3 - (SYM 130) Measuring In-session Lgbtq-affirmative Therapist Behavior: Development of the LGBTQ Identity Affirmation and Discussion Inventory (LADI) in a Community-based Treatment Sample

Introduction: LGBTQ-affirmative psychotherapy is supported by professional guidelines and mounting empirical evidence, yet little research has characterized the within-session processes that constitute affirmative care and how they relate to client outcome. To fill this gap, this study provides initial reliability and validity data for an observational measure of LGBTQ-affirmative psychotherapy activity and discussion with gay/bisexual men who received 10 sessions of community-based treatment-as-usual in two LGBTQ-affirmative mental health clinics as part of a randomized controlled trial.

Methods: A checklist (10 yes/no items) was drafted based on core LGBTQ-affirmative psychotherapy processes identified in prior research. Early (session 2/3) and middle (session 5/6) psychotherapy sessions were coded by doctoral-level raters (N = 57 clients, n = 114 sessions) and averaged across sessions. Clients completed 4-, 8-, and 12-month follow-up assessments of observer-rated depressive symptoms and self-reported anxiety and identity-based internalized stigma, rejection sensitivity, concealment, and self-affirmation. To examine interrater reliability, we tested overall score agreement via intraclass correlation coefficients and item-by-item observer agreement via Holley and Guilford’s G (akin to kappa). To examine validity, we tested associations between LADI scores and changes in mental health and identity-based stigma in multilevel models.

Results: Observers exhibited strong interrater reliability (ICC = .886 early session; ICC = .764 middle session). Item-by-item reliability ranged from fair to excellent (G = 0.40-1.00, M = 0.79). When therapists exhibited higher average observer-rated LGBTQ identity affirmation and discussion scores, their clients exhibited stronger decreases in observer-rated depressive symptoms (b = -0.70, p = .011, DR² = 3.3%) and self-reported internalized stigma (b = -0.04, p = .044, DR² = 0.6%). LADI scores were not significantly related to changes in anxiety, rejection sensitivity, concealment, or self-affirmation.

Conclusions: Results provide evidence that the LADI is a reliable and valid measure of LGBTQ identity affirmation and discussion in psychotherapy. Independent raters agree on the presence of LGBTQ-affirmative activity, which predicts stronger improvements in mental health and minority stress. Results can inform practice (e.g., helping therapists maximize treatment outcome) and future research (e.g., presence of LGBTQ affirmation in community-based psychotherapy).