On Psychotherapy With Lesbian, Gay and Bisexual Clients
Kristin A. Hancock, PhD
Graduate School of Professional Psychology
John F. Kennedy University
Pleasant Hill, California
Lesbian, gay, and bisexual (LGB) clients seek psychotherapy more often than their heterosexual counterparts (Bell & Weinberg, 1978; Jones & Gabriel, 1999; Perez, DeBord, & Bieschke, 2000; Cochran, Sullivan, & Mays, 2003). Although psychiatry and psychology once pathologized and sought to cure individuals with non-heterosexual orientations, LGB clients continue to believe in the benefits and value of psychotherapy. However, as Brown (2006) observes, these clients “…are more at risk for harm from ineffective therapies. As a vulnerable population, [they] have an enhanced need to receive psychotherapies that are effective and empowering” (p. 347).
Addressing the Needs of LGB Clients
For over 30 years, the American Psychological Association (APA) has encouraged an affirmative approach in working with clients with non-heterosexual orientations. APA’s Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients (Division 44/Committee on Lesbian, Gay, & Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients, 2000) were developed to assist practitioners by providing a frame of reference for the treatment of LGB clients and basic information in the areas of assessment, intervention, identity, relationships as well as the education and training of psychologists.
In order to approach treatment with LGB clients in an appropriate and affirmative manner, it is essential to be aware that, although progress has been made regarding the human rights of LGB people in the past several decades, LGB individuals are still subject to prejudice, discrimination, violence and harassment. Thus, practitioners should acquaint themselves with and assess clients for what is referred to as “minority stress.”
Minority Stress and Non-heterosexual Orientations
The term “minority stress” refers to the cumulative negative effects associated with prejudice, discrimination, violence, harassment, and any other abuse experienced by individuals in stigmatized groups (DiPlacido, 1998; Meyer, 2003). Indeed, studies suggest that LGB individuals have higher rates of stress-related disorders than do their heterosexual counterparts (e.g., Cochran & Mays, 2000; Cochran, Sullivan, & Mays, 2003; Gilman, Cochran, Mays, Hughes, Ostrow, & Kessler, 2001; Mays, Cochran, & Roeder, 2003). Meyer (2003) found that those who felt more frequently stigmatized or discriminated against, who felt they needed to conceal their sexual orientation, or who were prevented from affiliating with other LGB individuals were more likely to report mental health concerns. Practitioners need to appreciate the minority stressors their LGB and questioning clients experience and that these stressors may be directly related to or may exacerbate presenting problems.
The ability of the practitioner to evaluate the often subtle manifestations of stigma and prejudice is an essential skill in treating LGB and questioning clients. In order to do so, it is necessary to be able to recognize stigma and prejudice in the first place. There are countless ways in which LGB individuals sustain subtle “micro-aggressions.” Consider situations in which an adult LGB person in a committed relationship is asked to carry out most of the responsibilities for an elderly parent because other married heterosexual siblings are viewed as having familial responsibilities that prevent them from being available. Fassinger (2005) refers “a thousand points of slight”—ways in which LGB people are reminded relationally and institutionally second class status.
Practitioners should not view a client’s stress-related disorders as a consequence of his/her non-heterosexual orientation. This perspective is demeaning and pathologizing and denies the challenges that continue to confront sexual minorities. Moreover, for the past many methodologically sound studies have demonstrated that homosexuality in and of itself is not mental illness (Hancock, 2003). For over 30 years, the American Psychological Association has held that “…homosexuality per se implies no impairment in judgment, stability, reliability, or general social or vocational capabilities” (Conger, 1975, p. 633). As noted above, it is the stigma associated with non-heterosexual orientations that creates distress for LGB individuals—not the orientation itself.
