AWARENESS: Development of a Cognitive Behavioral Intervention to Address Intersectional Minority Stress for Sexual Minority Men Living with HIV who Use Substances

Abstract

Sexual minority (i.e., non-heterosexual) individuals are at greater risk than heterosexual individuals for substance use and poor mental health attributed to exposure to minority stress (Meyer, 2003). Minority stress is stress that places an additional burden on sexual minority people over and above the stress experienced by heterosexual people. Sexual minority men may also be subject to minority stress related to intersecting identities or individual characteristics (e.g., HIV status, race). This study obtained initial feedback about the AWARENESS intervention from sexual minority men living with HIV who use substances and determined the feasibility of the intervention to address minority stress related to intersecting identities. AWARENESS is a 9-session cognitive behavioral intervention targeting minority stress as a driver of greater substance use and poorer mental and physical health. Ten sexual minority men living with HIV who were episodic substance users (>1 episode of illicit drug use or binge drinking in the previous 3 months) began the intervention. Feedback on the intervention was obtained through open-ended interviews analyzed using thematic analysis and Likert scale questionnaires about experiences with the intervention. Therapists tracked identities discussed in relation to minority stress to evaluate feasibility of AWARENESS to address intersectional minority stress. Participants identified they gained cognitive behavioral skills to cope with intersectional minority stress and described destigmatization and integration of identities. Participants discussed an average of 3.2 identity characteristics in addition to sexual minority status in relation to intervention content. This study lays the groundwork for additional testing of this intervention.

Sexual minority (i.e., non-heterosexual) individuals experience higher rates of substance use (Green & Feinstein, 2012), mental health disorders (King et al., 2008), and health related distress and problems (Cochran & Mays, 2007; Conron, Mimiaga, & Landers, 2010) when compared to heterosexual individuals. Meyer’s (1995, 2003) model of minority stress attributes these health disparities to the additional stress burden that is placed upon sexual minority populations that is over and above the stress experienced by heterosexual people. Meyer outlines both proximal and distal stress processes specific to sexual minority individuals including: experiences of prejudice and discrimination, expectations of discrimination, concealment of sexual orientation, and internalization of social stigma. These stress processes, hereafter referred to as minority stress, are related to greater substance use (Livingston, Flentje, Heck, Szalda-Petree, & Cochran, 2017; McCabe, Bostwick, Hughes, West, & Boyd, 2010) and poorer mental (Meyer, 2003) and physical health (Cole, Kemeny, Taylor, & Visscher, 1996; Cole, Kemeny, Taylor, Visscher, & Fahey, 1996; Frost, Lehavot, & Meyer, 2015) among sexual minority people. Minority stress is theorized to cause these poorer health outcomes among sexual minority people (Meyer, 2003).

Meyer’s minority stress model has been extended to incorporate “multiple minority stress” (Bowleg, Huang, Brooks, Black, & Burkholder, 2003, p. 87) among individuals with intersecting minority identities or individual characteristics such as HIV-status, sexual orientation, race, and socioeconomic status (Bowleg, 2012; Bowleg et al., 2003). Multiple minority statuses can confer additional risk for exposure to minority stress (Meyer, Schwartz, & Frost, 2008). Importantly, additional minority statuses do not unilaterally confer additional risk for health disparities, for example, when considering race or ethnicity, rates of mental health disorders among Black sexual minority people are lower than White sexual minority people (Meyer, Dietrich, & Schwartz, 2008) and rates of mental health disorders among Latino sexual minority people are similar to (Meyer, Dietrich, et al., 2008) or lower than (Cochran, Mays, Alegria, Ortega, & Takeuchi, 2007) rates among White sexual minority people. HIV-specific stress has been incorporated into the minority stress model as contributing to an additional burden of stress among sexual minority men living with HIV (Rendina et al., 2017). Structural and individual level stigma related to intersecting identities can exacerbate the health disparities seen related to HIV risk, testing, treatment, and outcomes (Earnshaw, Bogart, Dovidio, & Williams, 2013). Furthermore, minority stress, substance use, and poor mental health are related to poorer HIV health outcomes (e.g., Carrico et al., 2014; Cole, Kemeny, Taylor, Visscher, et al., 1996; Leserman, 2008) highlighting the importance of addressing minority stress, substance use, and mental health among people living with HIV.

Minority stress in the form of discrimination is related to greater rates of substance use among sexual minority people (McCabe et al., 2010). Recent research using ecological momentary assessment shows that when non-clinical samples of sexual minority individuals encounter mistreatment due to their sexual orientation (i.e., a distal stressor), they are more likely to subsequently (i.e., in the next several hours) engage in substance use (Livingston et al., 2017). It has also been shown using ecological momentary assessment that sexual minority men living with HIV who experience HIV-related stigma are more likely to subsequently experience emotion dysregulation and use stimulants (Rendina, Millar, & Parsons, 2018). Rates of recent substance use are high among sexual minority men living with HIV (e.g., >50%, O׳Cleirigh, Magidson, Skeer, Mayer, & Safren, 2015), and while people living with HIV who use substances can have high rates of antiretroviral adherence and undetectable viral load, greater severity and frequency of substance use has been linked to poorer virologic control and HIV progression (Carrico et al., 2014; Nolan et al., 2017). Taken together, this suggests that reducing experiences of intersectional minority stress or improving coping with intersectional minority stress has the potential to reduce substance use and thereby improve health outcomes among sexual minority men living with HIV.

Individualized interventions that target intersectional minority stress processes can support sexual minority men living with HIV. Interventions are needed that are built upon a unifying framework (the minority stress model) for a specific population (sexual minority men) but that can be adapted to the intersectional minority stress processes (e.g., related to HIV-status, sexual orientation, race, income, gender expression) and the detrimental impacts (e.g., substance use, mood, anxiety, HIV treatment adherence) that are most relevant to the individual. This approach is consistent with the identity salience model, which posits that in order to integrate multiple identities into a therapeutic intervention, clinicians should follow the patient’s lead on which aspects of their identity are most salient at a given time (Yakushko, Davidson, & Williams, 2009). The identity salience model may be particularly relevant to an intervention designed to impact intersectional minority stress processes as recent work shows that poorer mental health is associated with stigma experienced in relation to the individual’s most important self-rated identity characteristic (Rodriguez-Seijas, Burton, Adeyinka, & Pachankis, 2019). The flexibility of this approach allows the sexual minority individual living with HIV to discuss components of their identity that may be relevant to a particular component of minority stress (e.g., HIV status, sexual orientation, or a disability status that is not visible to others as related to concealment), while not attempting to apply components of one’s identity that are not relevant to a specific element of minority stress (e.g., a visible disability status or visible racial minority identity as relevant to concealment for an in person interaction). This approach also builds upon the concept of generalization, meaning that teaching an individual skills in one context (e.g., as applied to sexual orientation or gender expression) may later empower the individual to generalize these skills to another context (e.g., when experiencing discrimination due to health status) and is enhanced by the similarity of these situations (i.e., discrimination or mistreatment from others) and the support provided to practice skills (Fischer & Farrar, 1987) related to multiple identities. An intervention that is built upon the minority stress model as a unifying framework for coping with stigma due to intersectional minority identities stands to enhance the generalization of these skills to intersecting minority statuses as they arise or as their salience changes as can occur with identity characteristics in response to external cues (e.g., with race, Shelton & Sellers, 2000). Such an intervention could then be used by psychotherapists who have limited experience bolstering their clients’ capacities to cope with minority stress. Recent work indicates that an individually delivered affirmative intervention targeting minority stress within the context of mental health treatment shows promise in improving mental health among sexual minority men (Pachankis et al., 2016), further strengthening the rationale for developing individually delivered interventions for sexual minority men living with HIV who use substances.

