also suggested enhanced well-being, and lower stress and depression at the 3-month follow-up.

Himelstein and colleagues (2012) investigated the experience of incarcerated male youth (n = 23) who participated in an adapted MBI. Participants reported an increase in well-being, self-regulation, awareness, and that the treatment was acceptable. Biegel and colleagues (2009) conducted a major randomized control trial with youth psychiatric outpatients (n = 102), utilizing an adapted MBSR protocol. Compared to the control group, there was a significant increase in self-esteem and GAF scores, and a significant reduction in anxiety, depression, stress, interpersonal problems, and psychiatric diagnoses. Barnert and colleagues (2014) report results of increased self-regulation and a sense of well-being in youth in a correctional setting. Other studies suggest an improvement in ADHD in youth after participation in MBIs (e.g. Haydicky et al. 2015; Van de Weijer-Bergsma et al. 2012). Another study explored the feasibility of an adapted MBI for African American youth living with HIV; participants reported enhanced self-efficacy, improved psychological well-being and quality of life (Sibinga et al. 2008). Tan (2016), in providing a recent critical review of MBIs and programs for youth, states that MBIs continue to be implemented safely in a variety of settings.

The current youth literature reflects limited empirical research on effective mental health interventions in the helping professions (e.g. social work, psychology, nursing) for working with SGMY (Austin and Craig 2015; Craig et al. 2013; Horn et al. 2009). As traditional mental health interventions are not addressing the psychological and emotional stressors SGMY experience (Craig et al. 2012), there is a great need for innovative mental health interventions for SGMY (Austin and Craig 2015; Craig and Austin 2016; Williams et al. 2005). While the mindfulness intervention literature has mainly focused on adult populations, mindfulness research with youth has begun showing that these interventions significantly increase mental health in youth (Biegel et al. 2009; Burke 2010; Zoogman et al. 2015).

Mindfulness practice has been shown to reduce mental health symptoms commonly reported in the SGMY literature, such as stress, depression, anxiety, and interpersonal challenges (Ernould 2013; Neff and Tirch 2013; Segal et al. 2002; Tan 2016). MBIs may help SGMY because they aid in helping one to cope better with stressful situations by increasing psychological flexibility (i.e. a dynamic process that allows for adapting to changing situational demands and shifts perspective) and creating mental space to make healthier choices in the face of adversity (Kashdan 2010; Semple et al. 2010). For example, SGMY may, through the cultivation of mindfulness, be better able to tolerate difficult emotions (Grabovac et al. 2011; Holzel et al. 2011), and use emotions and thoughts in a healthier manner (e.g. relating more gently with difficult thoughts and feelings) in various situations (Kashdan 2010). Mindfulness may be beneficial for many SGMY, as it is regarded as an approach that can be learned (Gilbert 2009; Segal et al. 2002). MBIs also teach skills that cultivate a gentle and compassionate awareness that helps with an intentional examination of the self, conditioned beliefs, stories and traumas; an important component for work with SGMY due to the elevated levels of psychological distress they experience (Marshal et al. 2011, 2013). Even if acceptance of psychological distress is not possible in a particular moment, SGMY may learn to gradually tolerate distress by bringing compassionate awareness to their experience of pain.

Despite the absence of research on MBIs for SGMY, some research with SGM adults points to the important role mindfulness plays in helping them cope better with various psychosocial issues. For example, a randomized controlled trial of a MBI for gay men living with HIV has been shown to significantly improve depression, increase positive affect, and increase mindfulness, compared to a control group at post-test (Gayner et al. 2012). Other studies suggest that self-compassion, which is a quality cultivated through the practice of mindfulness, helps SGM individuals enhance mental health by providing emotional safety during the coming-out process (Crews 2012). Chandler (2013) found that self-compassion, cultivated through mindfulness, predicted lowered self-stigma and fear of negative evaluation, and increased positive mood in a sample of SGM individuals. While this research is minimal, it suggests that mindfulness may be helpful for SGMY experiencing similar LGBTQ-specific problems. Teaching mindfulness skills to SGMY through MBIs may help ensure that they are receiving the best possible care from mental health professionals.