Psychotherapy Issues and Resources for Practitioners
The issues most salient to LGB and questioning clients are outlined in the Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients (Division 44/Committee on Lesbian, Gay, & Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients, 2000) and involve practitioner attitudes and awareness, information pertaining to LGB families and relationships, and the diversity within the LGB communities. Liddle (1996) found that a therapist’s knowledge of issues specific to LGB clients is associated with client satisfaction with therapy. For a more in-depth review of some of these issues, several books are suggested. One text, entitled Handbook of Affirmative Psychotherapy with Lesbians and Gay Men (Ritter & Terndrup, 2002), covers concepts of sexual orientation, heterosexism, legal issues, identity formation and other developmental issues. It also includes information on various aspects of affirmative practice (e.g., assessment, phase-specific interventions, diversity within sexual minorities, career issues, religious concerns and spiritual development). There is a section on working with couples and families as well. Two other fine works edited by Perez, DeBord, and Bieschke (2000, 2007) cover a wide range of topics regarding the treatment of LGBT and questioning clients. Both books include excellent chapters on the ethical treatment of sexual minority clients and provide informative sections on cultural context and considerations.
A key element in the provision of LGB affirmative psychotherapy is practitioner self-awareness and sensitivity to negative attitudes and/or heterosexist bias as well as the capacity critically evaluate his/her own attitudes, feelings, beliefs, and values regarding LGB people and their relationships (Greene, 2007; Hancock, 2000; Morrow, 2000). Heterosexist bias involves a kind of “sexual orientation blind” approach to the issues of LGB individuals, couples, and families. The practitioner who suffers from this bias views his/her LGB client and his/her problems through the lens of heterosexual norms for identity, behavior, and relationships. This perspective can negatively impact the interpretation of LGB behavior, thoughts, and feelings. It denies the culturally unique experiences (including stigmatization) of LGB people.
In a study on the practitioner qualities preferred by LGB clients, Burckell and Goldfried (2006) found that clients consistently responded negatively to tentativeness or discomfort regarding non-heterosexual orientations manifested by such behaviors as overemphasis of sexual orientation; failure to recognize that the client was not heterosexual; and heterocentric language. Gingold, Hancock, and Cerbone (2006) refer to a “heterosexist default:”
The heterosexist default affects what therapists hear and understand about their clients and it perpetuates in LGB clients a sense of feeling unacceptable, invisible or stigmatized by the therapist. For example, a therapist inquiring about a female client’s significant other says, “Tell me about him.” …This puts the client in the position of having to correct the therapist or may lead the client to feel invisible, or worse, abnormal. The therapist would create a more open climate by asking instead, “Tell me about your partner” or even just “Tell me more” (p. 21)
As noted above, practitioners need to acknowledge the role of stigma in the lives of LGB individuals and be aware of the fact that it can pose risks to the mental health and well-being of LGB clients. Stigma can be internalized and result in a client’s having negative attitudes towards his/her non-heterosexual orientation. Stigma is so much a part of the fabric of LGB lives, a client may simply have become used to it and not see it at all or the toll it takes up his/her mental health and well-being. LGB couples may seek therapy for relationship problems and measure their successes and/or failures against heterosexual norms which may not be appropriate and may be problematic. It is the practitioner’s task to examine the extent to which an LGB person suffers from stigma—that which comes from within and that which comes from without. It should also be mentioned that practitioner prejudice and inaccurate information about sexual minorities can affect a client’s presentation and the process of therapy (Division 44/Committee on Lesbian, Gay, & Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients, 2000).
Without socially sanctioned forms and supports for their relationships and family systems, LGB people often create their own relational models and support systems (Division 44/Committee on Lesbian, Gay, & Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients, 2000). It is essential for the practitioner to understand and respect these relationships and support systems. For instance, LGB families may include people who are not legally or biologically related. LGB parents may face various challenges from societal institutions as they try to have, adopt, and raise children. It is also important to understand that a client’s sexual minority status can have an impact upon his/her family of origin and his/her relationship with that family of origin. For instance, practitioners and their LGB clients need to be aware of the fact that families of origin have their own coming out process to deal with and that this can take some time. Ritter and Terndrup (2002) include an informative chapter on this subject in their text. Pachankis and Goldfried (2004) also address issues in working with LGB couples, families of origin, and families of choice.
