The mental health field is continuously evolving to serve our needs as a modern society. As a clinical practice, it is necessary to change our vocabulary with the times in order to best serve clients. What was accepted years before is not true now, and it is not an indictment on any party or generation. Society has simply evolved. And as therapy has evolved to include a multitude of practices, it is worth knowing and updating the many tools one has under their belt to work effectively with their clients.
Today, while not the only answer, identity and how we are identified in society hold a lot of weight and, thus, impact our relationships and emotional wellbeing. Counseling that is sensitive to this can help improve client self-esteem through affirmative lesbian counseling. This is new because, in the past decade, new therapy catered to mental health professionals to say, lesbian and gay clients, or transgender clients, were not a focus.
This article looks at the basics of what LGBTQ therapy is, defining guidelines for working therapists and mental health professionals, and defining microaggressions, which is a major stressor generally among minority groups like the LGBTQ community.
What is LGBTQ Therapy?
Many people seek counseling for gender differences because there are similarities in treatment approaches. While some issues have little or no connection to their gender identity, minority groups like the LGBTQ community face their own set of unique challenges that can benefit from their therapists or counselors sharing a similar connection. This can be a very isolating experience and can negatively impact someone’s mental health. Depression, anxiety, grief, and stress are some of the important reasons for seeking therapy.
While men are more likely to commit suicide, women at large report higher rates of depression and anxiety, and experience mental distress at higher rates than men do in all age brackets.
A lesbian woman is subject to the same environmental stressors as heterosexual women, with the added stress of questioning and searching for their own sexual orientation and gender diversity in a world that does not often acknowledge them. This is a unifying factor among the LGBTQ community. It may be why they are at a higher risk of depression, suicide, and different forms of psychological distress.
It is the job of the therapist, counselor, or psychologist to help guide their clients, no matter what their sexual orientation or gender, towards good mental health practices and other issues related to sexuality, but overall, their well-being.
Psychotherapy with Lesbian, Gay, and Bisexual Clients
It is encouraged to assess people’s motives when questioning or changing sexual orientation. The policy of the Appropriate Therapeutic Responses to Sexual Orientation (1998) provides a framework for psychologists who want to focus exclusively on the implications of sexuality. Such a passage may not be feasible for some people.
Another aspect of psychotherapy is the development of the relationship between therapist and client. Presenting concerns as a client goes through identity development requires a lot of vulnerability. It is the responsibility of the therapist to develop more awareness of how to best serve LGBTQ clients or those exploring their sexual identity. Empirical research shows that counseling that recognizes and affirms sexual orientation can help create more positive interactions (see also ‘Lesbian Relationship Advice‘).
The final goal that may make sense for so many conflicted clients is a combination of sexual orientation and religious identity. This is often because mental health support and social support are often provided through religious institutions established by the community.
It is important to be aware of stigmas related to a client, but also not to attribute everything to their sexuality or orientation. In the end, it is not necessary to decide whether to come out or not but to make sense of conflicted feelings and sometimes with relationships to religious identity.
Microaggressions
Knowing what defines a microaggression can be important to know when dealing with gay and lesbian clients. In the same way, a doctor works, it is necessary as a working professional to be aware of changes in the mental health professional’s work. Microaggressions are comments made by those a persona is around, from coworkers and strangers to family and friends. This can happen if a social circle is not sufficiently diverse or supportive. Psychologists are encouraged to assess the motives of people attempting a change in sexual orientation. This can be a sensitive topic, and an unchecked bias or privilege can set back a client and counselor relationship.
For example, microaggressions can be something a client faces on a daily basis. But someone who identifies as a lesbian versus a heterosexual woman may find that outwardly, they face similar issues, but microaggressions can cause more triggers with confusion around sexual identity even more. Negative attitudes can develop if a counselor who is unaware says something that could be misconstrued. Regular counseling can help a client better address and deal with society.
As a counselor or therapist, addressing the internal biases we hold through self-reflection is one way to better serve the client. Also, identifying as gay, lesbian, or transgender can help to inform that self-reflection in the hopes of improving this relationship. Just because a therapist does either absolves them of the risk of inducing harm to a client. It keeps the line of communication open so therapists can continue their work with most clients, and hopefully can bring both to a place of empathy.
Stigma
Many lesbians, gays, and bicultural people encounter social stigmas, discrimination, and harassment. Stigma is defined as a negative social attitude or social dishonor directed towards a characteristic. This negative experience can lead to prejudice and discrimination.
Minority stress, as in the stress of being a minority, is expressed through daily phenomena such as hearing anti-gay jokes, assumptions about gender roles, or worse, physical abuse situations. It appears antigay exploitation and discrimination have been linked to mental health problems and psychological distress, which gay and lesbian clients report experiencing more. Researchers have identified various factors that influence lesbian and bisexual/heterosexual clients’ experiences of the stigma. As well as religious beliefs, race and ethnicity comprise a great deal of these factors.
