Becoming an LGBT Affirmative Clinician: Introduction, Context, and Considerations

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Becoming an LGBT Affirmative Clinician: Introduction, Context, and Considerations

 

Lesbian, Gay, Bisexual, and Transgender (LGBT) Affirmative Therapy (Definition):

“the integration of knowledge and awareness by the therapist of the unique developmental cultural aspects of LGBT individuals, the therapist’s own self-knowledge, and the translation of this knowledge and awareness into effective and helpful therapy skills at all stages of the therapeutic process” (Perez, 2007, p. 408).

 

Introduction

 

In considering working with LGBT clients, clinicians should first consider whether or not they are interested in that population; at the same time, they should determine whether or not they possess sufficient knowledge of LGBT individuals’ concerns, capacity/willingness to support and validate those concerns, and experience in interacting with LGBT individuals in personal or professional contexts. The American Psychological Association (APA; 2009) has provided guidelines for ethical practice in working with LGBT individuals, which appear culturally sensitive while also seeming to come from a place of harm reduction. While “do no harm” is a vital fundamental principle, to be sure, certain providers may strive to reach a much higher benchmark. Many clinicians are interested in the utmost culturally competent and effective care for their LGBT clients and wonder how they might better arm themselves with the necessary tools for doing so. Namely, those providers may be interested in becoming LGBT affirmative clinicians.

 

This article serves as an introduction to LGBT affirmative clinical work and is by no means exhaustive. As such, the reader is referred to the growing body of literature on LGBT affirmative therapy and continuing education training on the topic. As an overview and stepping stone, the following sections present an historical context, including a history of complicated interactions between psychology and the LGBT community, before providing considerations for clinicians as they consider their own transition to competent LGBT affirmative care.

 

An Extremely Brief Historical Context

Clinicians would do well to remember that professional mental health organizations (i.e. APA) were not always so kind to LGBT individuals. In fact, until 1973, homosexuality was considered a diagnosable condition. In accordance with the view of non-heterosexual behaviors (and desires) as abnormal, many individuals were subjected to harmful “conversion” therapies that were designed to reframe or punish their same-sex preferences. Conversion techniques included but were not limited to electroconvulsive therapy, hormone therapy, punishment (i.e. inducing nausea or pain) for showing arousal to pictures of same-sex individuals, estrangement from certain friends and family members, or cognitive techniques to reframe homosexual thoughts and desires.  Our own American Psychological Association (APA) has since come a long way. At this point in time, the APA considers conversion therapies to be unethical, as research has shown that while such therapies have been shown to be ineffective in changing individuals’ sexual orientations, they are associated with increased anxiety, depression, hopelessness, sense of failure, and suicidal ideation, decreased sexual functioning and spirituality, and very high attrition. Unfortunately, many clinicians continue to champion conversion and other “reparative” therapies. In response, the American Psychological Association (2009) has recommended that before professional psychologists engage LGBT clients, they examine their own potential biases, collect sufficient relevant information about the LGBT population, and recognize diversity within the group itself, so as to ensure that clinicians are not harming clients by reinforcing negative biases held by the client, therapist, or society.

 

Considering a broader historical context, one can see that in recent years, western societies have introduced positive and celebrated changes to the lives of LGBT individuals. In 2010, the so-called “Don’t Ask, Don’t Tell” policy that banned (and discharged) openly gay and bisexual military service members was overturned following testimony that sexual orientation appeared to have no significant effect on military readiness(Cannistra, Downs, & Rivero, 2010). Only one year ago (June 2015) the U.S. Supreme tackled the case of Obergefell v. Hodges, which ultimately resulted in federal recognition of same-sex marriage. Despite those positive changes and legal protections for LGB individuals, as this article is written, the eyes of the American people are on rampant anti-transgender (as well as broader anti-LGBT) legislature, which have prevailed if not gained ground over time, as a result of dissenting conservative opinions. This is vehemently demonstrated in the state of North Carolina’s 2016 house bill 2 (HB 2), which, among other dangerous provisions, openly discriminates against transgender individuals by forcing them to use public bathrooms that correspond to their biological sex. Thus, as the country debates the validity of transgender concerns over the watercooler, those affected currently risk legal consequences and violent attacks simply by seeking to use the toilet or washing their hands (a public health concern).