Cognitive Behavioral Methods to Improve Coping

As applied to minority stress, coping strategies that target minority stress can be developed in partnership with the individual to modify how they respond to and interact with their environment. Minority stressors can impact both mood and substance use within hours (Livingston et al., 2017; Rendina et al., 2018), suggesting that increasing coping capacity for minority stress could potentially interrupt the process that ultimately leads to poorer mental and physical health outcomes through either the accumulation of episodes of substance use, which could result in the development of a substance use disorder, or of psychological distress, potentially before these behaviors or experiences become problematic. Cognitive behavioral methods are particularly well suited to coping with minority stress among sexual minority people because they take social context into account, can provide skills to help sexual minority people cope with minority stress, and they allow for reevaluation of beliefs reflecting internalized stigma (Balsam, Martell, & Safren, 2006). Additionally, several interventions using cognitive behavioral methods show promise in integrating minority stress components among sexual minority men (Bogart et al., 2018; Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015; Ross, Doctor, Dimito, Kuehl, & Armstrong, 2007), or in reducing stress related to HIV among sexual minority men living with HIV (Antoni, Cruess, Cruess, Lutgendorf, et al., 2000; Antoni, Cruess, Cruess, Kumar, et al., 2000; Lutgendorf et al., 1998). An intervention to help people cope with minority stress could be mapped onto the minority stress model. This intervention could support the individual in responding to distal stressors including the interpretation of and responses to external discriminatory, prejudice, or victimization events related to minority status or individual characteristics. The intervention could also aid the individual in coping with proximal stressors including: cognitive models and behavioral correlates of expectations of prejudice events reoccurring, choices made in interacting with the environment in regard to openness about or concealment of their individual characteristics (e.g., sexual minority status, HIV status), and challenging of internalized stigmatizing beliefs about minority statuses or individual characteristics. The premise of such an intervention is that the minority stress model can empower the individual with the knowledge that minority stress may have a negative impact on them in their day to day lives, that they are not to blame for these impacts, and they can gain coping skills and make conscious decisions in how to cope with these stressors.

Previous Interventions

Multiple clinical and research efforts have integrated the minority stress model into cognitive and behavioral interventions. Cognitive behavioral therapies have been used to treat a diverse range of problems among sexual minority people, including clinical applications for addressing specific types of minority stress such as stigmatizing beliefs (Martell, Safren, and Prince (2004). Clinicians have been integrating the minority stress model into cognitive behavioral practice for many years (e.g., see Balsam et al., 2006, Craig, Austin, and Alessi, 2013, Satterfield & Crabb, 2010, Walsh & Hope, 2010 for pertinent case examples). Empirical studies have examined potential interventions to reduce the impacts of minority stress. Cognitive behavioral group therapy modified to target minority stress processes, including concealment/openness about sexual orientation and internalized stigma, has been shown to reduce depression and increase self-esteem for sexual and gender minority people (Ross et al., 2007). A newly developed group intervention used cognitive behavioral methods to help Black sexual minority men living with HIV cope with discrimination related to intersecting identities (Bogart et al., 2018). An intervention adapted from the Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders (Ellard, Fairholme, Boisseau, Farchione, & Barlow, 2010) and informed by the minority stress model (Burton, Wang, & Pachankis, 2019) reduced depression, alcohol use, and sexual compulsivity in sexual minority men (Pachankis et al., 2015). Furthermore, cognitive behavioral interventions targeting stress management have been shown to improve social supports and coping (Lutgendorf et al., 1998), improve mood, anxiety and reduce psychoneuroimmunological markers of stress (Antoni, Cruess, Cruess, Lutgendorf, et al., 2000; Antoni, Cruess, Cruess, Kumar, et al., 2000), among sexual minority men living with HIV. In sum, distress that results from minority stress among sexual minority men living with HIV is amenable to cognitive behavioral intervention.

Specific Strategies within a Minority Stress Intervention

Several methods and techniques derived from classic cognitive behavioral methods (Beck, 2011) may be applied to sexual minority people (Balsam et al., 2006; Martell et al., 2004; Safren, Hollander, Hart, & Heimberg, 2001) and should be considered within a minority stress intervention. First, psychoeducation about minority stress and its impacts may enable the client to recognize stressors when they occur and identify the impacts within the client’s life. Additionally, identifying the relationships between minority stressors and thoughts, feelings, and behaviors is central to interrupting minority stress processes and a core process of cognitive behavioral therapy. Reduction of avoidance behaviors and reevaluation of cognitions around safety or anticipated discrimination is also an important component of a minority stress intervention. Safety-maintaining behaviors can become automatic once they are established (e.g., a person who doesn’t walk down a street where they were once called a gay slur), and may not be reconsidered after they are established. These established ways of interacting with one’s environment can maintain problematic behaviors such as avoidance behavior. Particularly in light of rapidly changing social environments for sexual minority people (Meyer, 2016), encouraging accurate and present focused evaluation of safety may be important in reducing the impact of minority stress. In addition, a minority stress intervention can also encompass many of the structural components of cognitive behavioral methods including a brief format; structured and directive intervention sessions; and between session assignments to encourage generalization of skills, behavioral experiments, and tracking of relevant thoughts, feelings, and behaviors.

In addition to methods pulled from classic cognitive behavioral therapy, an intervention targeting minority stress can also be informed by strategies and processes derived from newer cognitive behavioral therapies including acceptance, values clarification, and mindfulness (e.g. focused attention and thought observation), processes that have expanded cognitive behavioral practice (Hayes & Hofmann, 2017). These newer strategies may be helpful as they can provide support for the individual who may be encountering a hostile environment in which rational and accurate cognitions may have negative impacts on well-being and thus are not amenable to being challenged or replaced (e.g., one may actually endure harassment or discriminatory treatment at work if coworkers are aware of one’s minority sexual orientation, HIV status, or other status). In this case, acceptance strategies, in addition to making conscious, value-driven decisions about how to respond (e.g., when to challenge the social environment), may enable the individual to better tolerate the stressor. Values clarification has been proposed as a way to free oneself from the values put upon them from the outside, and instead recognize and move forward with one’s own values (Shapiro, Carlson, Astin, & Freedman, 2006). Values clarification can help the individual to clarify how they would like to respond to minority stressors and/or to weigh the decisions they make in response to these stressors (e.g., when to conceal versus be open about their sexual orientation or HIV status). It can also help sexual minority individuals living with HIV to separate themselves from heterosexist values or stigma associated with HIV or other minority statuses that may be adopted from others. Additionally, being able to take a step back from one’s thoughts is a tenet of mindfulness (Shapiro et al., 2006), which can allow the individual to tolerate challenging thoughts that may be difficult or not amenable to change. The skill of focusing one’s attention, also a component of mindfulness (Shapiro et al., 2006) may also aid the individual in tolerating minority stress. Focused attention, can enable the individual to attend to their environment in the present moment, developing a skill that can help the individual to notice their surroundings and their internal experiences, as well as tolerate distress. This skill has implications for enabling the individual to make more accurate assessments of safety in their present environment, rather than presumed assessments of safety based on previous experiences or thoughts, attend to how their internal experiences may be impacted by minority stressors, and tolerate distress associated with minority stress.