There is tremendous diversity within the LGB communities. Some of the most challenging issues for practitioners involve the interface of multiple identities—where, quite possibly, an individual may be experiencing stigmatization for two or more aspects of identity (e.g., race, gender, age, ability status, and sexual orientation). Moreover, practitioners need to understand that clients experiences differing degrees of stigma for different identities. For instance, two African American lesbians may have experiences with racism, sexism, and homophobia; however, each lesbian may experience these “isms” in different ways and to different degrees. Greene (1997) provides a thoughtful review of the challenges confronting ethnic minority lesbians and gay men and multiple sources of oppression.
Similarly, the experiences of bisexual women and men can be strikingly different from those of their gay and lesbian counterparts. The literature on this population has grown dramatically over the past decade. There is now a Journal of Bisexuality. This journal provides a considerable amount of information specific to bisexual women and men on such topics as negotiating (non) monogamy (McLean, 2003), the maintenance of marriages in mixed-orientation couples (Buxton, 2003), and the experience of coming out as bisexual (Knous, 2005). Firestein (2007) and Potoczniak (2007) provide two informative chapters on bisexual identity development in the text by Perez and his colleagues (2007).
The ways in which non-heterosexual orientations are defined and experienced by various age cohorts can present quite a challenge to practitioners. The societal context older LGB individuals experienced differs considerably from that in which today’s LGB youth find themselves. In addition, ageism is an issue—particularly in the gay male community. In his book Reeling in the Years: Gay Men’s Perspectives on Age and Ageism, Bergling (2004) takes an in-depth look at the issue of ageism in gay men from various perspectives.
LGB youth also have unique challenges. They can find themselves facing hostilities from peers, school authorities, and parents (D’Augelli, 1998). LGB youth are at risk for prostitution, sexual assault, truancy, suicide, and homelessness (e.g., Lock & Steiner, 1999) Practitioners should also take the time to consider the ways in which the psychological, ethical, and legal issues involved in the treatment of minors are made more complicated when working with LGB and questioning youth. The texts by Ritter and Terndrup (2002) and Perez and his associates (2000) include more detailed information regarding the treatment of this vulnerable population.
Advertising to Prospective LGB Clients
Most psychologists will likely encounter an LGB individual at some point in their practices (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991). Thus, a basic understanding of and respect for LGB individuals and the particular issues of sexual minorities is a good foundation for appropriate affirmative practice. It should be noted here that the practitioner characteristics that appear to matter most to LGB clients involve a good working knowledge of LGB issues and general therapeutic skill (Burkell & Goldfried, 2006)—not the sexual orientation of the therapist as is commonly thought.
Should a practitioner choose to develop his/her LGB client base, Cerbone (2006) suggests two general approaches to increasing the number of LGB and questioning clients: creating personal visibility and establishing professional credibility. Creating personal visibility involves local advertising (e.g., in the LGB press and program booklets for LGB events) and membership in LGB-identified organizations (e.g., Parents and Friends of Lesbians and Gays, political action committees and organizations, health service agencies, educational organizations such as Gay, Lesbian, and Straight Educational Network). Cerbone notes that the importance of being actively involved in such organizations can connect the practitioner to valuable referral sources. The same holds true for membership in LGB mental health associations. Cerbone (2006) emphasizes the importance of LGB sections of state psychological associations. Advertising in the association journal—and some of these might also be published on-line—will also increase a practitioner’s visibility to other professionals who may be looking for another professional who works with LGB individuals.