Unfortunately, much of modern society continues to harbor widespread and enduring heterocentrism.  Heterocentrism refers to the biased perspective that heterosexual practices are better than those of sexual minorities and typically includes the belief that a genderless society would be wrong. Many assume that heterocentrism is a culturally shaped unconscious bias rather than reflective of an individual’s (or system’s) potential homophobia; however, the effects are damaging nonetheless. Even if unintentional, heterocentrism can still lead to misunderstanding, inadvertent discrimination, and invalidating interactions; however, at the other end of the continuum, there are those in power that actively oppress LGBT individuals by denying them services and violating their civil rights, simply on the grounds of their status as LGBT. As such, LGBT individuals continue to experience frequent signals that they would better thrive in the workplace, school, or at home by hiding their true sense of identity. Thus, although it seems there has never been a better time in history to be LGBT, such individuals are a far cry from equal to the heterosexual majority; this notion sets the stage for the need for strong LGBT allies, advocates, and LGBT affirmative clinicians.

Becoming an LGBT Affirmative Clinician: Beginning Considerations    

 

There are many considerations for operating an ethical and culturally competent practice. In this case, being an LGBT affirmative clinician begins in the waiting room. To illustrate this point, the reader is asked to consider their practice through the eyes of an LGBT individual. Take a moment to look around your clinic waiting room. Does your clinic happen to have LGBT inclusive magazines or pamphlets available? Do the intake forms simply present “male” or “female” as gender options? Might the forms instead provide a blank line next to the question of gender, where clients may write in their own responses? Are there any symbols of LGBT advocacy in sight? In community agencies or private practice, this might include the trademark blue and yellow “equality” symbol circulated by the Human Rights Campaign (HRC; “Our Logo”) or, in the Veterans Health Administration (or VA) the poster released by Patient Care Services that boldly states, “We Serve All Who Served.” These are just a few simple methods of creating a more affirming environment.

 

As the initial session begins, an LGBT affirmative clinician makes use of a basic skill learned in professional training: adopt the client’s language. In this way, if a client refers to their “partner,” an LGBT affirmative clinician uses the term “partner,” as well, and does not assign a gender to that individual or assume that the client is of a particular orientation. LGBT affirmative clinicians also honor their clients’ requests for certain gendered pronouns (i.e. “he” or “she”) regardless of how they may appear. With all considered, such guidelines simply reflect thoughtful person-centered care.

 

That said, even clinicians with the very best of intentions may be perceived as potentially ill-informed or even invalidating. Due to the nature of being consistently marginalized, many LGBT individuals become attuned to possible bias or hostility; they may even come to expect it (Heck, Flentje, & Cochran, 2013). This can occur when a clinician asks a new male client if he has a wife, when unbeknownst to the clinician the client actually has a husband and consequently feels disappointed in his therapist for her assumption. Still other clinicians might convey hostility by asking biased questions such as, “You’re not gay, are you?” that seem to imply that there might be something wrong if the client were to answer, “Yes.” For these reasons, LGBT affirmative clinicians are careful to consider their choice of words before asking questions and also to ensure that their statements do not imply judgment. In many cases, LGBT affirmative clinicians directly inform their clients of their affirmative status. After  all, in the beginning stage of therapy, neither party knows the other and both seek to determine whether a good quality therapeutic relationship might develop between them. As Heck and colleagues (2013) suggest: “Thus, therapist affirmation during an intake interview is likely a key “nonspecific factor” relevant to an LGBT client’s continuation and progress in psychotherapy” (p.24).

 

When it comes to presenting concerns, an LGBT affirmative clinician remains open and does not presume to know why an individual might be seeking therapy. Psychology Intern Yinchi (Gigi) Li offers, “Don’t assume the LGBT person is coming in for therapy because they are distressed [about] their sexual orientation.” Indeed, although many LGBT individuals might experience higher rates of anxiety, depression, or substance use (see Heck et al., 2013), it is biased to assume that clients present with problems because they are LGBT or to conceptualize them only in terms of their sexual orientation or gender identity. Instead, LGBT affirmative clinicians continue to follow their client’s lead in uncovering their particular concerns.