In addition to coping strategies that have been established within the context of mental health interventions and can be adapted to be applied to minority stress, additional strategies may be adopted from coping that is used by people within the sexual minority community. In their qualitative study examining coping strategies for minority stress Madsen and Green (2012) identified several strategies used by adolescent sexual minority men including confronting the person who was responsible for the stressor, engaging in activism, participating in an activity that distracted from the stressor, getting emotional support from others, coping with feelings, and making conscious decisions about how to respond to the event. Incorporating strategies already used by people within sexual minority communities builds upon the idea that minority individuals have well developed patterns of coping which can be informative to intervention development, but may also benefit from evaluation of their coping to identify if it is in line with personal values (Bogart et al., 2017).

Finally, Stress and Coping theory suggests the importance of reappraising stressful events to identify positive benefits of the experiences (Folkman, 1997; Folkman & Moskowitz, 2000, 2004), thus a minority stress intervention should not only take an agnostic approach to the impacts of minority stressors on the individual (e.g., minority stressors may be interpreted by the individual to have enhanced community or made the individual more resilient), but should also seek to help the individual to identify the positive impacts of one’s minority status. This can be done through both attending to things that elicit feelings of pride and discussing the ways in which one’s minority status has improved their life.

Purpose of this Study

The purpose of this study was to get meaningful input and feedback from the community about an intervention developed to address intersectional minority stress among sexual minority men living with HIV: AWARENESS for Sexual Minorities: Approach the World with Acceptance, Respect, and Equity with New and Explicit Strategies for Self-Awareness. We also aimed to identify if it was feasible to use AWARENESS to discuss intersectional identities in relation to minority stress. AWARENESS is an individually delivered, 9–session cognitive behavioral intervention targeting intersectional minority stress as a transdiagnostic driver of greater substance use and poorer mental and physical health outcomes and intended for both clinical and subclinical populations impacted by minority stress. The structure, minority stress processes, and specific methods used in AWARENESS are outlined in Table 1. AWARENESS is different from previous individually delivered interventions as it is built upon the minority stress model as a unifying platform to develop skills for coping with stress due to intersecting identities and characteristics (e.g., HIV, race, or ethnicity) among sexual minority men living with HIV who use substances. It also includes specific tracking throughout the intervention of substance use, mood, and other selected target behaviors identified collaboratively by the therapist and client. AWARENESS was tested with sexual minority men living with HIV with, at minimum, episodic substance use. In its conception, AWARENESS was intended to intervene upon minority stress as a causal factor in poor substance use, mental health, and physical health outcomes, thus participants were recruited with only minimum substance use requirements as eligibility criteria and were not recruited on the basis of current distressing mental health symptoms. Initial feedback was obtained here through an open-pilot, using stage 1a of the stage model of developing behavioral therapies (Carroll & Nuro, 2002; Rounsaville, Carroll, & Onken, 2001) to support treatment development and revision. This study lays the groundwork for subsequent feasibility testing within a randomized controlled trial examining the potential for changes in substance use and mental health outcomes as well as biological function (e.g., gene expression) related to physical health.

Table 1:

Key components of a minority stress intervention

Structure
	Brief format
	Structured and directive sessions
	Between session assignments to encourage generalization of
	skills, behavioral experiments, and tracking of events,
	thoughts, feelings, and behaviors
Minority stress processes
	Discrimination/mistreatment/microaggressions
	Anticipation of discrimination or mistreatment/ hypervigilance
	Concealment or openness about identity
	Internalized stigma
Specific methods and processes
	History gathering about minority statuses and pertinent
	minority stress experiences
	Psychoeducation about minority stress and its impacts on
	physical and mental health
	Psychoeducation about the cognitive behavioral model
	Reduction of avoidance behaviors
	Identification and evaluation of cognitions
	Thought replacement
	Matching coping to the situation
	Skills for relaxation and distress tolerance
	Accurate assessment of safety in the present
	Acceptance
	Values clarification
	Conscious decision making in line with values
	Mindfulness: focused attention
	Mindfulness: thought observation
	Confrontation of others or speaking up
	Getting emotional support from others
	Reappraising events to identify positive benefits
	Attending to positive emotional experiences
	Summarization

Method

AWARENESS for Sexual Minorities was piloted with a target sample size of 10 sexual minority men living with HIV. Participants were told at the first session of the intervention that the purpose of this study was to get their feedback on this intervention, and that they would be asked questions about their experience with this intervention at the final session so that we could use that feedback to improve the intervention. Participants completed the 9-session intervention and follow-up interviews and rating scales regarding their experience with the intervention. Two doctoral level psychotherapists delivered the intervention. Participants received 10 total intervention sessions: a single session of Personalized Cognitive Counseling (PCC, an intervention designed to prevent HIV transmission, Coffin et al., 2014, Schwarcz et al., 2013, that was included to reduce sexual risk, which was not directly targeted by AWARENESS), then the 9 sessions of the AWARENESS intervention. The goal of this open pilot was to get meaningful feedback for revision of the intervention and identify the feasibility of using this intervention to address minority stress related to intersectional minority statuses, thus no control group was included. The [University of California, San Francisco] Institutional Review Board approved this study, which took place in [San Francisco, California].

Participants

We recruited participants with flyers in the community and at health clinics and through in person screening at community health clinics. The study was advertised as a “Stress Study” investigating a “talk therapy intervention to reduce stress” in men who have sex with men living with HIV. To be eligible for the study, participants had to: (1) be HIV-positive, (2) be cisgender men (due to biological measurements to be collected in the subsequent pilot RCT) at least 18 years of age, (3) have been sexually active with a male within 12 months of initial contact (this criterion was included because PCC discusses a recent sexual encounter), and (4) report at least one instance of drinking 5 or more drinks or using an illicit substance in the previous 3 months. Participants were excluded if they were (1) currently enrolled in substance abuse treatment (though they could rescreen after completing treatment), (2) met criteria for a severe substance use disorder (i.e., endorsing 6 or more symptoms of substance use disorder for one or more substances on the Mini-International Neuropsychiatric Interview [Hergueta, Baker, & Dunbar, 1998] adapted to be consistent with DSM-5 criteria for substance use disorder [American Psychiatric Association, 2013]), or (3) endorsed symptoms consistent with current psychosis or bipolar disorder. People who engage in moderate or episodic substance use were included, and those with severe substance use were excluded because AWARENESS was designed to reduce the impact of minority stress, thus acting upon what is believed to be the causal pathway between minority stress and poor substance use and mental health outcomes, and was not designed to directly treat substance use for people who may better be served by comprehensive substance abuse treatment services. AWARENESS was designed to target minority stress directly, rather than mental health problems within the context of minority stress, thus was trialed with individuals irrespective of mental health distress at the time of study enrollment.

