Introduction

LGBTQ + youth are known to have a significantly higher rate of suicide and mental health concerns than their heterosexual and cisgender peers (Gorse, 2022; Hatchel et al., 2021; Liu et al., 2020). The reasons for this are multifaceted, but often involve societal and relational rejection, stigma, discrimination, and bullying (Austin et al., 2022; Burton et al., 2013; Diamond et al., 2011; Tankersley et al., 2021).

Family as a Risk and Protective Factor

One of the factors that has been increasingly studied in recent years is the integral and unique role of family in the mental health and suicide risk of LGBTQ + youth. Specifically, family can serve as both a risk and protective factor for suicide in this vulnerable population.

Family rejection, lack of acceptance, and abuse have been identified as significant risk factors for suicide in this population (Austin et al., 2022; Ryan et al., 2009). LGBTQ + youth who experience rejection from their families are at higher risk for depression, anxiety, substance abuse, and suicidal ideation (Klein & Golub, 2016); repeated studies have shown family rejection as one of the most pronounced risk factors in predicting negative outcomes for the health of LGBTQ + youth (Austin et al., 2022; Baams et al., 2015; Klein & Golub, 2016; Puckett et al., 2019).

Conversely, research has shown that family acceptance can serve as a protective factor against suicide and mental illness in LGBTQ + youth (Olson et al., 2016; Puckett et al., 2019; Ryan et al., 2010). Supportive families can help LGBTQ + youth develop resilience, build coping skills, and mitigate the impact of discrimination and stigma (Hatchel et al., 2021; Olson et al., 2016; Puckett et al., 2019; Rothman et al., 2012; Ryan et al., 2010; Wigderson et al., 2019). Positive family relationships can also provide a sense of safety and security for LGBTQ + youth, which is associated with a reduction in risk of suicide. As such, it is essential to recognize the critical role that families play in the well-being of LGBTQ + youth. Within LGBTQ + community mental health organizations, policies and programs that utilize and facilitate family involvement may help reduce the risk of suicide among LGBTQ + youth.

Existing Evidence-Based Treatments for Suicidal LGBTQ + Youth

Relatively few empirically supported treatments (ESTs) specifically target LGBTQ + youth. Of these, treatments have predominately focused on sexual minority youth, with limited representation or inclusion of gender minority youth (Russon et al., 2022c). Several of these ESTs have specifically explored acceptability and preliminary efficacy for LGBTQ + youth with suicidal thoughts and behavior (Russon et al., 2022c, 2023).

As extant literature has indicated family as a unique, impactful risk and supportive factor, systemic work with LGBTQ + youth is indicated. However, limited research has explored (a) how best to implement family-based treatments for LGBTQ + youth and (b) the appropriate time, or when to implement family-based treatment for this population. Amongst the relatively few ESTs that have demonstrated feasibility, acceptability, or efficacy with LGBTQ + youth with suicidal thoughts and behavior, fewer are family-based or systemic treatment models (Frey et al., 2022; Russon et al., 2022c). Only one EST, Attachment-Based Family Therapy (ABFT) has specifically targeted family interventions as a core mechanism of change for suicidal LGBTQ + youth (Diamond & Boruchovitz-Zamir, 2023; Diamond & Shpigel, 2014; Russon et al., 2023; Russon et al., 2022a, b). In an exploratory study, ABFT was compared to family enhanced non-directive supportive therapy (FE-NST). ABFT demonstrated a greater reduction of depressive symptoms for LGBQ youth (Russon et al., 2023). ABFT has shown feasibility (low drop-out rate), acceptability according to LGBTQ + youth and their caregivers, and preliminary effectiveness with LGBTQ + youth and their caregivers in the form of reduced suicidality of LGBTQ + youth (Russon et al., 2022a). ABFT has also been through delivery adaptations for the specific ecologies of LGBTQ + community centers, first by Diamond et al. (2012), with further delivery adaptations made by Russon et al. (2022a). The latter elected to title this new delivery approach affirmative ABFT. Affirmative ABFT supports and affirms both youth and caregivers to allow for acceptance, understanding, and support to be bridged within families that include distressed or suicidal LGBTQ + youth.

Theoretical Framework

It is well-recognized that the gap between science and practice is large (Aarons et al., 2011; Hoagwood, 2013), particularly in organizations that serve vulnerable youth (Fish, 2020). As such, organizations serving LGBTQ + youth may have unique implementation challenges. To account for human and organizational factors affecting program implementation (Fixsen et al., 2005), we draw on the updated Consolidated Framework for Implementation Research (CFIR; Damschroder et al., 2022). CFIR is a determinant framework that seeks to identify and elucidate contextual barriers and facilitators influencing the implementation of ESTs into diverse settings. Domains to consider in CFIR include outer settings (external policy, local context, patient needs), inner settings (resources, fit, leadership), staff characteristics (training, knowledge, beliefs), intervention characteristics (complexity, relative advantage), and implementation processes (facilitation, planning, coaching). CFIR suggests a sequenced approach to program implementation with new target populations. Guiding principles include involvement from key stakeholders and the integration of feedback into the development of program policies.

Stakeholder Groups

Exploring the perspectives of all key stakeholder groups is crucial for understanding the implementation of ESTs (Landsverk et al., 2011). The perspectives of LGBTQ + youth clients, their families, the therapists (providers), and administrators of community organizations can help identify potential barriers to family involvement and tailor interventions to meet their needs. Understanding the perspectives of all key stakeholders can help promote buy-in and collaboration among stakeholders (Beidas & Kendall, 2014) to ultimately improve the delivery of interventions for LGBTQ + youth.