While not prescriptive, affirmative practice does provide general principles (i.e. affirm LGBTQ identity, explore oppression and discrimination, etc.) to guide mental health practice with SGMY (Van Den Bergh and Crisp 2004), making it a flexible approach that can incorporate mindfulness-based skills training. This approach places a specific focus on LGBTQ themes, which include: coming out, identity issues, high-risk sexual behaviors, internalized homo/bi/transphobia, relationship and familial matters, and the role of social support. Affirmative practice aims to enhance coping and resilience related to LGBTQ-specific minority stress and stigma. While SGMY clinical practice literature is relatively sparse, recently some promising research studies have demonstrated that affirmative-based interventions for SGMY are associated with a significant increase in self-efficacy, self-esteem, proactive coping and greater well-being in SGMY; however, further systematic investigation is needed as research in this area is relatively new (Craig 2012, 2013; Craig and Austin 2016; Craig et al. 2012). As SGMY face unique biases and challenges compared to other youth, an affirmative practice adaptation for evidence-based interventions, such as MBIs, may help address the specific needs of this underserved group (Austin and Craig 2015). Consistent with adaptation literature (Austin and Craig 2015; Diaz-Martinez et al. 2010; Interian et al. 2010), adapting MBIs for SGMY should retain core effective components of the intervention while “grounding the intervention in an affirmative framework to improve its cultural relevance” for SGMY (Austin and Craig 2015, p. 569).

MBIs may be particularly important for SGMY as a marginalized group in society because the therapeutic stance in MBIs is that sociopolitical and historical factors impact the way people experience and express distress (Fuchs et al. 2013; Hayes et al. 2006). MBIs offer SGMY the opportunity for acknowledgment and validation of the structural and systemic oppression they experience while also encouraging them to identify where they can exercise power and control in their lives in order to support them moving towards what matters most to them (Fuchs et al. 2013; Hick and Furlotte 2010).

The following case study, based on actual psychotherapy work with a SGMY client named “Amanda”, and the author’s clinical experience utilizing evidence-based mindfulness approaches with SGMY, will be used to examine the successful application of an affirmative mindfulness therapeutic approach for SGMY. The author chose this example, with the express permission from the client and disguised information to protect confidentiality, to provide anecdotal evidence that this approach can be effective with SGMY. See Table 1 for an outline of important steps for integrating both affirmative and mindfulness-based therapeutic approaches with SGMY. The steps in Table 1 are intended to be used as a guideline for treatment planning.

Amanda identifies as a lesbian 15-year-old South Asian female. Weekly therapy with Amanda began when she was referred to the author by a community-based agency. The therapy sessions were voluntary and provided in an outpatient clinical setting that focuses on LGBTQ communities. Amanda attended therapy for approximately 8 months, starting with weekly sessions, then biweekly, and finally monthly in the last couple of months. Based on a thorough biopsychosocial assessment, Amanda experienced significant anxiety related to her sexuality and found it hard to concentrate at school. Amanda was having a hard time accepting her sexuality and was not out to anyone. She experienced worried thoughts and heart palpitations when thinking about her sexuality, as well as anxiety-related irritability and tension in the body.

The first couple of sessions with Amanda involved building rapport, engaging in psychoeducation and discussion on the stress response (physiological, affective and cognitive reactions), and how mindfulness could help with managing worried thoughts, stress and anxiety. This discussion also involved psychoeducation on the mental health effects of minority stress, discrimination, and LGBTQ stigma. While not all problems SGMY present with in session will be related to their sexual/gender identities, it is important to assess for the impact of minority stress and provide space to discuss its potential impacts on their mental health. An affirmative practice approach with Amanda also involved identifying and building social supports and role models. This exploration involved determining ways Amanda could connect with other LGBTQ people, as well as identifying barriers to making connections.

