Psychotherapy with Lesbian, Gay and Bisexual Clients
Psychotherapy is a complex and often vulnerable experience for clients, and the therapy relationship is vital to the process and success of psychotherapy (Gelso & Carter, 1994). The therapy relationship has been conceptualized as a Tripartite Model (Gelso, 2014) which posits that the therapy relationship consists of three intertwining parts: a real relationship, a transference-countertransference configuration, and a working alliance. The development of a positive therapy relationship is fundamental to fostering client change and growth, and transcends therapy techniques and theoretical orientation (Norcross & Wampold, 2011).
The plethora of research on the therapy relationship over the past three decades rarely considered sexual orientation as a demographic variable. Hence, very little is known about the therapy experiences of lesbian, gay, and bisexual (LGB) clients, or the impact the therapy relationship has on the process and outcome of psychotherapy with these clients. We do know that LGB clients tend to utilize therapy more often than heterosexual women and men (Cochran, Sullivan, & Mays, 2003). The results of a recent study on the therapy relationship with lesbian and gay clients (Kelley, 2015) reveal that, more than two-thirds of participants reported that they had a positive therapy relationship with their therapist. Yet, despite this encouraging finding, the results also indicate that some therapists continue to hold biases about sexual minority clients that can lead to subtle, often unconscious and unintentional, denigrating verbal and nonverbal messages called microaggressions (Sue et al., 2007).
Microaggressions in Psychotherapy
As the field of psychology has developed more awareness and acceptance of sexual minorities, overt discrimination has given way to more subtle forms of heterosexist bias. Overt discrimination of clients’ sexual orientation has been supplanted by microaggressions, which can be as subtle as a look or tone of voice, or as blatant as a heterosexist comment.
The insidious nature of microaggressions can leave LGB individuals wondering if their confusion and hurt feelings are an overreaction or “wrong.” After experiencing a microaggression, clients can feel stigmatized, angry, invalidated and rejected by the psychotherapist. Minority stress can result from this sexual orientation-based oppression and can lead to psychological distress, trigger symptoms of depression and anxiety, and negatively affect physical health (Nadal, Griffin, Wong, Hamit, & Rasmus, 2014).
Microaggressions often convey the biases of the therapist and can undermine and damage the therapy relationship. However, microaggressors are often unaware of the implications or effect of their words or behaviors. This is a key point, because lack of awareness of biases regarding sexual minorities perpetuates negative stereotypes and stigma. The results of a recent study on sexual orientation microaggressions indicated that the presence of microaggressions during therapy negatively impacted the therapy process (Shelton & Delgado-Romero, 2013). The quality of the therapy relationship can improve when therapists are able to acknowledge and challenge microaggressions during psychotherapy with LGB clients. This creates an atmosphere of trust which can cultivate deeper conversations regarding power and privilege.
Microaggressions toward LGB clients can result from:
• Assuming a client is heterosexual.
• Assuming that all LGB individuals need psychotherapy.
• Assuming that identifying as lesbian, gay or bisexual is what caused clients’ presenting problems.
• Overemphasizing or minimizing sexual orientation during therapy.
• Believing stereotypical assumptions about the LGB culture.
• Displaying covert or overt heteronormative bias (the belief that heterosexuality is the only normal sexual orientation).
• Denying that existence of heterosexism, heterosexual privilege and a culture of heteronormativity.
• Using biased terminology (e.g., using the term sexual preference instead of sexual orientation; using the term homosexual instead of lesbian or gay).
• Feeling uncomfortable around LGB clients.
• Assuming trauma with the opposite sex causes some heterosexual men and women to change their sexual orientation.
• Minimizing or not acknowledging the sociopolitical environment for sexual minorities.
Building a Therapy Relationship with LGB Clients
In order to build a positive and affirming therapy relationship with LGB clients we suggest that you consider the following.
How do you feel about working with LGB clients?
- Have you explored and reflected on your own sexual orientation and gender identity?
- Have you explored your feelings, beliefs, attitudes, and biases about LGB individuals? From where did they originate, and how have they developed over time?
- What can you do to change any biases and negative attitudes about LGB clients?
If you identify as heterosexual, are you aware of your privilege?
- How do you benefit from being heterosexual?
- How does your heterosexual privilege affect the therapy relationship with your LGB clients?
Are you making heteronormative assumptions?
- Most LGB individuals are subject to receiving heteronormative healthcare services that do not address their unique needs.
- It is important that therapists be aware of the possibility that they are providing care through a heteronormative lens that can lead to misinterpretation of the thoughts, feelings, and behaviors of their LGB clients.
Do you know enough about the LGB culture to provide affirmative and supportive care?
- Developing competency in working with any diverse population is essential to providing ethical care. LGB clients have expressed frustration with their therapists for not knowing enough about LGB culture (Kelley, 2015).
- It is important that any therapist working with LGB clients increase their knowledge of LGB culture through training, supervision, consultation, and continuing education.
- Having LGB friends does not make you competent.
At what stage of sexual orientation identity development (Cass, 1979, 1996) is your LGB client?
- Ask your LGB clients how they identify (e.g., sexual and gender identity).
- Knowing at which stage of sexual orientation identity development your client is can help give context to your client’s presenting concerns and self-acceptance as an LGB individual.
- In addition to sexual orientation, other factors such as gender, race, ethnicity, class, religion, and disability can add complexity to LGB clients’ identity and clinical presentation (Moradi, van den Berg, & Epting, 2009). Intersectional identities can result in microaggressions about LGB clients’ multiple identities.
Preference for an LGB or LGB-friendly therapist
The results of a recent study found that 30% percent of lesbian and gay male participants reported a preference for a lesbian or gay therapist, or an LGB-friendly therapist (Kelley, 2015). It is important for heterosexual therapists to know that it is possible to provide supportive and affirmative therapy to LGB clients.
- Allow LGB clients to be the expert on their culture.
- Create a sense of safety and trust in the therapy relationship by:
Validating LGB clients’ experiences as a sexual minority.
Showing that you are aware of and understand the impact of stigma on the lives of your LGB clients.
Being aware of microaggressions that occur outside of therapy and during therapy, and being open to processing them with your clients.
Having LGB specific resources available that you have vetted.
Providing affirmative and supportive psychotherapy should be a goal of all therapists regardless of the client. This is particularly salient when working with any marginalized group including lesbian, gay and bisexual clients. Microaggressions can undermine the development or progression of the therapy relationship with LGB clients. It is incumbent upon all therapists to develop the self-awareness, competency and skills to work with sexual minority clients. This includes working to uncover, acknowledge, challenge, and change heterosexist beliefs and attitudes that can lead to perpetrating microaggressions. Most clients seeking therapy have presenting concerns that can be painful and confusing. LGB-affirmative therapists should strive to ease these concerns while not bringing underlying heteronormative biases and assumptions into therapy.