Clients

Despite the growing recognition of the role of family in the mental health and suicide risk of LGBTQ + youth, research has suggested that LGBTQ + youth clients can be hesitant to incorporate family into treatment for fear of disclosing their identity or further rejection when their identity is already known, though many report a willingness to try family therapy nonetheless and may ultimately recognize the value in family-based services after completing treatment (Diamond et al., 2011). Other youth may already have disclosed their identity to family and received a response that felt like disapproval or rejection. As such, the fear of further family rejection, lack of understanding, abuse, or even the possibility of subsequent homelessness may explain why other LGBTQ + youth are hesitant to involve their families in treatment, as many LGBTQ + youth attribute their caregivers as directly contributing to their distress (Diamond et al., 2011). However, some research has indicated that, despite perpetrating rejecting behaviors, caregivers who are not affirming the identity of their LGBTQ + youth may still wish to be involved in family-based therapy with their youth, and their presence can still be clinically indicated (Diamond & Boruchovitz-Zamir, 2023; Diamond & Shpigel, 2014). Additional research has found promising results for LGBTQ + youth and their caregivers in terms of clinical effectiveness (Russon et al., 2022a).

Therapists

Similarly, therapists at LGBTQ + community mental health centers may be hesitant to incorporate family into treatment due to concerns of the potential for family rejection. Therapists may feel that family therapy or the involvement of families in treatment may be outside the scope of their training, that families may not be receptive to involvement in their child’s treatment, or that family participation in treatment may worsen distress for the youth (Diamond & Boruchovitz-Zamir, 2023; Diamond & Shpigel, 2014).

Administrators

Existing research has primarily focused on the perspectives of LGBTQ + youth clients and their therapists (Diamond et al., 2011; Diamond & Boruchovitz-Zamir, 2023; Diamond & Shpigel, 2014). While these stakeholder perspectives are essential, it is important to consider the perspectives of all key stakeholders at LGBTQ + community mental health centers. Administrators play a critical role in shaping the policies and practices of their organizations and significantly impact the feasibility of incorporating family services for LGBTQ + youth. However, administrators may face unique, distinct challenges (when compared to youth clients and their therapists). As such, factors identified by this key stakeholder group are essential for the implementation of family-based interventions with LGBTQ + youth at LGBTQ + community mental health centers.

Administrative barriers to implementation for ESTs, such as additional burdens of paperwork, supervision, restrictive clinical manuals, employee turnover, and difficulty with reimbursement have been previously explored (Addis & Hatgis, 2000; Beidas et al., 2014; Fixsen et al., 2005; Glisson & Schoenwald, 2005; Godley et al., 2001). However, to our knowledge, administrator experiences in LGBTQ + healthcare centers have yet to be researched.

Present Study

The perspectives of all stakeholder groups are essential in order to better understand clinical and logistical factors associated with higher level implementation and use of treatment approaches. This is particularly true for administrative stakeholders who are often uniquely attuned to the systemic factors that influence the implementation needs and barriers of their specific populations (Addis & Hatgis, 2000). The present study explored the perspectives of administrators in LGBTQ + community organizations with regard to delivering a family-based treatment, attachment-based family therapy, for LGBTQ + youth with suicidal ideation and behavior. The study specifically focused on perceived needs, barriers, and facilitators associated with the implementation of this approach in these unique clinical settings.

Methodology

This qualitative study explored the perspectives and experiences of administrators who work and manage services within LGBTQ + community organizations. These interviews served as the initial phase of a 2022 implementation study focused on barriers and facilitators associated with delivering family-based care to youth with suicidal ideation and behavior.

Sample and Recruitment

Administrators (N = 10) from a large, mid-Atlantic city in the United States were selected to participate if they worked within LGBTQ + youth organizations. Participants represented sites with unique service ecosystems and included administrators from the three organizations participating in the larger implementation study (Russon et al., 2022a). Other participating administrators were identified by informants on the advisory board of this same study. The advisory board was responsible for steering the project, reviewing protocols, and supporting engagement from our stakeholder groups. Advisory board members included representatives from the local LGBTQ + task force and leadership from LGBTQ + community organizations in the city. Working with the advisory board, the project aimed to interview at least one member of the leadership of all youth-facing organizations in the city who had a clinical department or program embedded for the needs of LGBTQ + youth.

Administrators represented city and organizational leadership, including participants from the department of behavioral health, the city’s LGBTQ + task force, and directors and coordinators from regionally and internationally known LGBTQ + organizations. Participants included members of our advisory board who met the aforementioned characteristics. Administrators reported various backgrounds and experience, from healthcare professions to specific roles within LGBTQ + communities in the area. Healthcare-related backgrounds included primary care clinicians (n = 2), attending physician (n = 1), social workers (n = 3), therapist (n = 1). The remaining participants (n = 3) maintained roles in community-based services, such as a clinical consultant for a healthcare improvement and accountability program, a project director of a grant, and a Person First Coordinator. Of the 10 administrators, four had worked with HIV prevention/education, eight had extensive experience within the adolescent community, and one was a project director of a grant targeting children and families impacted by trauma with a population focus on LGBTQ + individuals. Other relevant administrator experiences included: owning a private practice where 90% of patients are LGBTQ+, work and research surrounding the role of social support and adherence to HIV preexposure prophylaxis (PrEP) in young men and trans women of color, executive board membership for a university’s LGBTQ + resource center, and work with homeless LGBTQ + youth.

Procedure

The present study received approval from the IRB at the principal investigator’s (second author) former institution prior to data collection. IRB approval was obtained from the principal investigator’s (second author) and study lead’s (first author) current institution before data were analyzed. Administrators were interviewed individually or, in one case, as a small group of participants who were working together or had worked together in the past. Using a semi-structured qualitative interview protocol, the second author asked participating administrators questions that explored (1) the unique needs of LGBTQ + youth, (2) which existing programs are working well or not working well, (3) where (e.g., outpatient, day treatment, mobile therapy) a family-based suicide treatment program could be housed, (4) existing regulatory barriers, (5) reimbursement models that could sustain a family-based suicide treatment program, (6) lessons learned from prior program implementation efforts, and (7) factors to ensure uptake and implementation of this program.