Eleven participants completed informed consent and began the intervention, one participant was removed after the first intervention session due to active psychosis that was not detected in screening but became evident during the first session. Participants completed measures at the first session to provide descriptive information about the sample including basic demographic and psychosocial measures. The demographic and psychosocial information of the 10 participants is in Table 2. Participants primarily identified as gay (80%, n = 8), and White (50%, n = 5), with an average age of 47.8 (SD = 11.4; see Table 2 for demographic and clinical information). Participants had variability on screening measures at baseline indicating baseline depression (50% using the Patient Health Questionnaire-9 [PHQ-9]; Kroenke & Spitzer, 2002)), generalized anxiety (30% using the Generalized Anxiety Disorder-7 [GAD-7]; Spitzer, Kroenke, Williams, & Löwe, 2006), and harmful alcohol use (40% using the Alcohol Use Disorders Identification Test [AUDIT]; Babor, Higgins-Biddle, Saunders, & Monteiro, 1992), and consistently screened as at risk for substance use (100% at moderate or high risk for alcohol or another drug using the Alcohol, Smoking, and Substance Involvement Screening Test [ASSIST]; Humeniuk et al., 2008). Participants also reported a range of internalized stigma related to sexual orientation as measured by the Revised Internalized Homophobia Scale (IHP-R, M = 1.7, SD = 0.9, range 1–3.8, Herek, Gillis, & Cogan, 2009), and on sexual minority stress as measured by the Cultural Assessment for the Risk of Suicide (CARS, M = 14.6, SD = 6.4, range 5–21), where 14 or greater is indicative of moderate or severe sexual minority stress (Chu et al., 2013).

Table 2:

Baseline demographic and clinical information of 10 sexual minority men living with HIV who participated in the AWARENESS open pilot

Demographic and clinical information	n (%)
Sexual orientation
Gay	8 (80%)
Bisexual	2 (20%)
Age M (SD), Range	47.8 (11.4), 34–72
Race/ethnicity
Asian & Hispanic/Latino	1 (10%)
Black/African American	1 (10%)
Multiracial	2 (20%)
Prefer not to answer	1 (10%)
White	5 (50%)
Income
< $10,000	4 (40%)
$10,000–$20,000	2 (20%)
$20,000–$30,000	2 (20%)
$30,000–$40,000	2 (20%)
Education
High school graduate	2 (20%)
Some college	3 (30%)
2 year college degree	1(10%)
Masters degree	4 (40%)
PHQ-9 ≥ 10a	5 (50%)
GAD-7 ≥ 10a	3 (30%)
AUDIT ≥ 8a	4 (40%)
ASSIST
Moderate risk for alcohol or another drug	9 (90%)
High risk for alcohol or another drug	1 (10%)
IHP-R M (SD), range	1.7 (0.9), 1–3.8
CARS M (SD), range	14.6 (6.4), 5–21

^aThese represent commonly used cutoff scores for clinical screening indicative of depression, anxiety, or problematic alcohol use

Iterative Manual Development

Existing literature on minority stress, stress and coping theory, cognitive behavioral methods, and clinical and research work with sexual minority individuals who use substances and people living with HIV informed the initial intervention manual. Four senior and established investigators and clinicians with expertise in minority stress, stress and coping, sexual minority men, HIV, substance use, and cognitive behavioral methods reviewed the initial manual and the author revised the manual in response to their feedback, then sent the manual out for a second round of expert review. The manual author and an additional psychotherapist provided the intervention sessions reported here within this open pilot. Both of these interventionists had significant experience working with sexual minority men living with HIV who use substances and with cognitive behavioral therapy. They met regularly throughout the intervention to discuss participant cases, make notes about intervention components that could be improved, and discuss application of sessions and intervention methods to individual participants. The manual was trialed in this open-pilot with sexual minority men living with HIV to gain feedback from the participants and interventionists to inform intervention development and revision. The feedback reported here was taken into account along with session by session input from the therapists to revise the manual after the completion of this study.

Participant Procedures

Participants attended 10 study visits, and were given $50 for first and final visits, and $20 for visits 2–9. The baseline assessment was given just prior to the first session and the final assessment was given immediately following the final intervention session. The new intervention was delivered after a single session of PCC (Coffin et al., 2014; Santos et al., 2014; Schwarcz et al., 2013), which is a one-session intervention that focuses on reducing risk in sexual encounters by examining cognitions related to these encounters (PCC is not further described in sessions here as it has its own published manual and materials [University of California, San Francisco AIDS Health Project, 2017]). PCC was provided as a platform for the AWARENESS intervention as it is one of the few interventions that have been shown to be efficacious in reducing substance use among sexual minority men (Santos et al., 2014), thus AWARENESS was intended to boost the effects of the single session of PCC, though AWARENESS was ultimately delivered as a standalone intervention (i.e., without a session of PCC) in a subsequent pilot randomized controlled trial. Two sexual minority women with PhDs in Clinical Psychology delivered the intervention: the manual author and another interventionist familiar with cognitive behavioral methods. Separate assessors delivered assessment measures to participants before the intervention and solicited feedback about the intervention after the intervention was completed to reduce response bias.

Description of AWARENESS Sessions

AWARENESS consists of 9 intervention sessions. These sessions focus on minority stress, which is conceptualized and divided into 4 main components for the purposes of this intervention. Pairs of sessions focus on each of the 4 components, with the first session in each pair introducing the component of the minority stress model, and the second session in each pair introducing coping strategies for the component of the minority stress model (see Figure 1 for a diagram of the flow of the AWARENESS sessions and the primary content addressed in each session, see Table 3 for specific content and skills discussed in each session as related to each component of minority stress). Each session follows a specific structure with a guiding outline delineating how much time should be spent on each task. In general, the specific structure of the sessions is as follows: (1) ~5 minutes are dedicated to setting the agenda for the session, check in about the intervention process, and review as relevant; (2) the next 15–20 minutes are focused on introducing new content/psychoeducation and/or on review of outside of session assignments as relevant; (3) the next 15–20 minutes are focused on discussion of how the new content applies to the individual or on introducing new skills; and (4) the final ~10 minutes are focused on the outside of session assignment to be done prior to the next session and on an overall summary and synthesis of the content and what was discussed within the session.

Figure 1:

Sessions of AWARENESS for Sexual Minorities

Table 3.

