Building resilience in marginalized patients

As a licensed counseling psychologist by training, Brown University’s Shufang Sun, PhD, who serves on APA’s Mental Health Technology Advisory Committee, focuses her research on developing and evaluating culturally responsive, trauma-informed digital mental health interventions for youth who have experienced adversity, including stigma, discrimination, poverty, war, and displacement.

Sun, who directs the Global Mental Health and Flourishing Lab (formerly the Mindfulness for Health Equity Lab) at Brown, is the author of Mindfulness-Based Queer Resilience (MBQR), an adapted mindfulness intervention designed specifically for LGBTQ+ young adults experiencing minority stress and mental health concerns. Her research emphasizes resilience as a learnable skill and advocates for interventions that incorporate what community members already use for healthy coping rather than imposing top-down, Western psychology frameworks.

Growing up in a psychiatric hospital campus in 1980s China, where her mother worked as a psychiatric nurse, Sun developed an early awareness of the global mental health gap and the stigma surrounding mental illness—motivations that continue to drive her work today.

We asked her to break down her research findings into the key takeaways for clinicians.

Mental health symptoms don’t affect all groups equally, and there are significant inequalities in both access to treatment and treatment outcomes. Young people bear a particularly significant burden. For example, globally, suicide is the fourth leading cause of death among young people—in the United States, it’s number two. About 75% of psychiatric disorders occur before age 24, and about 50% before age 14, which means early detection and early treatment are key to addressing mental health needs and preventing relapse.

For sexual and gender minorities, particularly youth, experiences of what we call minority stress—stress that stems from being a minority member of society—can include a range of experiences from very explicit discrimination and violence to internalized beliefs. Over time, people may start believing they are unlovable or unworthy as these external experiences “get under their skin,” or they start anticipating rejection even before it happens. All of this has a significant impact on mental health. For example, data from the Trevor Project’s Project SPARK Interim Report (2023–2025)opens in new window found that 1 in 3 LGBTQ+ youth reported seriously considering suicide within the past year.

Racial and ethnic minorities experience prevalent depression and anxiety, but they are less likely to seek psychological support. And when they do, they are more likely to prematurely withdraw from treatment, often in part because the treatment they receive is not very culturally competent.

As a field, we now have a much better understanding of how these “structural determinants of mental health” affect downstream mental health outcomes. But how we view treatment—both in intervention development and how we think about the system of treatment—has not been evolving in response to that knowledge. We’re still thinking in terms of symptoms. We’re still thinking about giving people manualized treatment that does not incorporate understandings of stigma or these structural forces of adversity that drive mental health outcomes.

It really depends on the patient and the salient identities they bring into therapy. Most clinicians already recognize cultural identities that carry stigma, but they might not be naming them explicitly.

The first step is naming the stigma and the context people live in. When we can articulate with a patient how their cultural context or lived experiences of adversity affect the way they cope, the patient feels understood. That understanding itself can help people relocate the self-blame and self-stigmatization to a better self-understanding and self-awareness, which can drive change.

Clinicians should ask: How do these experiences of adversity affect this specific individual’s nervous system, when, for example, an individual becomes hypervigilant to stay away from bullying at the expense of their capacity for emotional regulation? How can we conceptualize their struggle not just as a disorder, but as a response to their environment?

Early life adversity has a profound and long-lasting impact. We know from the literature that such adversity is linked to heightened physiological stress responses, such as altered hormonal response to stress, and that living in a chronically stressful environment can deplete a person’s internal coping resources over time.

In our research, we see this manifest as “downstream” effects: depression, anxiety, and even physical health risks like overeating or risky sexual behavior. When clinicians work with these patients, they need to understand that the patient’s nervous system has been trained to be in a state of hypervigilance.

Practices such as mindfulness can be a powerful tool to expand the window of tolerance, or an individual’s optimal zone where they can function effectively without becoming overwhelmed or shutting down and provide more psychological and physical resources for coping. Mindfulness emphasizes skill-building—treating wellness as a mental skill to be learned—rather than solely focusing on psychopathology, and this can be very affirming for communities affected by a health system that treats them as pathological.

Imagine a regulatory self-energy that we all have. If we have to use it constantly to navigate day-to-day experiences, we quickly become exhausted. Mindfulness can be a way of building reserves of this energy. It’s also a way of shifting attention. If you think about a child who must be very watchful of their environment, who must turn their attention almost always externally to be safe, they easily become hypervigilant. In our research, we find mindfulness can be a way to calm the nervous system and draw attention back to the self, supporting self-kindness and self-nurturing.

When we started developing more community-centered mindfulness interventional approaches, we were very careful about how mindfulness could be perceived. There is a version of mindfulness that is very predominantly White middle-class. We developed Mindfulness-Based Queer Resilience (MBQR) out of the need for culturally responsive interventions. Traditional models often assume a universal experience, but for sexual and gender minority individuals, the source of stress is often external—stigma, rejection, and exclusion, and grounded in their social identities.

MBQR is a 10-week program that explicitly targets minority stress. We use mindfulness to help participants become aware of internalized stigma—those deeply held beliefs that one’s identity is a source of shame or unworthiness. We incorporate LGBTQ+-related content and facilitate queer resilience by using nonjudgmental awareness to move toward identity integration and self-love. It’s about more than just reducing stress; it’s about patients affirming who they are in a world that has often told them they are “less than.” We’re working with Brown University to make the teacher manual for MBQR free to the public.

The experiences of meditating can be vastly different for people with high histories of trauma compared to those with relatively low trauma experiences. In fact, asking someone with a significant trauma history to close their eyes and pay attention to internal experiences can be very, very overwhelming and scary.

One of the intervention principles in MBQR is being sensitive to individual and community trauma. We actually never ask people to close their eyes, and there’s always options provided in the beginning in terms of having eyes open, closed, or gazing down. We also do a lot of scaffolding. We start with a curiosity practice that’s externally focused. Teaching people to be curious is a way of helping them be open and pay attention to particular experiences, helping them find ways to go deeper. It doesn’t have to be “What am I internally feeling right now?” Rather, it could be “What is this part of my body feeling?” or “Be curious about a particular sound I’m hearing.”

We also educate people early about zones of experience, which is an adapted version of the window of tolerance. For example, what’s the experience like when I’m in my comfort zone versus my growth zone, where I’m engaged, alert, and challenged, versus my overwhelmed zone, where I’m either too anxious or completely checked out, numb, and shut down? It’s helpful for people to identify early what that might look like for them, knowing those states could happen in life and in meditation. And how do we work with that? We provide lots of options to foster agency and skills building, including working with these difficulties during meditation practice by grounding oneself in the moment or even stopping meditating.

Recognize their resilience. Our work acknowledges the incredible resilience of the communities we serve. Mindfulness isn’t about fixing a person; it’s about empowering them with the agency and self-awareness to navigate a difficult world. When you help a patient feel safe in their surroundings or find peace in difficult situations, you aren’t just treating a symptom, you are helping them build a more fulfilling life.