Using the CFIR (Damschroder et al., 2022), questions attempted to highlight barriers (factors that currently exist, but hinder affirmative services), and facilitators (factors that currently exist which help facilitate affirmative services). Questions were generally designed to explore the availability of services to meet the needs of LGBTQ + youth with serious mental health concerns, highlight systemic barriers affecting affirmative, tailored programming, understand how a family-based treatment program like ABFT might fit within the social services for this population, and explore if a family-based treatment program could be sustainable.

Analytic Approach

Interviews were audio recorded and transcribed. Transcribers de-identified participant information during the transcription process, prior to analysis. Using a qualitative data analysis software, MAXQDA 2018 (VERBI Software, 2018), transcript analysis was led by the first author and the principal investigator of the larger project (second author). The coding team also included two advanced undergraduate research assistants receiving B.S. degrees in Human Development and Family Science. Coders used Braun and Clarke’s (2006, 2023) six-step analytic procedure to generate themes and make connections across participants in the dataset.

Using this procedure, coders engaged in initial transcript review and familiarization. During this process, the data were discussed and initial reflections shared in a group format. General descriptive features of the data were discussed and documented. Next, facilitated by the lead author, initial coding of the first three interviews was conducted by the two advanced undergraduate research assistants. These research assistants were trained by reading and discussing Braun & Clark (2006) and were coached to engage in a semantic approach to data analysis. To promote trustworthiness, they independently coded the first three transcripts and generated separate preliminary codebooks to review for consensus. Once preliminary codebooks were developed, the first author reviewed and discussed the codebooks and the initial coding results in a consensus meeting with the two research assistants. When discrepancies in interpretation occurred, the second author was consulted, and the review process did not continue until the research team formed a common understanding and revised codes accordingly. These resolutions occurred as a result of collectively examining explicit meanings within the data and drawing on the overarching domains of the CFIR framework for guidance. As a result of these discussions, a new codebook was generated to reflect the group’s consensus.

Next, using this codebook, the research assistants independently coded the remaining interviews, noting new codes as they were identified in the data. After completion of this next round of independent coding, similar review and consensus processes ensued. Once initial coding was completed, the research team began using the codebook to look for themes across the data. Specifically, using the CFIR framework (Damschroder et al., 2022), we deductively organized themes as barriers (current, existing factors which would hinder implementation) and facilitators (current, existing factors which would support implementation) of family-based services for LGBTQ + youth. While analyzing the data, we began to notice an additional theme: administrators frequently spoke of absent factors which they believed would be helpful or necessary– these were categorized as needs. The process of crystallizing themes was led by the first author who then identified associations between the needs, barriers, and facilitators in the larger dataset. The research team discussed the significance of the themes as they related to the primary purpose of the study. Notes from this discussion served as the first draft of the results section presented in this manuscript. Finally, all three authors further consolidated themes as part of the ongoing process of writing and revising results.

Research Team Reflexivity

The research team is aware of how our own reactions to the data are interwoven into the processes of analysis moved forward in this study (Goldberg & Allen, 2015). Study authors and coders represent a diverse group in terms of age, sexual orientation, gender, and socioeconomic background. The principal investigator (second author) identifies as a white, bisexual, cisgender woman and a family therapy researcher dedicated to the studying the adaptation and implementation of family-based models that can help prevent suicide amongst LGBTQ + youth.

All aspects of this study are informed by the authors’ transformative worldview (Mertens, 2010). Namely, an understanding that the clinical challenges we face, and their corresponding solutions, are interwoven with the social and political change agendas that shape the health systems in which we work. During research team meetings, dialogue about our engagement with the wider systems and sociopolitical forces influencing LGBTQ + youth and families in clinical settings was encouraged as a means to recognize the influence of our positionalities. These discussions continued throughout the process of data analysis.

Results

Themes

We identified three themes and 30 subthemes related to implementing family-based treatment LGBTQ + youth with suicidal thoughts and behavior. We found needs (absent, but beneficial factors which would support implementation), barriers (current, existing factors which would hinder implementation) and facilitators (current, existing factors which would support implementation) of family-based services for LGBTQ + youth.

Needs

9 subthemes (see Table 1) were created for absent, but necessary factors that support affirmative, family-based treatment for LGBTQ + youth. These needs included addressing provider biases, establishing safe spaces for LGBTQ + youth, and creating standardized, collaborative care.

Safe Space. Two administrators (20%) described the need for safe spaces for LGBTQ + youth. Safe spaces are physical areas where LGBTQ + youth feel protected and validated in expressing their identities in the context of both affirmative services and family-based services. Administrators described safe spaces as not just important, but frequently lacking, especially in healthcare contexts outside of organizations that specifically serve LGBTQ + individuals.

They need that validation and support and a safe space where they can come and actually open up and talk about what’s happening in their own minds and hearts. I think that we don’t have a lot of that here. (Participant 1)

Needing Affirmative Care. Seven administrators (70%) stated that affirmative care is necessary, but often absent for LGBTQ + youth. Affirmative care involves validating clients’ identities and recognizing associated oppressive forces that affect people within their community. This theme is similar, but distinct from “Need for a Safe Space” in that it describes actual characteristics of healthcare providers. One administrator explained,

A lot of our providers speak… “oh we are affirming, we are affirming” but if you ask LGBT people I feel like a lot of individuals may have a different response, and I don’t think that there is a lot of safe spaces for queer people to go, especially youth to go that is an affirming space… I think that that’s something that we don’t have. (Participant 1)

This was a common sentiment expressed by administrators, who also described harm that non-affirmative care has on LGBTQ + youth. Notably, administrators described a concerning repercussion of this when there are pressing concerns regarding safety and suicidality, as many outpatient providers do not feel equipped to provide ethical care for clients with a high level of suicidal ideation.