Description of AWARENESS Sessions and Content and Skills for Each Session

Session number and minority stress focus	Content and Skills
1.Introduction, Discrimination, Prejudice, and Microaggressions	Psychoeducation about discrimination and physical and mental health Discussion of client’s relevant identities or characteristics that expose them to minority Stress Discussion of client’s experiences with discrimination and victimization Introduction and discussion of microaggressions and experiences of pride Daily monitoring of discrimination, microaggressions, and monitoring of the following core experiences which are monitored in all future sessions where outside of session assignments include tracking: pride events and mood, substance use, anxiety, and other behaviors deemed significant or related
2. Coping with Discrimination	Psychoeducation about the cognitive-behavioral model Psychoeducation about matching the type of coping to the type of stressor (solving the problem, managing how the problem is viewed, or managing feelings related to the problem) and how to apply coping Practice different strategies for coping with discrimination and track these outside of session along with core experiences (as described in session 1).
3. Anticipation of Discrimination	Discussion of the client’s experiences in applying coping strategies to discrimination experiences Further discussion of the connection between events and thoughts, feelings, and behaviors Psychoeducation on hypervigilance and health Discussion of client’s experience of anticipation of discrimination or hypervigilance Psychoeducation about accuracy of safety assessments and decision tree about making safety assessments Outside of session tracking of settings, thoughts that discrimination may occur or safety may be at risk, body sensations they experience, actual experiences of discrimination or threat, ratings of hypervigilance, and core experiences (as in session 1)
4. Coping with Anticipation of Discrimination	Discussion of client’s tracking of anticipation of discrimination Collaborative empiricism focused on safety assessments Values clarification exercise on anticipation of discrimination with hypothetical scenario related to chronic anticipation of discrimination Introduction of skills for coping with hypervigilance: assess the evidence, identify skills for coping with both credible threats and hypervigilance in the absence of a threat, including both cognitive and relaxation skills Introduce “intentional attention,” a mindfulness exercise that directs the client to practice gaining control of their attention by intentionally focusing it on different internal and external stimuli Outside of session assignment to practice making conscious choices consistent with one’s values in response to hypervigilance and situations in which one makes automatic assessments of danger, to have daily intentional attention practice, and to track core experiences (as in session 1)
5. Concealment or openness about individual characteristics	Discussion of client’s responses to hypervigilance, assessments of danger, and intentional attention practice Psychoeducation about concealment, openness, and physical health Discussion of client’s experiences of concealing or being open about identity characteristics Outside of session assignment to track situations in which they conceal or are open about their individual characteristics, related thoughts, emotions, behaviors, and core experiences (as in session 1)
6. Skills and Choices Related to Openness or Concealment	Review of openness and concealment tracking assignment Discussion of intentions and values related to openness and concealment, and changes over time Outside of session assignment is behavioral experiments related to openness about and concealment of individual characteristics, and to track thoughts and feelings related to these behaviors Shame is introduced as a topic related to concealment, openness, and stigma
7. Internalized Stigma	Thoughts, feelings, and behaviors (and their connections) related to openness and concealment are discussed Psychoeducation about internalized stigma and how it can be related to avoidance, substance use, or sexual behavior Discussion of client’s experiences with internalized stigma and its connections with other behaviors (e.g., substance use, sexual behavior) Outside of session assignment to track internalized stigma and pride, thoughts, feelings, and core experiences (as in session 1), as well as to continue intentional attention practice
8. Coping with Internalized Stigma	Discussion of the tracking of internalized stigma and the client’s associated thoughts, feelings, and behaviors Skills are offered for coping with internalized stigma (challenging the thoughts through logic or through the eyes of a benevolent other, modifying or replacing thoughts, or observing thoughts, and maximizing prideful thoughts) Outside of session assignment is to document challenges to internalized stigma and track the outcomes of these challenges
9. Integration and Making Meaning	Discussion of client’s experiences challenging internalized stigma Summary of the intervention content Summary of client’s work in intervention Discussion of the components of the intervention that the participant plans to use Discussion of making meaning of difficulties, and of how individual characteristics have improved the client’s life

Outside of session assignments are focused on daily tracking of minority stressors as well as the setting, thoughts, and feelings that accompanied the stressor; mood, substance use, and other relevant experiences or problem behaviors determined for the individual; affirming experiences or those that resulted in feelings of pride; and coping skills used each day. In addition to tracking the experience of minority stressors and use of coping skills, between session assignments also involve trialing (i.e., behavioral experiments) and reporting back on new approaches related to minority stress and the use of coping skills that were learned in previous sessions. When minority stressors are not encountered, sessions discuss past instances of minority stressors or if these are not elicited, then hypothetical minority stressors, though in our experience past stressors rarely needed to be elicited, and hypothetical stressors never needed to be solicited. The final session focuses on consolidation and integration of content including: what was learned and found to be helpful, making meaning of stressors and responses to stressors, understanding the role minority stress has played in individual development, and considering how one’s minority status(es) have improved one’s life.

Study interventionists disclosed their sexual orientation when they introduced themselves to participants in the first session in order to model openness about sexual orientation from the outset. In the first AWARENESS session, participants are instructed that the intervention uses examples describing stress related to minority sexual orientation, yet the processes and skills can and should be applied to other minority statuses or individual characteristics as relevant or helpful (e.g., HIV status, disability status, racial or ethnic minority status). These relevant statuses are then discussed and interwoven throughout the intervention with the therapist following the participant’s lead on which individual characteristics the individual would like to discuss in relation to the material within the given session.

Feedback on the Intervention

We obtained feedback through both Likert scale questions and open-ended interviews about participants’ experience with the intervention. Likert scale questions queried the degree to which participants: discussed subject matter they had not talked about before, gained new coping skills, would recommend the intervention to a friend, would recommend to a friend just coming out as sexual minority, would recommend to a friend who came out as sexual minority several years before, and received something of lasting importance from the sessions. Open-ended interviews were structured and included questions that queried: challenges in completing the intervention; whether they looked forward to sessions and why or why not; if there were specific sessions that were particularly helpful or unhelpful; how they felt about the length of the intervention; what they thought about the content of the PCC session; whether any coping skills were helpful, and if so, which ones; how the intervention has affected their day to day life; whether the intervention had any impact on their day to day decision making; how the intervention helped them manage stress; how they view their life as a sexual minority person living with HIV after the intervention; who they have talked to about the intervention, with queries about what they said; and whether they would recommend the intervention to their peers.

Analysis.

Responses to Likert scale questions were tallied. Thematic analysis (Braun & Clarke, 2006) of open-ended responses to questions about the intervention provided feedback about the intervention and informed an intervention revision. To ensure rigor of the analysis, 2 researchers (the primary investigator and a graduate student in counseling psychology) read through all of the transcribed interviews and identified specific codes that occurred within text. This was done using a theoretical thematic analysis approach (Braun & Clarke, 2006) to answer the primary research questions: (1) what was acceptable or unacceptable about the intervention and may warrant alteration in a subsequent iteration, and (2) what processes did participants describe as occurring during or in relation to the intervention. The researchers discussed these coding units and came to consensus on a coding structure. Through discussion, rereading of interviews, and consensus, the codes were then organized into themes that occurred within the interviews. Both researchers then coded all of the 8 interviews for the coding units and themes. Codes were compared to ensure consistency.

