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(p. 234) Psychotherapy with Lesbian, Gay, and Bisexual Clients 

(p. 234) Psychotherapy with Lesbian, Gay, and Bisexual Clients
(p. 234) Psychotherapy with Lesbian, Gay, and Bisexual Clients

Kristin A. Hancock

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Subscriber: null; date: 16 December 2019

In many instances, the presenting problems of lesbian, gay, and bisexual (LGB) clients in psychotherapy are no different than those presented by heterosexual clients. The one factor that complicates and, in some cases, exacerbates these problems is stigma. People with nonheterosexual orientations are subject to societal disapproval and negative attitudes and/or pejorative religious beliefs as well as the prejudice, discrimination, and violence that can accompany such attitudes and beliefs. LGB individuals continue to live with stigma or the prospect of it each and every day. In providing mental health services to LGB individuals, it is essential that this context and its effects be taken into account.

Stigma: Without and Within

Despite the progress made regarding the rights, benefits, and privileges of LGB people (and perhaps because of it), the national debate about the right of LGB individuals to marry their same-sex partners has resurrected negative myths and stereotypes.

It is important for therapists to realize that the sociopolitical context can significantly impact the mental health and well-being of their LGB clients. Discrimination and victimization have been shown to be associated with significant psychological distress. The kind and degree of societal stigma with which LGB people contend may include negative attitudes about their sexuality, their adherence to gender norms, their families, and their relationships. When same-sex relationships become the subject of political campaigns, the experience and impact of stigma can intensify. Rostosky, Riggle, Horne, and Miller (2009) found increased psychological distress—particularly depressive symptoms—in states that had passed anti-gay marriage amendments. The authors also found that the negative impact was not due to preexisting conditions in their participants and that individuals may experience negative effects for some time—beyond the particular campaign period. For therapists who work with LGB clients during and after such tumultuous times, it may be helpful to assist the client by (1) validating his or her experience; (2) employing approaches that monitor and avoid internalization of the negative messages put forth in the media and elsewhere in the client’s environment; and (3) reframing these experiences in a manner that empowers the client (Rostosky, Riggle, Horne, & Miller, 2009).

In addition, LGB individuals endure homophobic messages from some conservative religious groups and/or individuals (some of whom may be family of origin members). The conflicts that surface for those LGB individuals whose religious beliefs play a primary role in how they view themselves and behave in the world can be profound when those religious (p. 235) beliefs or the way they are interpreted condemn lesbian and gay sexual orientations. While religion and spirituality can mean different things to different people, Haldeman (2004) observes that “religious affiliation can serve as a central, organizing aspect of identity that the individual cannot relinquish, even at the price of sexual orientation” (p. 694). When working with individuals who are struggling with questions of sexual orientation in the face of conservative religious beliefs, it is essential to create a safe and respectful environment for the client to explore these issues without leading or directing the client to any particular decision. Rather, the therapeutic relationship should afford the client the space and safety to examine his or her experiences, feelings, and values and develop his or her own solution (Haldeman, 2004). It is important to note that efforts to change sexual orientation are generally considered ineffective and possibly even harmful (American Psychological Association, 2011). The therapist’s obligation is to provide accurate information and assist the client by exploring sources of bias and a client’s internalized prejudice that can impact the client’s self-esteem. It is also important to note that many major religious traditions are supportive of LGB people and can provide an affirmative community to clients (American Psychological Association, 2011).

Generally speaking, therapists are urged to conduct a thorough evaluation of the client’s history with regard to stigma—in its obvious and more subtle forms. It is also essential to evaluate the way in which any negative attitudes or instances of discrimination impact the client. When stigma is internalized, it can create and/or exacerbate problems with self-esteem, depression, anxiety, physical health, relationship quality, support systems, and job performance (Szymanski, Kashubek-West, & Meyer, 2008). Therapists working to address internalized stigma should create a safe and supportive interpersonal environment; consider the use of stress reduction techniques when appropriate; help the client to develop personal and social support resources; address the effects of trauma associated with discrimination and victimization; and support the client’s capacity to confront stigma (American Psychological Association, 2011).