It is association membership that helps establish practitioner credibility. LGB tend to select psychologists as their therapists (Jones & Gabriel, 1999). This is likely not a coincidence. The American Psychological Association is well-known and well-regarded in the LGB community for its affirmative policies regarding LGB issues. State and regional psychological associations can also help establish practitioner credibility—particularly when those state and regional associations have LGB affirmative policies. Cerbone (2006) suggests offering workshops on topics of interest and importance to LGB individuals, couples, and families through LGB health and mental health agencies. The provision of continuing education workshops on topics related to LGB issues can connect the practitioner with referral sources as well. Volunteer work in the LGB community is an addition way to establish credibility. Teaching courses on LGB issues or teaching courses that contain specific course content on LGB issues can establish credibility and possibly result in referrals. Of course, word-of-mouth referrals cannot be neglected when talking about establishing practitioner credibility. Prospective LGB clients are very likely to ask about an LGB person’s experience regarding a practitioner’s comfort level and competence with sexual minority clients.
References
Bell, A., & Weinberg, M. (1978). Homosexualities: A study of diversity among men and women. New York: Simon & Schuster.
Bergling, T. (2004). Reeling in the years: Gay men’s perspectives on age and ageism. New York: Haworth Press.
Brown, L.S. (2006). The neglect of lesbian, gay, bisexual, and transgendered clients. In J.C. Norcross, L.E. Beutler, & R.F. Levant (Eds.), Evidence-based practices in mental health: Debate and dialogue on the fundamental questions (pp. 346-353). Washington, DC: American Psychological Association.
Burkell, L.A., & Goldfried, M.R. (2006). Therapist qualities preferred by sexual-minority individuals. Psychotherapy: Theory, Research, Practice, Training, 43, 32-49.
Buxton, A.P. (2003). Works in progress: How mixed-orientation couples maintain their marriages after the wives come out. Journal of Bisexuality, 4, 58-82.
Cerbone, A.R. (2006). Practice opportunities in the lesbian, gay, and bisexual community. Retrieved June 13, 2007 from http://www.apapractice.org/apo/insider/professional/apaapproved/GuidelinesPractice/opportunities.html.
Cochran, S.D., & Mays, V.M. (2000). Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: Results from NHANES III. American Journal of Public Health, 90, 573-578.
Cochran, S.D., Sullivan, J.G., & Mays, V.M. (2003). Prevalence of mental disorders, psychological distress, and mental services use among lesbians, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71, 53-61.
Conger, J. (1975). Proceedings of the American Psychological Association for the year 1974: Minutes of the annual meeting of the Council of Representatives. American Psychologist, 30, 620-651.
D’Augelli, A. (1998). Developmental implications of victimization of lesbian, gay, and bisexual youth. In G. Herek (Ed.), Psychological perspectives on lesbian and gay issues: Vol. 4. Stigma and sexual orientation: Understanding prejudice against lesbians, gay men, and bisexuals (pp. 187-210). Thousand Oaks, CA: Sage Publications.
DiPlacido, J. (1998). Minority stress among lesbians, gay men, and bisexual: A consequence of heterosexism, homophobia, and stigmatization. In G. Herek (Ed.), Stigma and sexual orientation: Understanding prejudice against lesbian, gay men, and bisexuals (pp. 138-159). Thousand Oaks, CA: Sage Publications.
Division 44/Committee on Lesbian, Gay, & Bisexual Concerns Joint Task Force on Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients. (2000) Guidelines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440-1451.
Fassinger, R. (2005). A thousand points of slight: Diverse lesbian sexualities in heterosexist context. Paper presented at the University of Maryland colloquium on Intersections and Sexualities” April 21, 2005. Retrieved on June 13, 2007 from http://www.crge.umd.edu/events/cs0504.htm.
Firestein, B.A. (2007). Cultural and relational contexts of bisexual women: Implications for therapy. In R.M. Perez, K.A. DeBord, & K.J. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp. 91-117). (2nd ed.) Washington, DC: American Psychological Association.
Garnets, L., Hancock, K.A., Cochran, S.D., Goodchilds, J., & Peplau, L.A. (1991). Issues in psychotherapy with lesbians and gay men: A survey of psychologists. American Psychologist, 46, 964-972.
