Practitioner's Info - LGB Clients and their Therapists

As psychology turns its attention to the concerns of a more diverse population, practitioners are confronted with a “learning curve.” Most practicing psychologists have had little training in the specific issues of these populations. Yet, the potential for practitioners to expand their practices into these areas remains for those who pursue the “learning curve.”

Consider the lesbian, gay, and bisexual (LGB) communities. It is likely that most psychologists will encounter an LGB individual at some time in their practices (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991). Furthermore, LGB individuals tend to seek psychotherapy more frequently than their heterosexual counterparts (Bell & Weinberg, 1978; Jones & Gabriel, 1999). Therapist knowledge of issues specific to LGB clients has been found to relate to client satisfaction (Liddle, 1996) making increased knowledge and skills valuable.

LGB individuals are still subject to social prejudice, discrimination, and violence. “Minority stress” is a term used by researchers (DiPlacido, 1998) to describe the cumulative negative effects associated with the prejudice, discrimination, violence, and other adverse social conditions experienced by individuals in stigmatized groups. There are some indications that LGB individuals may have higher rates of stress-related disorders than do their heterosexual counterparts (see e.g. Meyer, 2003).

It is important to note that psychology has acquired substantial credibility within the LGB communities. In fact, LGB individuals tend to choose psychologists for their therapists (Jones & Gabriel, 1999). Psychology has long been a leader among mental health professions in fostering mental health practices and policies based on accurate information and understanding of LGB individuals and their lives and has advocated for anti-discrimination policies and legislation (Cerbone, 2004).

The most important issue to name involves the effects of stigma and discrimination. Whether a response to culturally imposed forms of stigma and discrimination or a response to internalized stigma, practitioners should learn to recognize the often subtle manifestations of stigma and prejudice and to evaluate the psychological toll on the client. It is also important to remember that cultures vary considerably in their views regarding homosexuality and that these views are made more complicated by a culture’s notions of gender, gender roles, and other values (e.g., religiosity) (APA, 2000).

LGB persons often present issues in psychotherapy such as depression or anxiety that are not manifestly related to sexual orientation (e.g., coming out at home or work). One study found that, in about two-thirds of cases, clients viewed their problems as having nothing to do with sexual orientation (Jones & Gabriel, 1999). Heterosexist bias (Anderson, 1996; Brown, 1989) which views the LGB client through heterosexual norms for identity, behavior, and relationships can negatively effect the interpretation of LGB behavior, thoughts, and feelings (APA, 2000.) Therapists may also be vulnerable to approaching treatment with a “sexual-orientation blindness” which denies the culturally unique experiences of LGB persons (APA, 2000). Indeed, clients themselves may not recognize that their symptoms may be due in part to stigma. One effect of stigma for clients may be internalized negative attitudes toward their sexual orientation. This can be especially true of older LGB clients who have had different developmental experiences than younger LGB men and women (Kimmel & Sang, 1995).

Many same-sex couples seek therapy for typical sources of conflict in relationships, (e.g., money, family, sex, or religion). A couple may be referencing their success or failure as a couple against heterosexual norms, which can be problematic. Exploring cultural norms in LGB communities and the couple’s understanding of them may help to normalize their conflicts and improve their hopes for resolution.

HIV/AIDS remains a potent source of discrimination and bias for gay and bisexual men. In communities of color, it is complicated further by racial and ethnic prejudice. Religious values may positively or negatively affect a person living with HIV/AIDS, depending on the religion’s attitudes toward sexual orientation and sexuality in general. Because more gay, bisexual, and transgender men are living longer and symptom free, they may seek counseling for life issues that are not directly related to health issues. HIV/AIDS, nonetheless, continues to be an incurable, though manageable, life-threatening disease that affects every aspect of a person’s life. Examining with a gay client his experience and history with HIV/AIDS can illuminate the subtle and not-so-subtle ways that the disease affects his relationships, career, sexual behavior, and social life. For example, has his diagnosis changed his friendship to include primarily other HIV-positive men? Recognizing the relevance of several cultural norms and their overlapping effects can positively affect treatment.