There are so few providers who can give LGBTQ-sensitive, affirming care… And then you intercept that with suicidality, and so many clinicians feel worried about taking that on… Because if someone’s really, really active[ly suicidal], we don’t have the capacity to see them. We would not take them because we wouldn’t be able to keep them safe because we don’t have the infrastructure. I know the [agency name] is maxed. I mean, they need like 12 more therapists there. (Participant 8)

Educating Healthcare Providers. Administrators frequently explained that providing affirmative, family-based treatment requires education and training. Six administrators (60%) spoke of a need to educate healthcare providers on affirmative, family-based services. Administrators need providers to be aware of the concept of family of choice, high rates of suicidality, and general inclusive language towards the LGBTQ + community. Participant 2 stated, “It kinda is roulette for these families, that it’s the luck of the draw if you do get a clinician that’s trained, that’s culturally sensitive and aware… I think that’s a grave indication and it doesn’t help the process.”

Interestingly, participants reported many healthcare providers agreed with this need, stating that providers often notice the shortcomings of their education to provide affirmative, family-based care and frequently request additional training. Participant 6 stated, “I feel that staff members will say, ‘We need the training,’ or ‘It would be helpful’” but that training does not sufficiently occur, “probably [because of] availability” of people to provide training on affirmative, family-based services. Another administrator echoed this, stating:

The exciting thing is that agencies jumped right on board. I was not pulling them to do this. They really understood, and it was very humbling for people to say, “I really do not have this skill. I really need to do a better job. (Participant 9)

Standardizing LGBTQ + Informed Care. Similar to the prior theme, three administrators (30%) identified the need for all providers to receive consistent and comprehensive education on LGBTQ + care, not only those specializing in working with LGBTQ + youth. Unfortunately, administrators described LGBTQ + informed care as tending to be viewed as a specialty within healthcare fields, and that this is a disservice to LGBTQ + youth.

I think the bulk of the work will be with providers that don’t center their work around this and having them understand why is important to have that skillset… all of us know that there’s LGBTQ people in the world, but if you are so used to serving this certain type of family, it’s not something that crosses your mind, nor does it feel like something you have to know about until you face it. (Participant 2)

Participant 6 further described this theme, stating that “you don’t hear that it’s an ongoing training. Talking with members receiving services, they might say that the training is needed.”

Perceived Value of ABFT. Six administrators (60%) expressed the belief that there is a need for implementing ABFT with LGBTQ + youth. They spoke to the need for viewing family challenges as related to attachment theory, the need for family-based services, and the need for providing validation and support for both caregivers and youth, all being core tenants of ABFT.

I think your particular formula [ABFT] seems very intriguing, because I don’t think our young people tend to explore their family challenges as attachment based… I think it would be beneficial… helping the young person be validated in their view but also understand the challenges their caregiver or loved ones that surrounds them maybe still be experiencing. (Participant 2)

Participant 7 validated this point and further described ABFT’s treatment potential, even in families where stigma, distrust, homophobia, or transphobia are present.

I’m very interested in ABFT, and I think it holds a ton of potential for this population. I think the hardest thing is just finding the parents where the stigma or the distrust or the homophobia or transphobia is not so great that they couldn’t get there. But I have to say my sense is, is that most families would be able to get there. (Participant 7)

Necessary Considerations for Implementing ABFT. While administrators were overwhelmingly interested in ABFT and family-based services, seven (70%) expressed logistical considerations for implementing ABFT with LGBTQ + youth. They highlighted a need to assess for and establish emotional safety for the youth, which administrators indicated may be difficult in a context where the youth have previously experienced significant ruptures of trust toward caregivers.

I think that this is a very intimate model in which very sensitive conversations are being held and there’s the potential that, if it’s in a very sterile setting, that people won’t be as open and there will be higher degrees of guardedness… I think it’s important to make it as comfortable as possible when controlling the space. (Participant 2)

A similar sentiment was expressed by another administrator who affirmed ABFT’s approach (which builds up to including all members of the family in the room) as being necessary as including caregivers with LGBTQ + youth too early holds the potential for creating further damage.

I appreciate the approach, and I agree that starting out with everyone in the room for some LGBTQ youth may be impossible and/or challenging and maybe even further damaging depending on what that relationship with the parent looks like… I imagine that it would, when the parties are ready to come together, need to be the thing that is prioritized over talking about school and relationships and other things. (Participant 10)

Support For Healthcare Workers. Two administrators (20%) described the need to provide increased support and supervision for existing healthcare workers. Participant 2 stated, “I would also learn and recognize that the clinicians from the ground floor weren’t getting good consistent clinical supervision… they very frequently weren’t getting the support they needed.” This was also described by participant 9 who described how service providers for LGBTQ + youth may be spread too thin due to the high level of need, stating, “maybe this child needs a different level of care or a different kind of attention or different interventions… providers may not be noticing because again they’re just caught on the hamster wheel” within their role.

Understanding Unique Experience of Racial/Ethnic Minorities. Four administrators (40%) described the need to consider how experiences for LGBTQ + youth with marginalized racial and ethnic identities vary from White LGBTQ + youth, as LGBTQ + youth of color have distinct needs which frequently go unmet.