Initial Feasibility of Discussing Minority Stress in Relation to Intersectional Identities and Characteristics

To assess the initial feasibility of the intervention to be applied to multiple intersecting identities and individual characteristics, study interventionists noted which minority statuses or characteristics were discussed during sessions in session notes and within a study database. Identities and individual characteristics discussed during sessions were tallied to assess the feasibility of applying the intervention to multiple identities or individual characteristics.

Results

Of the 10 participants, 8 completed all sessions. Two participants had to discontinue their participation due to physical injuries that were unrelated to the study; one of these participants completed all but the final session, the other one completed through session 6 of the AWARENESS intervention. These two participants were not available to complete the final feedback visit due to their injuries.

Feedback on the Intervention

Participants indicated that they discussed content in the intervention that they had not spoken about before; participants reported this occurred occasionally (n = 1), sometimes (n = 2), frequently (n = 3), and a great deal (n = 2). All participants indicated that they learned new skills during the intervention, reporting learning a few new skills (n = 4), some new skills (n = 2), and many new skills (n = 2). Participants indicated they would recommend the intervention to a friend, with half (n = 4) reporting they were “moderately likely” to do so and half (n = 4) reporting they were “extremely likely” to do so. Participants indicated they would recommend the intervention both to friends who were just “coming out” as sexual minority (moderately likely [n = 2], extremely likely [n = 6]), and to friends who “came out” several years before (slightly likely [n = 1], moderately likely [n = 2], and extremely likely [n = 5]). One participant reported that they “probably” received something of lasting importance from the sessions, and all remaining participants (n = 7) reported that they “definitely” received something of lasting importance from the sessions.

Thematic analysis of interviews indicated three themes that were discussed within the interviews that addressed the question of what parts of the intervention were acceptable or unacceptable and may warrant modification (identified themes and selected quotes are in Table 4). The three themes (bolded) related to acceptability of the intervention were: factors that impacted usefulness of the intervention, logistics of the intervention, and challenges encountered during the intervention. Within the theme factors that impacted usefulness of the intervention, participants indicated that the concurrence of external events related to minority stress in their lives (e.g., “external factors like the election”) made the intervention more useful and that the lack of concurrence of external events related to minority stress made the intervention less useful. Participants identified specific sessions that were more useful or challenging, typically identifying earlier sessions as more difficult and later sessions as most helpful. Participants identified logistics (e.g., the number of intervention sessions, or structural components like outside of session homework) as a factor in the acceptability of the intervention. Most participants described the intervention as being the right number of sessions, among these participants some also indicated that the intervention could have been longer, and some suggested that sessions be less than a week apart or on a different schedule. One participant indicated the intervention could have been slightly shorter. Participants also spoke about the homework as being a very useful strategy for practicing skills. Also within the theme of logistics, participants described a need for clarity about the intervention schedule or topics and a need for flexibility in content discussed or scheduling. Additional summarizing throughout the intervention and a summary during session 5 (midway through) were requested to clarify intervention progress. Participants described challenges associated with completing the intervention including difficulty associated with self-reflection, difficulty remembering schedules or skills, and difficulty talking about things.

Table 4.

Themes identified through thematic analysis of post- AWARENESS intervention interviews

Theme	Number of participants who spoke about content relevant to theme (n)	Quote(s)
Themes related to acceptability or unnacceptability
Factors that impacted usefulness	8	“This very last one was really cool and because of external factors like the election, it was really good to have a chance to talk about all that stuff.”
Logistics	8	“I felt it was very helpful because I was able to look at each one with the homework assignments and go, OK, this is what I need to do with this.”
Challenges	5	“Um, talking about the past old wounds is hard.”
Themes related to intervention processes
Within intervention processes	8	“Because like I mentioned a lot of the things we brought up were things that I have known. And I’ve known in myself and discussed with myself, but revisiting them with a different set of tools can give me some new insights.”
Skills	8	“He didn’t yell at me like he made this comment to his girlfriend as he walked by he was with this other guy and these two girls and he said something about me and I just kind was like… ‘Oh he just…’Maybe I’m constantly doing what [interventionist] would call ‘recognizing a thought.’ Or the same thing she does when I have a thought, just go, ‘Oh I just had the thought.’ Just recognize that I had the thought. You know? Instead of reacting emotionally or anything. And what I said was, ‘Oh he just said that.‘ And I kept walking. I know I shouldn’t get into conflict or anything, but afterwards I felt no resentment towards him. I wasn’t like, I dislike the guy.” “Its lowered my stress level a lot and how I interact with people as well as how I handle situations in regards to like, instead of personalize them, or go, ‘Oh my god!’ Instead stepping back, take a minute to breathe, reflect, think your thought process, separate your thoughts from your emotions.”
Specific minority stressors	7	“it seemed to me that our work together was not only about the stigma of my sexual persuasion. That it could have to do with being an elder. That it could have to do with having too much stuff in my place…actually we didn’t talk about that.” “How to deal with anticipation of discrimination, you’re always expecting to be the, someone yells at you. Oh, that’s you. Are they yelling at you? You could be like…oh they weren’t yelling at you. Little tools like that?”
Awareness	7	“I’m more aware of all the differences. I’m more aware of some of the specific challenges I face being that kind of minority…those kinds of minorities.”
Thoughts	6	“One that comes to mind is when dealing with internalized stigma, is to think about what a loved one would think about that thought. So like if I have a feeling, if I’m feeling shame around my sex like, thinking about what my partner thinks about my sex life is helpful. Because he doesn’t have anywhere near the same level of judgment that I do about myself.” “I think this is my own way of looking at things, but this is helpful because I still have these negative scripts. I’m getting better. But I will curse myself out and say things to myself that I would never think of saying to anyone else. Which is, well I’m working on that.”
Core changes because of the intervention	5	“Especially with the situations in my life where the me, the ID is at odds with society, in the situations where I want to be or express something in a certain way but I feel constrained or judged, in those situations I feel like I’m a little more confident or safe going with my gut. It’s minor but I think like before I dress down for an urban environment, like a lot of times if I’m in a different environment where I’m less comfortable, less safe, I’ll like dress more neutrally, I won’t wear pink or dress as queer. And I feel a little bit more comfortable more confident in doing what I want and setting aside those external pressures.”
Feelings	5	“It was like someone giving me walking shoes. Like someone saying, “here, you’ll be more comfortable if you walk in these.”