Resources

The American Psychological Association (APA) has developed a number of resources and policies designed to assist psychologists in the provision of services to LGB people. APA’s Appropriate Therapeutic Responses to Sexual Orientation (APA, 1997) discusses important issues to be considered when psychologists are asked to participate in sexual orientation change (also known as “reparative therapy”). The APA also has its Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients (APA, 2000). This document was developed to help psychologists identify the fundamental issues unique to the assessment and treatment of LGB individuals, couples, and families and contains references practicing clinicians may find most useful.

In addition, entire textbooks are now available on the psychotherapeutic treatment of LGB clients. For clinicians interested in couples and families, Laird and Green (1996) discuss same-sex parenting, relationships, and issues with families of origin. Ritter and Terndrup (2002) have written an excellent book called the Handbook of Affirmative Psychotherapy with Lesbians and Gay Men. Perez, DeBord, and Bieschke (2000) have given us the Handbook of Counseling and Psychotherapy with Lesbian, Gay, and Bisexual Clients. Continuing education coursework also offers practitioners the opportunity to become more informed about current issues in psychotherapy with LGB clients. This coursework is presented at the national, state, and local levels through such organizations as APA, various state psychological association conferences, and individual continuing education programs all over the country.

References

American Psychological Association (1997). Therapeutic Response s to Sexual Orientation.

American Psychological Association (2000). Guidelines for psychotherapy with lesbian, gay, and bisexual clients.

Bell, A., & Weinberg, M. (1978). Homosexualities: A study of diversity among men and women. New York: Simon & Schuster.

Cerbone, A. (2004). “Catering to Queers: Succeeding in Independent Practice.” In R. Dudley-Grant (Chair), Expanding diversity in your practice. Symposium conducted at the 112th annual convention of the American Psychological Association, Honolulu, HI, 2004.

DiPlacido, J. (1998). Minority stress among lesbians, gay men, and bisexuals: A consequence of heterosexism, homophobia, and stigmatization. In G. Herek (Ed.), Stigma and sexual orientation: Understanding prejudice against lesbians, gay men, and bisexuals (pp.138-159). Thousand Oaks, CA: Sage Publications.

Garnets, L., Hancock, K., Cochran, S., Goodchilds, J., & Peplau, L. (1991). Issues in psychotherapy with lesbians and gay men: A survey of psychologists. American Psychologist, 46, 964-972.

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.

Kimmel, D. & Sang, B. (1995). Lesbians and gay men in midlife. In A. D’Augelli & C. Patterson (Eds.), Lesbian, gay, and bisexual identities over the lifespan: Psychological Perspectives, (pp. 190-214). New York: Oxford Press.

Laird, J., & Green, R.J. (1996). Lesbians and gays in couples and families: A handbook for therapists. San Francisco, CA: Josey-Bass.

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.

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, Second Edition (pp. 699-731). New York: Columbia Press.

Perez, R.M., DeBord, K.A., & Bieschke, K.J. (2000). Handbook of counseling and psychotherapy with lesbian, gay, and bisexual clients. Washington, DC: APA.

Ritter, K., & Terndrup, A. (2002). Handbook of affirmative psychotherapy with lesbians and gay men. New York: Guilford Press.

¹ This article is based on a paper presented by Armand R. Cerbone as part of a symposium, R. Dudley-Grant (Chair), Expanding Diversity in Your Practice, conducted at the 112th annual convention of the American Psychological Association, Honolulu, HI, 2004, sponsored by the Division 42 Diversity Task Force. It also appears here, co-authored by Cerbone & Hancock, as the first contribution to Independent Practice of the Division 42 Lesbian, Gay, Bisexual, and Transgender Task Force.

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