Once mindfulness and its benefits were thoroughly discussed, mindfulness instruction and practice (e.g. mindfulness of breath, mindfulness of sounds, body-scan) were introduced to Amanda and practiced for approximately 3–5 min per exercise. Within the mindfulness evidence-base for youth, there are a variety of skills that may be particularly useful for SGMY, such as: insight meditation (awareness of all arising and passing mental and physical sensations), concentration meditation (one-pointed focus on a particular object such as the breath), and mindful body-scan (Burke 2010; Kabat-Zinn 1991; Tan 2016). These do not have to be practiced for long periods (as little as 5 min per day). After practicing each exercise with Amanda, a debrief on the impact of the practice occurred. Following these practices, Amanda and the author collaborated on a suitable homework assignment to practice mindfulness. Amanda ended up choosing daily practice of mindful breathing for 3–5 min before bed and when she felt stressed and anxious. Subsequent sessions with Amanda involved further establishment of mindfulness by practicing exercises already introduced at the beginning of treatment. Carving out segments of each session to engage in mindfulness practices and debriefing will help SGMY develop their mindfulness skills and reinforce the rationale for using mindfulness to address stress and anxiety.

It was also important to discuss internalized oppression (i.e. internalized homo/bi/transphobia) with Amanda to determine how this was impacting her. Exploring whether SGMY are experiencing high levels of internalized oppression is a critical mental health task, as it can have an adverse impact on their well-being and functioning. Working with Amanda involved utilizing mindfulness skills—such as bringing moment-to-moment awareness to what she was experiencing in session—and an affirmative stance to support her to gently and compassionately touch the pain and suffering she was experiencing as a result of internalized homophobia, racism and other forms of oppression. This process was particularly challenging for Amanda, however it allowed her to see how her experiences are a part of a larger sociocultural production, helped bring some soothing and distance to her emotional pain, and helped her relate to the pain in a more self-compassionate manner (Neff and Germer 2013).

In line with an affirmative practice approach, therapeutic work with Amanda also involved consciousness-raising. Consciousness-raising is a process that involves the exploration, and opening up of the sociopolitical dimensions that adversely impact one’s life (Hick and Furlotte 2010). This reflexive process aims to enhance awareness of our experiences in the context of oppressive social and structural systems (Fook 2002). Mindfully engaging in this reflexive process of consciousness-raising with Amanda first involved practicing mindful awareness (e.g. mindfulness of the body). Following this establishment of mindful awareness, the author then engaged Amanda in a discussion to help build understanding of her sexuality in the context of cultural, systemic and societal negative messages about LGBTQ people. While Amanda found this process challenging and painful at times, the author supported Amanda to remain mindful by encouraging her to continually bring awareness of her bodily sensations, emotions, and thoughts related to negative LGBTQ messages as the sessions progressed. As mindfulness can aid in enhancing awareness, it may potentially make it easier for SGMY to resist negative self-narratives and create their own alternative narratives that enhance a greater sense of well-being and self-worth (Heinonen and Spearman 2001). This mindful process may also be helpful to explore how SGMY’s “problems” are not naturally occurring but are the result of various positions imposed by innumerable powerful discourses (Sinclair and Monk 2005).

Berila (2014) posits that internalized oppression, such as internalized homophobia and transphobia, is not only contained in our minds but is also felt in our bodies, operating beyond an intellectual level. Encouraging Amanda to engage in gentle, compassionate and mindful curiosity about her experiences (e.g. mindfully connecting with her bodily sensations, emotions and thoughts), helped her build resilience and unlearn internalized oppression (Dominelli 2002; Fook 2002; Wong 2004). This approach is not a quick fix, however (Brito 2013), but is well worth cultivating as it may allow for the discovery and honoring of marginalized and embodied knowledge (Wong 2004). This marginalized knowledge, discovered by cultivating a gentle awareness through mindfulness practice, can help cultivate a more compassionate stance, greeting “discomfort with a gentle smile and a friendly hello” (Wong 2004, p. 5).

One particularly important mindfulness practice that was used with Amanda when she experienced psychological distress was the Three Minute Breathing Space (Segal et al. 2002). This portable and brief informal practice helped Amanda to ground herself when she experienced psychological distress (Segal et al. 2002). In discussing this practice with Amanda, the author explained that this practice involves bringing awareness to the present moment when she feels distress (e.g. when she experiences heart palpitations and tensions in the body). Amanda was first instructed to acknowledge her experience of pain, noting what she was thinking and feeling (e.g. “I feel my heart racing, and anxiety”). Following this acknowledgment, she then gently redirected attention to her breathing for a minute or so, and finally she expanded her field of awareness to include a sense of the whole body. This portable mindfulness exercise was supported by her regular practice of mindfulness in session, as well as by her mindfulness homework practices. The Three Minute Breathing Space may help SGMY get in touch with themselves and can be prescribed to be used throughout the day or whenever they are feeling stressed (Segal et al. 2002). For a more detailed review and instructions, this exercise is described in detail elsewhere (Segal et al. 2002).