I think we’re seeing this in other areas of the LGBTQ world where a lot of those services are geared towards, frankly, people who are not people of color or who are not youth or who do not have some of those other stressors. I think it’s great that we have those agencies for that sort of more mainstream and stable population. But meanwhile, these youth of color aren’t getting their needs met. (Participant 3)

Another administrator contextualized this need by describing the importance of attending to culture with sensitivity.

It depends on what cultural groups you’re interacting with, the intersection of being a double minority you are also a minority in sexual orientation but a minority racially, and the cultural implications that come with that. I think it’s way more delicate and sensitive also you have to be a lot more big picture because it’s so easy to miss something that’s staring right at you. (Participant 2)

Flexibility in Clinical Work. Two administrators (20%) expressed a need for flexibility in their approach to implementing family-based services with their clients, specifically in a desire to utilize treatments which allow for clinical flexibility to adapt to the unique needs for specific LGBTQ + youth.

There’s a lot of things that I appreciate about evidence-based practice, but there’s also things that make me feel like I’m limited to that particular idea, like… I can’t say certain things because I have to stick to the model… like, “today we have to work on this because it says on the pamphlet that this is how we have to do it.” It makes you feel like you are limited… But kids can see when it’s not authentic. (Participant 6)

Another administrator expressed the need for treatment to be flexible, not regimented or standardized, particularly in the context of involving family within treatment.

There’s some challenges to family integration… like at the fifth session, now is when you should have had a family session. There’s a lot of those regimented therapists I’ve mentioned before and nothing against them, because their particular skill set is great for certain populations and interactions, but I worry about those folks reading the manual and being like, alright session five, let’s go– even if the family isn’t ready. (Participant 2).

Barriers

Barriers are existing factors which prevent or hinder affirmative, family-based treatment for LGBTQ + youth. Nine barriers (see Table 2) were identified which generally focused upon insufficient affirmative services for LGBTQ + youth, concerns regarding harm from rejecting or invalidating caregivers, and forms of marginalization toward LGBTQ + individuals and youth.

Provider Reluctance to Refer. Three administrators (30%) described concerns referring to non-LGBTQ + healthcare organizations due to historical discrimination towards LGBTQ + individuals in healthcare settings and the failure of healthcare providers to serve their medical needs.

Historically… LGBTQ have not received the services they deserve… my experience has been… that they just don’t want to refer out even if you are reassuring them that the agencies you have identified do have the capacity or the competence and willingness to serve. But I think it stems from decades of not trusting, right? (Participant 9)

Participant 9 highlights mistrust that can occur as a result of decades of historical harm, but this reluctance can stem from ongoing reports from youth of negative experiences with other healthcare providers:

There are so few providers who can give LGBTQ-sensitive, affirming care. I know that’s a huge issue for the staff, because they don’t feel safe referring some of their youth to certain agencies in the city because of what they’ve experienced there. (Participant 8)

Invalidation from Caregiver. Four administrators (40%) described familial invalidation, such as denial of youth’s identity or mixed messaging about the acceptance of the youth’s identity, as a barrier to family-based services.

She would be open with her foster parent… and the foster parent would relay the message like, “you’re not, because you’re young, and this is just a phase you’re going through.” So essentially, she kind of shut that door of communication around that… you have to go with the comfortability of the client. And if they’re saying, “I don’t want them to know,” that’s a huge fear. (Participant 6)

Mistrust of Research. Two administrators (20%) discussed a mistrust in researchers due to historical discrimination within the LGBTQ + community, particularly for LGBTQ + individuals of color, which may act as a barrier to family-based services, but also accessing healthcare services generally.

I was sort of floored by the sort of level of not just mistrust towards research but towards the… medical establishment as a whole, and it wasn’t necessarily coming from the youth. It was actually coming from the adult leaders in the group… the history of Tuskegee and that there has been horrible racist things done in the spirit of medicine and research in the past. But I think it also can create this sort of barrier and distrust. (Participant 7)

Pattern of Inconsistent Relationships with Caregivers. Three administrators (30%) described concerns regarding family-based treatment for youth who have inconsistent relationships with their caregivers, a common phenomenon for LGBTQ + youth. Participant 7 described that it may be possible to work with the parents, but there can be contexts where youth do not want to re-establish relationships with their caregivers due to too extensive of a history of inconsistency, rejection, and hurt.

With the parents it’s almost easier because you can start with this, “we know you love your kid… we know you’re a good parent,” because it is sort of universally true. I think with the teen it’s harder… because sometimes there has been so much disappointment and let-down that the teen may really feel like they don’t know that they love their parents, and they may not really want that person in their life… they may have really made a definitive decision… that person just is not going to be in their life anymore. (Participant 7)

Concerns For Family Involvement. Seven administrators (70%) expressed concerns regarding utilizing family-based services for LGBTQ + youth, such as timing of involvement, youth fears, or need to incorporate family of choice. However, the most common theme, described concisely by participant 2, emphasized that LGBTQ + youth may frequently have immediate safety concerns that must be addressed prior to incorporating caregivers.

[Sometimes] rupturing is so severe that it’s very hard to figure out the appropriate stage to do that integration… You become so focused on how can I get this young person stable… how can I help them feel pride in themselves after they spent most of their childhood or most of their life being brought down and brought down. Sometimes you can’t do that work simultaneously. (Participant 2)

Current Logistical Barriers. Eight administrators (80%) highlighted logistical barriers to providing family-based treatment. These included such as scheduling conflicts, lack of comprehensive family assessments, and provider burn-out.

My main frustration was the clinicians challenge with rapport building and their lack of flexibility around working with the families… I understand, coming from the provider world its challenging, you don’t have a lot of time, you don’t have a lot of flexibility, you’re just trying to get through your caseload and off to the next one, but in terms of diligence to these families I don’t think it’s fair. (Participant 2)

Similarly, participant 3 described the high level of need for mental health services, generally, with an even greater need among specific services such as gender-affirming healthcare.