 

 

Conceptual Considerations: Self-acceptance, Identity, and Disclosure

 

Many clients may seek help with self-acceptance related to their own sense of identity, morality, or internalized homophobia (Pachankis & Goldfried, 2004). Clinicians might assess some of the ways in which their clients have learned to hide their true identities throughout development and into adulthood. LGBT individuals might not readily report experiencing a period of internalized heterocentrism or homophobia but their actions to hide or avoid (i.e. through overcompensating by adopting strict traditional gender roles, substance abuse, etc.) might suggest a core sense of shame. For these reasons, adopting an identity as lesbian, gay, bisexual, transgender, queer, questioning, or an otherwise non-heterosexual might have been a very laboring and confusing process. Therefore, it is important for therapists to keep in mind that LGBT individuals may find themselves in varied stages of identity development. Even those who report a strong and unquestioning sense of LGBT identity, the so-called “out and proud,” may remain sensitive to others’ reactions to their behaviors and, especially upon meeting for the first time, may look for signs that they might be misunderstood, disrespected, or marginalized in some way. Thus, an LGBT affirmative clinician creates a secure space for the individual to explore those concerns, work within the relationship, and get to know the pieces of their own unique identity.

Although this might be challenging ground for some clinicians, the interaction between LGBT identity and faith/morality may be an area that clients would like to address in treatment. Brynn White is a protestant chaplain working in the Department of Veterans Affairs and a staunch supporter of LGBT individuals. She offers, “I think one of the most overlooked areas in working with the LGBT population is the spiritual component. It has been my experience that many (not all) people who are LGBT who were affiliated with a religious upbringing have endured spiritual injuries…[my work] often begins with simply affirming and honoring the person as a beautiful creation that actually is not “defective,” not “less than,” not “abnormal.” As such, this existential realm may actually hold a great deal of pain as well as potential for psychological (and/or spiritual) healing. Further, the notion of honoring the person of the client, with all of their complexities, histories, and defenses, is central to a meaningful therapeutic relationship and crucial to a corrective emotional experience.

 

Although not all struggle with identity, many clients might still experience distress related to disclosing their sexual orientation to others. It is a commonly held myth that individuals “come out” at one point in time and, from that point on, are forever known and accepted as “out” (Ali & Barden, 2015). Emily Burt, a counselor working in the Department of Veterans Affairs, shared an experience with a veteran client: “I remember distinctly him saying that you don’t come out just once; you have to do it all the time. This was not a concept I had ever really thought of.”  Indeed, individuals are faced with making a recurrent decision to come out or to refrain from disclosing their sexual minority status. With every new person or system encountered, LGBT individuals must weigh the costs and benefits to disclosing or not disclosing, any of which may be potentially risky or distressing. Further, some individuals may relive their experiences related to coming out to important others in the past, which have the potential to trigger painful emotional memories and negative coping strategies (Ali & Barden, 2015). Therefore, LGBT affirmative clinicians do not take for granted their clients’ disclosing of sexual minority status. Instead, they typically thank their clients for trusting them with such disclosure and assure them that they are interested in those clients’ experiences, should they decide to disclose more about themselves, their histories, desires, or concerns.

 

Clinician Characteristics and Training Considerations

 

Trainees in psychology and other mental health fields learn that the desire to help others is a necessary but not sufficient ingredient for clinical practice; in particular, professional psychologists need professionalism (including knowledge of ethics and cultural diversity), relational proficiency, empirical knowledge, clinical practice, education, and experience in various systems (APA, 2011). Even with the necessary professional training, however, not all trainees attain the same level of proficiency and, to be sure, not all clinicians are well suited for work with vulnerable populations.