Thematic analysis identified seven themes (bolded) which were related to the processes that occurred during the intervention. All participants discussed within intervention processes that occurred including the importance of the therapeutic alliance, which was mentioned by all but one participant; being open about thoughts, feelings, and experiences; revisiting issues and having the opportunity for self-reflection; describing the role of the structured commitment of going to sessions each week; noting that there was a specific trajectory and progression to the sessions; and finding the intervention stimulating, interesting, challenging, or humorous. Participants also discussed the acquisition of skills, including specific skills of assertiveness, behavioral activation and increased activities, mindfulness, relaxation and breathing, and skills to cope with discrimination. Within the theme of skills participants also discussed having greater empathy, the ability to generalize skills to different contexts, feeling prepared for encountering minority stress, and being able to differentiate real versus perceived discrimination. Participants discussed using the intervention to explore specific minority stressors including experiences of discrimination, anticipation of discrimination, concealment of identity, intersectional stigma, HIV stigma, stigma related to sexual orientation, and other types of unspecified stigma. Participants described increased awareness as a result of the intervention, including greater awareness of environments or surroundings, self-awareness, and awareness of feelings. Participants described specific skills related to thoughts including challenging thoughts, identifying the relationships between thoughts and feelings, and thought observation or decentering. Participants also spoke about core changes because of the intervention, including destigmatization of identities, integration of identities, greater positive self-view, and increased sense of safety within their surroundings. Participants described changes in their feelings including increased positive affect, less resentment, greater optimism, and new tools for coping with their feelings.

Initial Feasibility of Discussing Minority Stress in Relation to Intersectional Identities and Characteristics

Participants discussed multiple identities including: sexual minority identity (n = 10), HIV status (n = 9), racial or cultural minority status (n = 5), gender identity and presentation (n = 5, this included 1 participant who was transgender, 1 participant who spent a substantial portion of his time as a woman but had a gender of man, and 3 participants who discussed stress related to feminine characteristics), low socio-economic status (n = 3), disability status (n = 2), mental health status including substance use status (n = 2), older adult status (n = 2), religious identity (n = 1), weight status (n = 1), and status as a partner in a polyamorous relationship (n = 1). All participants screened in to the study endorsing male sex at birth and gender identity of man, yet one participant reported a gender identity of woman as study sessions progressed and applied the intervention to her identity as a transgender woman throughout the study, in addition to her identity as a sexual minority person living with HIV. In total, participants discussed a mean number of 3.2 (median 3, range 1–6) different intersecting identities in addition to sexual minority status (which was discussed by all participants). These data support the feasibility of applying the minority stress content to multiple identities or individual characteristics.

Revisions in Response to Open Pilot

Revisions were made in response to the open pilot based on participant and interventionist feedback. Selected revisions are described here. Explicit guided breathing practice was added in response to participant feedback that breathing was a helpful skill gained from the intervention, thus while breathing was introduced as a coping skill in the open pilot, explicit guided breathing practice was added to session 2 of the manual. A review and summary segment was added to the middle of the intervention at the beginning of session 5 in response to participant feedback. In response to interventionists’ feedback, modifications were made including alteration of terminology used in the manual, for example different or additional language was added for terms that were challenging for some participants (e.g., “outside of session assignments” replaced “homework, “subtle discrimination” was added in addition to “microaggressions”, “high blood pressure” was added in addition to “hypertension”). Specific ways of accommodating participants with limitations in carrying out intervention tasks were added (e.g., completing between session tracking through means other than worksheets such as in one’s phone). Specific handouts were added to help explain concepts within the intervention that interventionists found required additional explanation (e.g., a handout on “Noticing Events that Make You Feel Pride”) and additional language and prompts were added to help facilitate discussion. Additional time was added for discussion of the participant’s history as a sexual minority person and/or history related to other minority statuses to the first session of the AWARENESS intervention. Additionally, the single session of PCC was removed based on interventionist feedback that the transition from PCC to AWARENESS was challenging and that participants had very few recent experiences of high risk sexual behavior (e.g., participants were not recently sexually active, participants were low risk in the context of sustained viral suppression, participants had sexual partners on pre-exposure prophylaxis).

Discussion

This study provided initial feedback on a 9-session cognitive behavioral intervention targeting intersectional minority stress among sexual minority men living with HIV who use substances. Participants identified having increased awareness and coping skills as a result of the intervention. Participants also indicated that they received something of lasting importance from the intervention. This study laid the groundwork for a manual revision before the implementation of the next stage of behavioral therapy development (1b, Rounsaville et al., 2001). This open-pilot informed a manual revision and is being followed by a pilot randomized controlled trial to identify the feasibility of the intervention as well as potential for changes in substance use, mood, anxiety, and biological functioning (i.e., gene expression) that may occur in response to the intervention. The development of this treatment is an important step in identifying interventions that can reduce the deleterious effects of intersectional minority stress among sexual minority men living with HIV.

This intervention was designed to target intersectional minority stress, yet was unified by sexual minority status, and inclusive of stress related to HIV status. We demonstrated the initial feasibility of using the intervention to address intersecting minority statuses, with participants discussing a median number of 3 minority statuses in addition to sexual minority status, and all but one participant discussing HIV status. Minority stress was discussed in sessions in relation to racial or cultural minority status, gender identity and presentation, socio-economic status, disability status, mental health status, older adult status, religious identity, weight, and status as a partner in a polyamorous relationship. The examples given as part of the intervention materials did not specifically address these other minority identities or individual characteristics, yet participants applied the skills to their other minority statuses. In post-intervention interviews, participants described the usefulness of the skills in relation to all of the components of minority stress including: experiences of discrimination, anticipation of discrimination, concealment of identity, and internalized stigma related to HIV, sexual orientation, and the intersection of identities. This supports the idea that AWARENESS is an intervention that can be applied to all of the components of minority stress and be applied to multiple intersecting identities and individual characteristics. Future work may examine which minority statuses participants discuss in relation to specific skills and components of minority stress.

Significant progress has been made in the last several decades towards reducing stigma associated with sexual minority identity and HIV status, and [CITY NAME REMOVED: San Francisco] has led the charge on many of these cultural shifts (e.g., same sex marriage, “Gay Marriage Timeline,” 2015). Despite this intervention being tested within [CITY NAME REMOVED: San Francisco], a place thought of as a safe haven for sexual minority people and at the forefront of HIV care, the content of the intervention was still relevant for sexual minority men living with HIV in [CITY NAME REMOVED: San Francisco]. Participants who completed AWARENESS described benefitting more from AWARENESS when there were concurrent events in their lives that were relevant to the intervention. This suggests that this intervention may have even greater applicability to people who are living in places where sexual minority, HIV status, and other individual characteristics are more stigmatized.

Participants identified many intervention processes consistent with common factors in psychotherapy (Laska, Gurman, & Wampold, 2014) including the importance of the therapeutic alliance, having a structured commitment of attending sessions each week, and having a place to revisit or be open about thoughts, feelings, experiences, and self-reflection. These characteristics are not unique to AWARENESS but do indicate that common factors were important for participants within the structured format of AWARENESS. The therapeutic alliance was identified as an important part of the intervention in open-ended questions about the intervention experience by all but one participant, suggesting that a strong therapeutic alliance was a critical component of the intervention. Notably, the earlier sessions when the therapeutic alliance was not as well established were more difficult for participants than the later sessions. This may suggest that delivering components of this intervention within the context of a strong existing therapeutic alliance could be easier for and more successful for clients. Furthermore, working with clients on issues related to minority stress is likely reliant upon the foundation of a strong therapeutic alliance. Within this study, both of the therapists had significant psychotherapy training and experience, so while the AWARENESS manual did not outline the building and maintaining of the therapeutic alliance, these common psychotherapy skills were prerequisites that occurred within the intervention. As such, the methods described herein were not intended to be used outside of a psychotherapy setting.