Identity Development (“Coming Out”)

Psychotherapy with an LGB client can be affected by the extent to which that client has accepted his or her sexual orientation. A number of identity development models have been presented (cf. Ritter & Terndrup, 2002) to assist therapists in the exploration of this process. The process generally involves several phases. In the first phase, the individual develops an awareness of nonheterosexual attraction and struggles with its meaning in light of any internalized negative attitudes and beliefs about homosexuality. The extent to which the individual struggles depends upon numerous intrapersonal (e.g., self-esteem or religious beliefs) and environmental/contextual factors (e.g., attitudes of family of origin and friends, prior experiences with LGB people or institutional homophobia). As noted earlier, some contextual factors can intensify an already difficult journey. Another phase (which may or may not begin during the first phase described earlier) involves the exploration of one’s nonheterosexual orientation. Often this includes first relationships, coming out to others (i.e., friends, family, coworkers), and interactions with the LGB community. Finally, the last phase addresses the integration of one’s LGB identity. In this phase, the person’s nonheterosexual orientation becomes another part of the self without dissonance or distress from the internalization of stigma. Still, therapists should keep in mind that experiencing discrimination or victimization because of one’s nonheterosexual orientation can retraumatize or, at the very least, resensitize a person to stigma and result in considerable psychological distress at any point in the life span.

The identity development process for bisexual individuals is rendered more complicated by the attitudes toward bisexuality on the part of heterosexual individuals, lesbians and gay men, and even some mental health providers who question the validity of bisexuality as a bona fide sexual orientation (Ritter & Terndrup, 2002). It is therefore important for therapists to respect the unique challenges individuals face as they come to terms with a bisexual orientation. Individuals may begin to address a bisexual (p. 236) orientation having come from heterosexual, lesbian, or gay relationships. The complexity of the challenges bisexual people experience should also be considered—particularly those that involve nontraditional relationship structures (American Psychological Association, 2011).


Greene (2007) notes the ease with which therapists focus upon a single aspect of identity—especially a stigmatized aspect of identity—without considering the interactions among this identity and others (which may be privileged or similarly devalued). “The tendency for a clinician or researcher to launch an exclusive focus on gender, sexual orientation, or ethnicity with no sense of the ways that they overlap or interact can be a serious hindrance to an understanding of these phenomena and to the therapy process” (Greene, 2007, p. 52). The task of the therapist is to understand the intersections of identities—not just the identities themselves. It is important to consider stigmatized and privileged aspects of identity as they connect and interact within the individual and between individuals. It is also useful to keep in mind that stigma impacts individuals to varying degrees. Greene (2007) reminds us that members of stigmatized groups may not readily identify the ways in which they are privileged. For instance, a White lesbian may have some difficulty acknowledging racist behavior or negative attitudes about bisexual individuals; an African American gay man may have some difficulty acknowledging sexist behavior.

Well-intended therapists have sometimes made the mistake of approaching their work with LGB clients with the attitude that says “we’re all really alike” as people. Such a perspective ignores or denies the culturally unique life experiences of the individual—including the ways in which stigma and privilege have affected him or her. While this approach may provide temporary comfort to the therapist, it is likely to hinder understanding of the client. Similarly, an overemphasis of any single aspect of identity ignores or denies other aspects of identity and context. Therapists are urged to respect and pursue the various aspects of self as they relate to a client’s nonheterosexual orientation.