 

When it comes to working with LGBT individuals, there is research to show that certain clinician characteristics are associated with competent LGBT client care. With regard to specific personality traits, it seems that trainees who are more agreeable and open to new and differing experiences are also less likely to be homophobic (see O’Shaughnessy & Spokane, 2013 for review). Further, clinicians who know an LGBT individual personally or who have worked with a sexual minority client in the past tend to rate their competence with working with LGBT clients much more highly than those who have no experience with LGBT individuals (O’Shaughnessy & Spokane, 2013). Based on this finding, training programs might specifically recommend that their students seek at least one LGBT client during their professional training.

 

There does appear to be an upward trajectory when it comes to competency and ethical treatment of LGBT individuals. There are data to show that over time, an increasing number of psychologists have reported that they adopt an LGBT affirmative clinical stance (5% in 1991 as compared to 58% in 2005). Further, one study showed that over 92% of doctoral level clinicians surveyed viewed LGBT behavior to be “acceptable” (Kilgore, Sideman, & Amin et al., 2005). So, in fact it seems that less and less clinicians are viewing their LGBT clients in a negative light and an increasing number are adopting an LGBT affirmative stance to clinical treatment. 

 

Conclusion

 

This discussion was by no means exhaustive; the fact is that LGBT individuals present with a wide array of complex issues, some of which may be related to their sexual orientation and/or gender identity and some of which may not. As with any cultural group with which clinicians are unfamiliar, it is important to gain experience and knowledge. Independent of their reason for seeking therapy, an LGBT affirmative clinician puts the client at ease from the very beginning, follows the client’s lead, adopts the client’s language, and remains attuned to the person of the client. LGBT affirmative clinicians remain open and also seek experiences with LGBT individuals so as to increase their knowledge and broaden their perspectives. Further, truly affirming clinicians are knowledgeable about their own biases, complexities, and ideals.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

                       References

 

Ali, S. & Barden, S. (2015). Considering the cycle of coming out: Sexual minority identity

development. The Professional Counselor, 5(4), 501-515.

 

APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation (2009). Report of

the American Psychological Association Task Force on Appropriate Therapeutic

Responses to Sexual Orientation. Washington, DC: American Psychological Association.

 

American Psychological Association (2011, June). Competency Benchmarks in Professional

Psychology. Retrieved from http://www.apa.org/ed/graduate/competency.aspx.

 

Cannistra, M.K., Downs, K. & Rivero, C. (2010, November 30). “A history of ‘don’t ask, don’t

tell’.” Retrieved from http://www.washingtonpost.com/wp-srv/special/politics/dont-ask-dont-tell-timeline/.

 

Heck, N.C., Flentje, A., & Cochran, B.N. (2013). Intake interviewing with lesbian, gay, bisexual,

and transgender clients: Starting from a place of affirmation. Journal of Contemporary Psychotherapy, 43(1), 23-32.

 

Human Rights Campaign. (n.d.) “HRC Story: Our Logo.” Retrieved from http://www.hrc.org/

hrc-story/about-our-logo.

 

Kilgore, H., Sideman, L., Amin, K., Baca, L., & Bohanske, B. (2005). Psychologists’ attitudes

and therapeutic approaches toward gay, lesbian, and bisexual issues continue to improve: An update. Psychotherapy: Theory, Research, Practice, Training, 42(3), 395-400.

 

O’Shaughnessy, T.O. & Spokane, A.R. (2013). Lesbian and gay affirmative therapy competency,

self-efficacy, and personality in psychology trainees. The Counseling Psychologist, 41(6), 825-856.

 

Pachankis, J.E. & Goldfried, M.R. (2004). Clinical issues in working with lesbian, gay, and

bisexual clients. Psychotherapy: Theory, Research, Practice, Training, 4193), 227-246.

 

Perez, R.M. (2007). The “boring” state of research and psychotherapy with lesbian, gay,

bisexual, and transgender clients: Revisiting Baron (1991). In K.J. Bieschke, R.M. Perez, & K.A., DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (2^nd ed., pp. 399-418). Washington, DC: American Psychological Association.

 

VA LGBT Outreach (n.d.) Retrieved from http://www.patientcare.va.gov/LGBT/VA_

LGBT_Outreach.asp.