Participants described acquiring skills during AWARENESS that are consistent with cognitive behavioral skills. These included assertiveness, behavioral activation, mindfulness, and breathing and relaxation. Participants described challenging thoughts, becoming clearer about the relationships between their thoughts and feelings, and learning to observe or decenter from thoughts. Participants also described changes in the way that they felt including more positive affect, less feelings of resentment, and greater optimism. Taken together, this suggests that the participants gained cognitive behavioral skills and knowledge within the framework of this minority stress intervention. Future research can elucidate if these skills were able to interrupt the relationship that has been observed between minority stress and subsequent substance use or psychological distress (Livingston et al., 2017; Rendina et al., 2018). Learned within the context of the minority stress model, these skills may be generalizable to other situations that individuals may encounter that are not directly tied to minority stress (e.g., depression, substance use). Consistent with this, participants described being able to generalize skills to other contexts that were not minority stress specific. Future research is needed to identify the extent to which this generalization occurs.

Participants also discussed core changes that occurred due to the intervention. One of the core changes that was identified within the participants’ post-intervention interviews was destigmatization of their identities and more positive self-views, a theme that could also be described as identity valence. Participants also described increased integration of their identities. Both identity valence and integration are specified within Meyer’s (2003) minority stress model as influencing the path from proximal minority stressors to poor mental health outcomes. Our results suggest that participants who received AWARENESS identified changes in both valence and identity integration, which could be expected to, in turn, improve substance use and mental health outcomes. This suggests that further testing of AWARENESS is warranted. Not specified within Meyer’s model, participants also described feeling an increased sense of safety in their environments. Accurate and present-focused safety assessment was a focus within the intervention, and participants discussed feeling safer in their environments. Participants also described feeling a much greater awareness of their environments, and of their own selves and feelings.

One person within this study endorsed a gender of man and assigned sex at birth of male when they began the study, then during the study visits subsequently identified as a woman. This individual found the intervention to be helpful as related to minority stress due to transgender status. Despite this, future adaptation of this intervention should occur to incorporate gender minority specific content before this intervention is purposefully tested with gender minority people. This adaptation could incorporate specific components of the minority stress model relevant to gender minority people (Hendricks & Testa, 2012). Despite this being the only participant who was clearly gender minority, four additional participants discussed content and stress related to their gender or gender expression, suggesting that minority stress related to gender and gender expression remains salient among sexual minority men.

Psychotherapy practitioners can consider adopting the techniques outlined in this intervention in their own work with sexual minority clients living with HIV. This study tested this intervention as a complete package to reduce the impacts of intersectional minority stress, but specific modules or techniques could be applied with clients who are challenged by one of the specific components of the minority stress model as indicated by client case conceptualization. For example, a client who brings up concerns related to outness or concealment of their sexual orientation or HIV status may benefit from the exercises or one component of the exercises described in sessions 5–7. Psychotherapists may also want to consider integrating the overarching strategy of this intervention, which is to empower the client with the science of what is known about minority stress and its health impacts and then to educate them about the skills that can be used to overcome these impacts.

Limitations

There are several limitations of this study that should be noted. First, this intervention was tested among sexual minority men living with HIV, and future research will be needed to get feedback on this intervention among other groups of sexual minority people and to adapt and test this intervention with gender minority people. Nevertheless, our results suggest that individuals gained skills from the intervention and applied the intervention to multiple individual characteristics that were salient to them, which suggests that the intervention may also be able to be adapted to sexual minority women or sexual minority men without HIV. This study is a preliminary step in the development of this intervention, and additional research will be required to test the feasibility and efficacy of this intervention. This study presented acceptability evidence and initial feasibility evidence on the use of this intervention to discuss intersectional identities. Future work could examine which identities are discussed with respect to specific skills and types of minority stress to better understand the applicability of specific minority stress foci within psychotherapy to different identity characteristics. This study also does not report on the outcomes of this intervention, as the purpose of this stage of treatment development was to first gain feedback on the intervention, and to inform a treatment revision and feasibility study and eventual finalization (consistent with stage 1a of treatment development, Rounsaville, Carroll, & Onken, 2001). A subsequent pilot randomized controlled trial will report on feasibility and initial outcomes in comparison to an active control condition. This study was also implemented by sexual minority women, and different challenges could be encountered if the intervention were to be delivered by someone who was heterosexually identified or had a different gender or sexual orientation. Past literature has suggested that sexual minority clients may fare better working with therapists who are sexual minority (Jones, Botsko, & Gorman, 2003), thus future research will have to identify if the intervention is differentially effective based on the sexual orientation of the therapist. Nevertheless, this intervention was not designed to be solely delivered by a sexual minority person, thus heterosexual therapists should also be able to use the content with their clients. While the therapists within this study met to discuss and consider the case conceptualizations of each of the participants, all participants received each of the modules within the intervention so that we could obtain feedback on the intervention. In future use, AWARENESS may be more effective if specific modules are selected based upon case conceptualization and we anticipate that specific modules may be helpful to therapists who are inexperienced addressing specific components of minority stress.

Conclusions

This study provided feedback and input on AWARENESS, a 9-session cognitive behavioral intervention targeting intersectional minority stress among sexual minority men living with HIV. It also supported initial feasibility of using AWARENESS to address minority stress due to multiple intersectional identities. Participants identified that AWARENESS taught them new skills to cope with minority stress and was related to core changes including destigmatization of identities, greater identity integration, and greater sense of safety. This process led to a revision of the AWARENESS manual. Components of AWARENESS may be adopted for integration into existing psychotherapy modalities. Future testing of AWARENESS in a randomized controlled trial is warranted to identify the extent to which this intervention is feasible and shows promise in reducing substance use, improving mental health, and improving biological functioning. This study is a critical step in the development of treatments to reduce the health impacts of minority stress among sexual minority men living with HIV.

Clinical Impact Statement:

Question:

What feedback do sexual minority men living with HIV who use substances have regarding a 9-session cognitive behavioral intervention to reduce intersectional minority stress, and can this intervention be used to address minority stress related to intersectional identity characteristics?

Findings:

This study demonstrates that sexual minority men liked the intervention, thought that they gained meaningful skills from the intervention, and reported experiencing destigmatization and integration of their identities; sexual minority men also used the intervention to discuss minority stress related to multiple identity characteristics in addition to sexual minority status.

Meaning:

Clinicians may wish to adopt specific strategies described within this intervention to use with clients who are experiencing intersectional minority stress.

Next steps:

Future studies will establish the feasibility and efficacy of this intervention in reducing substance use and improving mental and physical health.