The Role of the Therapist

There is no denying the importance of the therapist in working with LGB clients. Certainly, the attitudes of the therapist toward nonheterosexual relationships is of the utmost importance. Negative attitudes on the part of the therapist can adversely impact both the assessment and treatment of LGB clients. These attitudes may be explicit or they can be implicit and even unconscious. Negative attitudes may be the result of a particular therapist’s views, religious or political beliefs; however, they may also be a function of the education and training that therapist has received. A heterosexist perspective has permeated the language, psychological theories, and interventions in psychology (American Psychological Association, 2011). Whatever the source, negative attitudes and behavior on the part of the therapist continue to be a challenge in the competent treatment of LGB clients.

Despite the fact that lesbian and gay sexual orientations per se are no longer viewed as indicators of mental illness, some therapists may persist in attributing a client’s presenting problems to his or her nonheterosexual orientation (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991; Shelton & Delgado-Romero, 2011). Therapists also pathologize clients more subtly by assuming that the client needs additional therapy or lecturing clients about the difficulties of being LGB (Shelton & Delgado-Romero, 2011). Therapists have also avoided or minimized sexual orientation or overemphasized it when working with LGB clients (American Psychological Association, 2011; Shelton & Delgado-Romero, 2011). Some therapists may overidentify with their LGB clients (e.g., referring to their own LGB family member or, in the case of LGB therapists, assuming a client’s conflicts are the same as their own) in an effort to minimize the discomfort of difference.

It is clearly essential that therapists take the time to evaluate their own attitudes, feelings, and beliefs about nonheterosexual orientations (p. 237) and LGB people (American Psychological Association, 2011). Greene (2007) recommends that therapists reflect upon their own identities and experiences with privilege and stigma and how these might relate to the identities and experiences of the client. She also encourages the therapist to consider the impact of difference upon his or her practice with a particular client and to develop a greater tolerance for the anxiety that often surfaces with difference—particularly that associated with power and privilege.

A therapist also needs to consider whether his or her education, training, and supervised experience have adequately prepared him or her to work affirmatively with LGB clients. If not, he or she should consider an appropriate referral or, at the very least, pursue professional consultation and additional education and training.

For optimal assessment and treatment of LGB clients, there needs to be an ongoing self-assessment for explicit and implicit bias. Where biases are explicit, therapists are ethically required to take steps to eliminate the effects of these biases in their work with LGB clients. When biases are more implicit or unconscious, they are more difficult to identify. Nevertheless, they can have a profound effect on the work. Research suggests that a combination of motivation and personal contact may significantly impact implicit or unconscious bias (Lemm, 2006).

References and Readings

American Psychological Association. (2011, August 29). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist. ePub ahead of print, doi: 10.1037/a0024659Find this resource:

    Garnets, L. D., 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.Find this resource:

    Greene, B. (2007). How difference makes a difference. In J. Muran (Ed.), Dialogues on difference: Studies of diversity in therapeutic relationship (pp. 47–63). Washington, DC: American Psychological Association.Find this resource:

      Haldeman, D. C. (2004). When sexual and religious orientation collide: Considerations in working with conflicted same-sex attracted male clients. Counseling Psychologist, 32, 691–715.Find this resource:

      Lemm, K. M. (2006). Positive associations among interpersonal contact, motivation, and explicit and implicit attitudes towards gay men. Journal of Homosexuality, 51, 79–99.Find this resource:

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

        Rostosky, S. S., Riggle, E. D. B., Horne, S. G., & Miller, A. D. (2009). Marriage amendments and psychological distress in lesbian, gay, and bisexual (LGB) adults. Journal of Counseling Psychology, 56, 56–66.Find this resource:

        Shelton, K., & Delgado-Romero, E. A. (2011). Sexual orientation microaggressions: The experience of lesbian, gay, bisexual, and queer clients in psychotherapy. Journal of Counseling Psychology, 58, 210–221.Find this resource:

        Szymanski, D., Kashubek-West, S., & Meyer, J. (2008). Internalized heterosexism: A historical and theoretical overview. Counseling Psychologist, 36, 510–524.Find this resource:

        Related Topic

        Chapter 64, “Tailoring Treatment to the Patient’s Race and Ethnicity”