Gilman, S.E., Cochran, S.D., Mays, V.M., Hughes, M., Ostrow, D., & Kessler, R.C. (2001). Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey. American Journal of Public Health, 91, 933-939.
Gingold, H.G., Hancock, K.A., & Cerbone, A.R. (2006). A word about words: Stigma, sexual orientation/identity, and the “heterosexist default.” NYPSA Notebook, 18, 20-24.
Greene, B. (1997). Ethnic minority lesbians and gay men: Mental health and treatment issues. In B. Greene (Ed.), Psychological perspectives on lesbian and gay issues: Vol. 3. Ethnic and cultural diversity among lesbians and gay men (pp. 216-239). Thousand Oaks, CA: Sage Publications.
Greene, B. (2007). Delivering ethical psychological services to lesbian, gay, and bisexual clients. In R.M. Perez, K.A. DeBord, & K.J. Bieschke (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp. 181-199). (2nd ed.) Washington, DC: American Psychological Association.
Hancock, K.A. (2000). Lesbian, gay, and bisexual lives: Basic issues in psychotherapy training and practice. In In B. Greene & G. Croom (Eds.), Psychological perspectives on lesbian and gay issues: Vol. 5. Education, research, and practice in lesbian, gay, bisexual, and transgendered psychology (pp. 91-130). Thousand Oaks, CA: Sage Publications
Hancock, K.A. (2003). Lesbian, gay, and bisexual psychology: Past, present, and future directions. In J.S. Mio & G.Y. Iwamasa (Eds.), Culturally diverse mental health: The challenges of research and resistance (pp. 289-307).
Jones, M.A. & Gabriel, M.A. (1999). Utilization of psychotherapy by lesbians, gay men, and bisexuals: Findings from a nationwide survey. Journal of Orthopsychiatry, 69, 209-219.
Knous, H. (2005). The coming out experience for bisexuals identity formation and stigma management. Journal of Bisexuality, 5, 37-59.
Liddle, B.J. (1996). Therapist sexual orientation, gender, and counseling practices as they relate to ratings of helpfulness by gay and lesbian clients. Journal of Counseling Psychology, 43, 394-401.
Lock, J., & Steiner, H. (1999). Gay, lesbian, and bisexual youth risks for emotional, physical, and social problems: Results from a community-based survey. Journal of the American Academy of Child and Adolescent Psychiatry, 38, 297-304.
Mays, V.M., Cochran, S.D., & Roeder, M.R. (2003). Depressive distress and prevalence of common problems among homosexually active African American women in the United States. Journal of Psychology and Human Sexuality, 15, 27-46.
McLean, K. (2003). Negotiating (non) monogamy bisexuality and intimate relationships. Journal of Bisexuality, 4, 84-97.
Meyer, I. (2003). Minority stress and mental health in gay men. In L. Garnets & D. Kimmel (Eds.), Psychological perspectives on lesbian, gay, and bisexual experiences (pp. 699-731). (2nd ed.) New York: Columbia University Press.
Pachankis, J.E. (2004). Clinical issues in working with lesbian, gay, and bisexual clients. Psychotherapy: Theory, Research, Practice, Training, 41, 227-246.
Perez, R.M., DeBord, K.A., & Bieschke, K.J. (2000). Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients. Washington, DC: American Psychological Association.
Perez, R.M., DeBord, K.A., & Bieschke, K.J. (2007). Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients. (2nd ed.) Washington, DC: American Psychological Association.
Potoczniak, D.J. (2007). Development of bisexual identities and relationships. In R. M. Perez, K.A. DeBord, & K.J. Bieschke, K.J. (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients (pp. 119-145). (2nd ed.) Washington, DC: American Psychological Association.
Ritter, K.Y. & Terndrup, A.I. (2002). Handbook of Affirmative Psychotherapy with Lesbians and Gay Men. New York: Guilford Press.