This can be especially difficult. A client that has had negative experiences with religion, specifically Western religions or monotheistic religions like Christianity, may not have a good track record with a therapist or counselor. Religion and religious institutions can be an emotional subject for clients, as they may have had traumatic emotional experiences with regards to therapy in the past. A client may have been asked to hide their identity or may have been told that it is a problem that can go away. It is necessary to address the emotional aspects these stigmas can bring as well as be careful not to re-traumatize clients while in therapy.
Counseling the Gay and Lesbian Client: Treatment Issues and Conversion Therapy
Affirmative Therapy
Therapists and the field of psychoanalysis historically do not have a good track record with the gay and lesbian community. This has led to mistrust and not seeking treatment for an extended period of time. While psychology and society have moved forward with accepting sexual minorities, overt discrimination has turned into being more subtle. Feeling rejection after being vulnerable can really exert a lot of emotional energy on a client and can lead to both further symptoms of depression and anxiety and a negative view of therapy as a whole.
The American Psychological Association (APA) Council of representatives adopted the Guidelines for Psychological Practice for lesbian, gay, and transgender customers on Feb. 19, 2011. Each of the 21 new guidelines provides an update of psychological literature that supports this.
They assist psychologists in affirmative work for lesbian, gay, bisexual, or gay and bisexual clients. Affirmative therapy, also known as “come as you are” therapy or gender-affirming therapy, does not attempt to change a person’s sexual orientation. It centers around empathy and acceptance of gay identity. Coping strategies may be something talked about in session to help address issues at the moment (sometimes with family relationships or partners).
Professional therapists should be in accordance with criteria issued by the American Psychological Association for practice development assessment and practice. Often today, affirmative therapy, ‘come as you are’ therapy, or ‘gender-affirming therapy’ is explicit in a therapist’s or counselor’s profile.
Conversion Therapy
According to the UCLA Williams Institute of Law, approximately 698,000 LGB adults have received conversion therapy in their lifetime, and about 350,000 received it in their adolescence. It has been known for decades that efforts to change someone’s sexual orientation or gender identity are often associated with poor mental health, including suicidal thoughts.
“Reparative therapy” or “conversion therapy” is seen as a dangerous practice that targets LGBTQ youth and seeks to change their sexual or gender identities. It is a range of practices that aim to change a person’s sexual orientation or gender identity or expression and has been discredited for decades by the American Psychological Association (APA).
Such practices have also been banned in multiple states (California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Nevada, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, Utah, Virginia, Vermont, Washington, the District of Columbia and Puerto Rico) However, this can still be a form of therapy still used in certain communities and circles, especially when the therapist or counselor works out of a religious institution.
Historically, practices put the patient’s physical health in danger, and have progressively gotten less harmful to the body, but still causing trauma.
Often, it can involve a lot of invalidating statements of questions and feelings that go unexplored or questioned. This type of therapy is usually something forced upon someone by an authority figure.
Some people may seek conversion therapy on their own, due to emotional distress or other personal reasons. Continued negative connotations with homosexuality are, unfortunately, a reality, and as a professional, our heterosexist bias is something to actively
Stigma and continued societal bias against LGBTQ people have allowed conversion therapy to exist. Some still seek out this form of therapy through the pressure of family, friends, and most often, religious institutions. Conversion therapy can lead to depression, anxiety, substance use, homelessness, and suicide.
Most states have banned conversion therapy. To date, California, Colorado, Connecticut, Delaware, Hawaii, Illinois, Maine, Maryland, Massachusetts, Nevada, New Hampshire, New Jersey, New Mexico, New York, Oregon, Rhode Island, Utah, Virginia, Vermont, Washington, the District of Columbia and Puerto Rico all have laws or regulations protecting youth from this harmful practice.
Identifying Conversion Therapy
Decades ago, it was near impossible to be open about homosexuality and fluid sexuality in any faith tradition. But religious institutions have been showing signs of changing with the times. Counseling and therapy offered to the community through religious institutions are invaluable in terms of social support and preventing social isolation. And today, as many open their doors, proclaiming to be open and affirming, it is worth vetting out if they are as they say, or disingenuous.
The Human Rights Campaign in partnership with the National Center for Lesbian Rights defines any attempt at changing someone’s sexuality as some form of conversion therapy. This is something that often happens at a very young age. Some signs that a therapist or counselor models their practice after conversion therapy look like:
- Rejecting identifiers like “gay,” “lesbian,” “bisexual” or “transgender” in favor of phrases like “same-sex attraction” or “same-gender attraction”
- Insisting that LGBTQ people not “label themselves” or that acceptance of an LGBTQ identity represents “a distorted view of self”
- Phrases such as “struggling with homosexual feelings” or “struggling with same-sex attraction”
- Viewing homosexuality as a “habit” or an “addiction”
- Language implying that LGBTQ people need to “align their behavior” with their religious values
- Language about being free from homosexuality (and in general speaking, as if abstinence was the default)
- Referring clients to conversion therapists, conversion camps or retreats, or support groups providing conversion therapy is a good first step.