There’s such a need for mental health, and no program has the staff to support what their need is. I mean, everyone is strapped… There’s a huge waiting list at [agency name]. Huge waiting list everywhere. I don’t know what our wait is to get into our gender program now, but it is long. (Participant 3)

Family Rejection. Four administrators (40%) recognized how family rejection serves as a barrier to treatment for clients receiving affirmative care. Expected family rejection can prevent youth identity disclosure to family due to fears of homelessness and loss of financial support, and this can also prevent affirmative treatment.

It’s like, “Yes, I want you to be on hormones. I want you to be looking the way you want to or have the voice you want or be recognized by this name all the time, but also, is starting that going to mean that you lose your housing? Or does it mean that you’re going to lose all these supports in your life? Does it mean that you won’t be able to continue going to college because your parents are paying for college, and they don’t know or they’re not going to be approving, right?” (Participant 3).

Mandated Reporting Implications. Four administrators (40%) expressed that mandated reporting obligations might affect relationships between LGBTQ + youth and healthcare workers, as youth may have consistently felt outed, manipulated, betrayed, or trapped, and this may prevent youth from feeling comfortable participating in treatment.

No one wants to feel like they’re trapped, and three sessions into something, you say something and it’s like, “oh, by the way, I now have to report you.” These are potentially traumatic themes that have existed in peoples’ lives for a long time, these kind of manipulative power dynamics that I think are so detrimental. (Participant 5)

Concerns Perceived to Disproportionately Impact LGBTQ + Individuals. Six (60%) administrators discussed unique considerations for providing treatment to LGBTQ + youth, such as homelessness, trauma, and inconsistent caregiving, which they describe as disproportionately affecting LGBTQ + youth.

We tend to see LGBTQ populations that are at high risk for a lot of other socio-psychosocial factors, like homelessness, like being a person of color, like having trauma in your background, or not being raised by parents or loving caregivers… there are a lot of other cultural competencies that they need from a provider… their clinicians might not have all of those things. (Participant 3)

Facilitators

Facilitators are defined as existing factors which support affirmative, family-based treatment for LGBTQ + youth. Facilitators can be understood to be distinct from needs in that facilitators are described by administrators as existing, helpful factors, while needs are described as absent, but necessary factors. We identified 12 facilitators of care (see Table 3), which generally describe the benefits of integrative care, factors that assist organizations in navigating family involvement, and youth driven care.

Value of Integrative Care Model. Four administrators (40%) described the benefits of integrative care, which occurs when varying healthcare professionals collaborate (ideally within the same agency) to support LGBTQ + youth. Two administrators discuss these benefits below and highlight the ways in which this can increase treatment utilization and adherence.

I think the one-stop-shop is great. (Participant 3)

Yeah. I think we’re all medical home enthusiasts. That’s why we like it. (Participant 5)

I think what’s unique about trans patients in particular is that for better or for worse, there’s a huge motivator to keep coming because you want to keep… getting your hormone scripts. It’s not because they really want to be on their HIV meds. It’s because their motivator is the hormones… that can be great… because you just have that frequency of contact with the patient. (Participant 3)

Timing of Family Involvement. As previously described, many administrators expressed concerns regarding family involvement. However, two administrators (20%) emphasized the importance of individualized timelines for family involvement fit the needs of the youth, as all youth have unique backgrounds and family dynamics.

It’s situational too, like for one kid… their family might be involved earlier on in their treatment than another child… that child might not be ready for that conversation with mom or that child may not be ready to sit down and explain things or answer questions that mom or dad or grand mom or whatever might have. (Participant 1)

Facilitators of Family Involvement. Four administrators (40%) highlighted factors that aided in the involvement of family or caregivers in the treatment for LGBTQ + youth. These factors include establishing trust with caregivers or resolving attachment ruptures for youth. One administrator described the way in which relational work can reduce suicidality, depression, or poor medication adherence.

If you can work on the attachments related to suicidality or depression and that brings them to a closer point, that might be able to shift the parent… if you can build trust in that one domain, you may be able to move them closer… I think about my HIV patients, where we know that having parental support is going to help adherence… family support is going to help adherence. (Participant 7)

Another participant described how beginning treatment with individual meetings with youth and caregivers can facilitate the process of family-based services later on.

There’s a lot of things that I liked about that model in the sense that you are working with the individual first. It was a family-based modality, but you would work with them individually. And so, we would work with the individual… and then also doing the same thing with the parents… and then you bring them together and discuss.” (Participant 6).

Existing Support for Healthcare Workers. One administrator (10%) described how receiving internal agency support positively impacted their work and ability to help clients. While it was described as a facilitator by only one administrator, this theme directly related to a need (Need to Support Healthcare Workers) discussed by two other participants. Authors chose to include this theme as it highlighted the positive, facilitative effects that occur when agencies provide essential support for healthcare workers.

The supervisions really did help. We had phone conversations. But that was… once every month. That is a lot of time in between… So we had our supervisions every week regarding those cases, and it was pretty good. We got a lot of support. (Participant 6)

Importance of Affirmative Care. Two administrators (20%) described the importance of affirming LGBTQ + youth identities and experiences in providing treatment for LGBTQ + youth, which could include provider-client interactions, stakeholder representation, client paperwork, and website content.