SGMY are trailblazers when it comes to rocking the foundations of modernist notions of sexual and gender identity (Savin-Williams 2005). In working with Amanda, it was important to explore how she experienced her multiple (e.g. lesbian, female, South Asian, etc.) and fluid identities. Engaging in mindful discussions with Amanda about identity was helpful in shedding light on how categories are constructed, and in questioning her deeply held assumptions about her sexual identity. These mindful discussions (which included bringing acknowledgment and awareness of her embodied experience) led to a more open way of being for Amanda, a deeper appreciation and understanding of her resilience and strengths (Germer 2009), and laid the groundwork for addressing intersecting forms of marginalization (e.g. problem-solving, advocacy, etc.). Mindfulness may help SGMY cultivate new insights about themselves that can foster identity construction exploration. For instance, from a Buddhist psychology perspective, there is great emphasis on the constructed nature of the “self”. What is seen as “truth” is fluid and constructed through our perceptions; this sense of the self and reality may lead to deconstruction and identity transformation (of self-critical views of self and identity) through the practice of mindfulness (Mayer 2014). Foucault (1978) has described this fluid construction of self and experience as the non-existence of a fixed reality (Mayer 2014). Thus, through mindfulness, SGMY can be supported in the process of identity construction.

Ultimately, incorporating mindfulness and an affirmative approach helped Amanda develop a sense of calmness and grounding, and helped shift her relationship with her cognitions, deeply held negative beliefs and emotions that contributed to psychological distress (Brito 2013). Amanda initially experienced significant feelings of shame related to her sexual identity; helping her bring an intentional attitude of patience, compassion and non-striving, cultivated through simple mindfulness practices (e.g. mindfulness of breath; body scan) allowed for the development and construction of a healthy relationship with herself, as well as the development and capacity to experience comfort in her suffering (Shapiro et al. 2006). In the process, Amanda also came out to her parents and close friends, and was able to meaningfully connect with LGBTQ community supports to build her social support network. Coming out and building a social support network was quite difficult for Amanda; this hard work involved bringing mindfulness to difficult beliefs related to being out and connecting with others, while simultaneously bringing a sense of gentleness and self-compassion to her process. Although Amanda continued to struggle with minority stress and navigating intersections of her identities, she reported a significant reduction in anxiety, an improvement in concentration, feeling more empowered, and increased comfort with her sexuality at the end of treatment.

As traditional mental health approaches are not meeting the myriad of mental health needs of SGMY, mental health interventions that affirm the lives of SGMY and address LGBTQ-specific minority stressors are desperately needed (Craig and Austin 2016; Kelleher 2009). Furthermore, in light of the research evidence, an adapted MBI that provides an LGBTQ-affirmative foundation, may be helpful in addressing this glaring gap in effective treatments for SGMY. Some limitations of this approach do exist. First, mental health professionals must consider the values and beliefs of SGMY before suggesting or integrating Buddhist-informed practices. Despite the fact that MBIs are secularized in the West, SGMY may be reluctant to use skills that are rooted in a spiritual context (Strauss and Northcut 2014). Second, mental health professionals also need to be trained in providing MBIs to SGMY. Fortunately, there are many mindfulness professional training opportunities for youth that are provided at low-cost. Third, mental health professionals that teach mindfulness also need to have some sort of personal mindfulness practice to be able to support the teaching and modelling of mindfulness to SGMY (Grepmair et al. 2007; May and O’Donovan 2007). Ultimately, this proposed model of practice—integrating mindfulness and affirmative practice—could provide an effective approach for working with vulnerable SGMY. This approach may be empirically evaluated through outcome-based intervention research. It may also be adapted for individual or group practice. While great gains have been made in society (e.g. legal, policy, and structural changes) that will help improve the lives of SGMY, these changes take time. In the interim, SGMY are in great need of effective mental health support in order to flourish (Russell and Fish 2016). An LGBTQ-affirmative MBI is one approach worth exploring.