- Referring clients to “ex-gay ministry,” in the form of “support groups” or other gatherings led by clergy or laity
Oftentimes, family and authority may mean well by sending their children to counseling and therapy. But being gay and transgender, or even just being open to the idea of exploring the possibility, is not an inherent problem. Finding the right gender therapist that can identify the difference can really help to improve a client’s mental health. Acceptance goes miles beyond attempting to talk about homosexuality.
Practice Guidelines for Gay and Lesbian Clients
A report was issued by the APA in 1975 that addressed guidelines when performing psychotherapy with lesbian, gay, and bisexual clients. These are suggested guidelines to follow and not necessarily a standard across the psychotherapy profession. The guidelines are listed below:
1. Psychologists understand that homosexuality and bisexuality are not indicative of mental illness.
2. Psychologists are encouraged to recognize how their attitudes and knowledge about lesbian, gay, and bisexual issues may be relevant to assessment and treatment and seek consultation or make appropriate referrals when indicated.
3. Psychologists strive to understand the ways in which social stigmatization (i.e., prejudice, discrimination, and violence) poses risks to the mental health and well-being of lesbian, gay, and bisexual clients.
4. Psychologists strive to understand how inaccurate or prejudicial views of homosexuality or bisexuality may affect the client’s presentation in treatment and the therapeutic process.
5. Psychologists strive to be knowledgeable about and respect the importance of lesbian, gay, and bisexual relationships.
6. Psychologists strive to understand the particular circumstances and challenges faced by lesbian, gay, and bisexual parents.
7. Psychologists recognize that the families of lesbian, gay, and bisexual people may include people who are not legally or biologically related.
8. Psychologists strive to understand how a person’s homosexual or bisexual orientation may have an impact on his or her family of origin and the relationship to that family of origin.
9. Psychologists are encouraged to recognize the particular life issues or challenges that are related to multiple and often conflicting cultural norms, values, and beliefs that lesbian, gay, and bisexual members of racial and ethnic minorities face.
10. Psychologists are encouraged to recognize the particular challenges that bisexual individuals experience.
11. Psychologists strive to understand the special problems and risks that exist for lesbian, gay, and bisexual youth.
12. Psychologists consider generational differences within lesbian, gay, and bisexual populations and the particular challenges that lesbian, gay, and bisexual older adults may experience.
13. Psychologists are encouraged to recognize the particular challenges that lesbian, gay, and bisexual individuals experience with physical, sensory, and cognitive-emotional disabilities.
14. Psychologists support the provision of professional education and training on lesbian, gay, and bisexual issues.
15. Psychologists are encouraged to increase their knowledge and understanding of homosexuality and bisexuality through continuing education, training, supervision, and consultation.
16. Psychologists make reasonable efforts to familiarize themselves with relevant mental health, educational, and community resources for lesbian, gay, and bisexual people.
In addition, clinics that are not accredited by larger bodies may provide different levels of care and their view of mental health services and treatment can differ. This is often why we suggest vetting your therapist and psychologist to see if both parties are comfortable working together.
Transparency is one factor in building trust with this group of clientele. It may require acknowledgment of limits as a professional, but admission to continued education to better understand their client.
Homosexuality is not new to the psychology field, but how it confronts it has changed, and arguably towards being more humane and effective. The field of psychology and therapy, like all industries, is increasing in diversity and awareness of minority groups. With that comes the professional responsibility to adequately prepare for the job and for its therapists to be as supportive as is reasonable.
In conclusion
In order to provide care for the LGBTQ community, it is necessary to continue research paired with self-reflection and empathy on the part of the therapist and counselor.
Affirmative therapy has been shown to be far more effective in improving quality of life than conversion therapy and other previous therapies. That is because, ultimately, it does not see homosexuality as a disease or a mood disorder to diagnose.
Identity will continue to impact our marriage, relationships and emotional wellbeing, and it is the hope that a better understanding of self and being free of negative attitudes and judgment can help LGB clients live their best lives. Therapy offered through institutions like schools and churches is still a valuable resource, as therapy can be cost-prohibitive. When seeking them out, being explicit is also part of the profession. This works in the reverse as well.
A working therapist would aim to follow the appropriate guidelines but also be considerate of the fact that if they are straight, they run the risk of seeming like they are enacting their biases on the client. Being aware that they are not implying conversion therapy is an option is also important in order to repair the perception of therapy and counseling in the LGBT community.