The present study used qualitative methods to examine the approaches and experiences of 12 psychologists who were nominated by their peers to be highly skilled at LGBT-affirmative counseling in college and university counseling centers. A semi-structured interview was conducted with each participant addressing two research questions: What characterizes highly skilled LGBT-affirmative counseling in a college or university setting? What is challenging about LGBT-affirmative counseling in a college or university setting and what helps support this work? The data was analyzed using Consensual Qualitative Research (CQR) methodology. A total of seven domains and 48 categories were identified. The results present a detailed description of the characteristics, conceptualizations, and interventions of highly skilled LGBT-affirmative psychologists in college and university settings, as well as an engaging picture of the challenges and sources of support found in this work. Major study findings, study strengths and limitations, and implications are discussed.