When we became affirming, we really assessed ourselves at every level… we thought about board representation and staff make-up in terms of having staff on board to reflect the communities that we want to serve.…We looked at forms. We looked at our website. We looked at our brochures, made sure that that was all LGBT-affirming language. (Participant 8)

Recognizing One’s Own Biases. Three administrators (30%) emphasized the benefits when providers, including themselves, consider how their implicit biases, assumptions, and beliefs affect youths’ care. Administrator 2 described how self-reflection and awareness of biases builds trust with LGBTQ + youth, rather than eroding credibility:

Acknowledging that I’m in this clinician space, but there’s still things I can learn or there’s things I may have been unaware of. I don’t think that leads to lack of credibility, nor does it seem like this person doesn’t know what they’re doing. If anything, it’s again affirming to that person and their experience. (Participant 2)

Importance of Safe Space. Two administrators (20%) highlighted the facilitative effects of creating safe physical locations where LGBTQ + youth feel validated in their identity. One administrator described their agency as “a safe space that is confidential that they can talk about… all the things that they don’t necessarily want to talk about with their families” (Participant 4). This theme related directly to an identified need (Need for a Safe Space, which describes lacking, but needed safe spaces for LGBTQ + youth) and highlighted the positive impact that safe spaces provide for LGBTQ + youth to feel empowered to speak honestly about experiences with their providers without family present.

Youth Driven Care. Six administrators (60%) described positive effects that arise from centering the youth in all treatment decisions, even if the youth chooses to not involve family members in treatment.

It should just be youth led… if the youth says I want my family to be involved… I think then we should have the door open. If the child does not want their family involved… I think that agencies should honor that as well. (Participant 1)

Family of Choice. Six administrators (60%) described the facilitative, positive impact that occurs when providers recognize and incorporate youths’ family of choice in addition to or in replacement of their biological family in treatment, as chosen family is a common phenomenon for LGBTQ + youth.

I definitely have seen a lot of positive work around the family work in general and being receptive to the families that are not always biological… sometimes their actual families members don’t show up for family visits or they haven’t heard from them… I do think that providers are getting that the family system is not what it used to be once upon a time. (Participant 2)

Shift in Healthcare Culture. Five administrators (50%) explained how shifts in healthcare culture, like increasing the quantity and quality of LGBTQ + affirming providers, has led to far better care for LGBTQ + youth.

We do such amazing work with trauma and general patients… but none of them were or are LGBTQ specific… that, in a way, is the most exciting because we’re bringing it to general. Our goal will be that within each agency, there will be at least two or three, four, five clinicians who have this strong competence to serve LGBTQ youth, so you don’t have to depend on the, I don’t know, three, four LGBTQ-specific programs, many of which do not have the therapy piece. (Participant 9)

Importance of Involving Family. Six administrators (60%) stated that involving families can be essential to the treatment of LGBTQ + youth, including the positive effects of addressing prior attachment ruptures and reestablishing trust and safety.

We understand how intergenerational attachment ruptures, traumas, stressors impact people’s ability to parent and to provide that safe space… we start to prepare the parents and youth to have a different kind of conversation together. We call it reattachment experiences. We really want the parents to interact with the youth in a very different way than they have before and for the youth to experience the parent for the first time as being responsive and supportive… we find that once the relationship is more secure, that after these injuries are aired and there’s space for reflection and responsiveness around them, we’re able to tackle more of the bigger issues like transitioning, school, healthy relationships, other things that the parents could be a good resource. (Participant 8)

Inter-Agency Collaboration. Five administrators (50%) described the benefits of working collaboratively with other organizations. They described how establishing relationships with other agencies can improve trust and overcome common referral concerns for LGBTQ + youth, which can improve treatment outcomes.

At first, I thought, okay, they want nothing to do with me. And then the second conversation, things got better. Then we got to partner with them. And, okay, maybe they’re not at a point where they will refer out to our programs, but they’re being more open and they know that we’re doing this work, right? And maybe a year from now, they will refer… it’s all about showing that there’s other people doing this work, interested in this population, and interested because of the right reasons… I think the most important part is that you have the competence to do it. (Participant 9)

Discussion

This study explored the perspectives of administrators at LGBTQ + community centers to gain an understanding of needs, barriers, and facilitators related to the implementation of family-based treatment for LGBTQ + youth at LGBTQ + community organizations. While prior research has explored the perspectives of other key stakeholder groups, such as youth, their caregivers, and treatment providers, the present study is the first to explore the perspectives of administrators at LGBTQ + community organizations in the context of implementing family-based treatment for LGBTQ + youth with depression or suicidal ideation and behavior.

Our findings align with the existing literature on LGBTQ + mental healthcare, which have highlighted the importance of chosen family (Jackson Levin et al., 2020; Milton & Knutson, 2023) and a lack of family-based services and funding (Pachankis et al., 2021; Russon et al., 2022c). The present study provides insight into the perspectives of administrators, who echo the reports of clients and parents (Russon et al., 2022a) by describing family-based services for LGBTQ + youth as needed and beneficial. As the perspectives of LGBTQ + community organization administrators have not been previously explored, our findings represent novel contributions to the literature.

Needs

Within the nine distinct themes identified as needs, administrators repeatedly highlighted education and training regarding affirmative, family-based treatment for LGBTQ + youth as absent, inadequate, or inconsistent. All administrators recognized the utility of family-based services for LGBTQ + youth and expressed sincere interest in the implementation of these services in their respective agencies. They highlighted important, absent factors such as limited safe spaces (LGBTQ + affirming providers), a lack of training for LGBTQ + care amongst general healthcare providers, and insufficient clinical resources and support for LGBTQ + individuals with intersecting marginalized identities, echoing Pachankis et al. (2021). Administrators also consistently spoke of being insufficiently staffed and funded to provide sufficient training and quality of care for the high (and increasing) need to support this at-risk population.

Barriers

Nine distinct themes were created for existing factors that would impede or prevent the successful implementation of family-based services for LGBTQ + youth. One notable example is the reluctance or outright mistrust that administrators felt towards external agencies; this, to our knowledge, has not been documented in the literature on LGBTQ + affirmative healthcare. Born of decades of societal and institutional discrimination, administrators reported fears of providing referrals to non-LGBTQ+-specific organizations due to the feedback they had received: a pattern for providers to provide insufficient healthcare for LGBTQ + individuals. This could include benevolent ignorance, but also overt or covert perpetration of discrimination from treatment providers. Administrators expressed that LGBTQ + individuals, particularly individuals of color, may be reluctant to participate in research due to historical discrimination within research communities, as described by Pachankis et al. (2021). Administrators also reported concerns of the impact of discrimination and rejection of LGBTQ + youth from their families.

Ultimately, administrators appeared to view their role as providing a unique safe haven for LGBTQ + youth. Many of the barriers related to this role appeared to leave many administrators feeling two conflicting concerns, that (1) the LGBTQ + youth clients they serve are in need of far more support and services than can be provided at any one agency, as LGBTQ + community organizations are consistently overwhelmed by a need greater than the scope the existing staffing and funding can provide, findings that have been documented elsewhere (Pachankis et al., 2021). Conflicting with this, as a result of watching LGBTQ + youth experience harm and discrimination from healthcare providers, school systems, and their families of origin, (2) administrators are extremely protective of the population they serve and may be reluctant to refer their clients to other organizations.

Facilitators

12 existing factors were identified as being are essential for the successful implementation of family-based services for suicidal LGBTQ + youth. Administrators consistently voiced that family of origin cannot always be a part of treatment and it is essential to understand that LGBTQ + youth may, instead, rely upon their chosen family with whom they may not have shared genetics, a concept that has been previously documented (Jackson Levin et al., 2020; Milton & Knutson, 2023). Administrators described other facilitators such as youth driven care, a collaborative or integrative care model, regular training on LGBTQ + affirming care, and the benefits of sufficient funding and support for providers.

Throughout, administrators consistently described a need for more affirmative healthcare for LGBTQ + youth. They described progress made in recent years, such as increased awareness of LGBTQ + issues, quality and consistency of training programs, dedicated funds to support LGBTQ + youth, and the number of healthcare providers who wish to learn about providing affirmative care. While structural changes within an agency can be challenging, administrators reported optimism in the possibility of introducing family-based services for suicidal LGBTQ + youth due to witnessing positive structural change within their organizations in recent years.

Implications

Administrators in this sample come from a diverse range of healthcare and research backgrounds, allowing invaluable insights from the progress in recent years in the quality of affirmative LGBTQ + healthcare. However, administrators recognize that LGBTQ + youth have specialized needs and many barriers to implementing family-based services still exist. In order for LGBTQ + community organizations to provide the care (including family-based services) that is needed, there is a need for (1) improved, comprehensive education and training on LGBTQ + issues, (2) more consistent collaborative care with other affirmative organizations, and (3) improved resources in terms of funding and staffing.

Family represents both a strong risk and protective factor for the wellbeing of LGBTQ + youth (Austin et al., 2022; Puckett et al., 2019; Ryan et al., 2010) and family-based treatments for suicidal LGBTQ + youth show promising outcomes (Diamond et al., 2012; Russon et al., 2022a, c). Results from the present study suggest that administrators at LGBTQ + organizations view family-based services as helpful and needed.

In community organizations serving LGBTQ + youth, administrators are tasked with visioning how to respond to the sociopolitical challenges their constituents encounter as a pathway to attend to their individual health needs. As such, the inclusion of family as a supportive resource may serve as a means to create changes in the systems surrounding LGBTQ + youth. The themes elucidated in this study offer potential points of organizational inquiry that administrators might draw on when considering the addition or refinement of family-based services in their settings.

Limitations

This study explored the perspectives from LGBTQ + organization administrators in a large, mid-Atlantic city in the United States. While these results highlighted some insights into the needs, barriers, and facilitators associated with implementing family-based treatments in these settings, we recognize that these factors are likely influenced by the political landscape of the region. Participating organizations were well-known in the city and, in some cases, had been providing services for decades. In other regions of the country, LGBTQ + youth organizations may not have or desire the level of visibility as the organizations participating in this study. Navigating the implementation of family in clinical services would likely pose unique challenges for organizations who are in rural settings or are navigating a political landscape where LGBTQ + focused services may be less visible or resourced. In addition, although it was a major strength that our participant pool had such a broad knowledge, training, and expertise in their varying fields, the scope of focus and small-scale concerns and responses may differ between agency focuses (PrEP, therapy, gender affirming care), and the differences of reported concerns between agency focuses were not explored.

A final limitation of this study was the delay between data collection and analysis. Data collection occurred prior to major shifts in the sociopolitical landscape in which this study took place. As such, the results here illustrate administrator’s perspectives on their organizations prior to COVID-19 and the expedited transition of services to telehealth platforms. We recommend further research that re-examines the administrator perceptions in light of the vast changes to healthcare settings that occurred during and after the pandemic. Given the recurrent themes of administrator mistrust and hesitation with referring clients to outside organizations, we also recommend further research to explore strategies to build trust, foster partnerships, and strengthen referral networks to provide actionable insights for LGBTQ + community organizations.

Conclusion

This study employs the CFIR as a framework to explore administrators’ perceptions with regard to implementing family-based treatments in their LGBTQ + community centers. With the specific concerns of LGBTQ + youth with suicidal ideation and behavior in mind, administrators identified key needs, barriers, and facilitators associated with offering such services. While concerns were raised about the delivery of approaches like attachment-based family therapy, results demonstrated participant’s view of family-based treatments as important, beneficial, and needed.