Psychotherapy Articles

Psychotherapy Articles

Training Graduate Students to Work with Sexual Minority Clients

Affirmative and Culturally Competent Psychotherapy

Internet Editor’s Note: Dr. Alessi and his colleagues recently published an article titled “Determinants of lesbian and gay affirmative practice among heterosexual therapists” in Psychotherapy.

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In the last 20 to 30 years, we have come a long way when it comes to practicing with sexual minority clients (King, Semlyn, Killaspy, Nazareth, & Osborn, 2007). Lesbian, gay, and bisexual (LGB) identities are affirmed and celebrated rather than pathologized, and affirmative psychotherapy is now the preferred practice approach for working with this population. According to Perez (2007), affirmative psychotherapy requires:

. . . the integration of knowledge and awareness by the therapist of the unique developmental and cultural aspects of [LGB] 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 (p. 408).

Affirmative psychotherapy is not an independent practice approach and can be easily incorporated into psychotherapists’ existing treatment methods (e.g., cognitive behavioral, psychodynamic, or humanistic) (Davies, 1996). However, engaging in affirmative psychotherapy is not simply about practicing without discriminating against sexual minority clients (Crisp, 2006) or about being politically correct. Culturally competent psychotherapy with LGB clients involves understanding and thoughtfully responding to the hardships associated with living in an environment that devalues and marginalizes sexual minority identities, experiences, and lifestyle choices (Alessi, 2013).

Training as a Clinical Component of Affirmative Practice

In our recent study on affirmative practice, we proposed a conceptual model to understand the mechanisms through which therapists engage in affirmative practice with lesbian and gay clients. As we expected, training was a critical component of affirmative practice. In particular, training in sexual minority issues positively influenced therapists’ beliefs in their confidence to work with sexual minority clients (i.e., affirmative counseling self-efficacy), which in turn influenced their self-reported engagement in affirmative practice. Numerous studies, such as ours, continue to support training in sexual minority issues for therapists and therapist-trainees. Furthermore, King and colleagues (2007) astutely point out that therapists should rely on continuing education and training programs, not their sexual minority clients, to increase their knowledge about LGB identities and lifestyles. Doing so demonstrates the therapist’s commitment to practicing affirmatively, whereas depending on one’s client for knowledge about sexual minority issues may further marginalize a person who may already be skeptical about whether a mental health professional can fully understand his or her struggle.

What Can Training Programs Do to Foster Inclusiveness?

While efforts have been made to incorporate training in sexual minority issues into psychology, social work, and marriage and family therapy programs, more still needs to be done (Edwards, Robertson, Smith, & O’Brien, 2014; Martin et al., 2009; Sherry, Whilde, & Patton, 2005). Training programs must increase inclusiveness and affirmation of sexual minority identities and develop plans for addressing situations where students express homophobic attitudes or refuse to work with sexual minority clients (Edwards et al., 2014).

Creating policies for managing situations where students refuse to work with sexual minority clients is of paramount importance. State legislation in Arizona and Michigan, referred to as “conscience clauses,” allows a student enrolled in a psychology, social work, or counseling program to refuse to counsel or serve sexual minority clients when doing so conflicts with his or her religious beliefs (Anastas, 2013). This legislation may not only interfere with the ability of graduate programs to impart the knowledge and skills students need to practice affirmatively, but also may create additional barriers in accessing culturally competent mental health services (APA, 2014).

Our study demonstrates that affirmative attitudes, positive beliefs about affirmative practice, as well as affirmative counseling self-efficacy are necessary for engaging in affirmative practice with sexual minority clients. Thus, it is imperative that graduate programs:

  • Prioritize clinical practice with sexual minority clients rather than viewing it is a ‘‘niche’’ area. Students should be exposed to sexual minority-focused content not just in elective courses but also in required assessment, practice, and diversity courses (Alessi, 2013).
  • Ensure that graduate students acquire a solid understanding of sexual identity development and the specific health and mental health issues associated with identifying as a sexual minority person.
  • Foster affirmative counseling self-efficacy by offering graduate students the opportunity to work with sexual minority clients. These opportunities should be used to teach trainees how to establish an affirmative environment, manage their heterosexist bias, and advocate for sexual minority clients.
  • Eradicate the subtle messages of heterosexism and homophobia by openly supporting LGB-focused research and sexual minority faculty members and students (Bieschke et al., 1998).
  • Invite affirmative clergy members to class to serve as a guest may help to challenge some trainees’ deeply held religious convictions. It may also help to ask sexual minority individuals, who are active members in affirmative churches, synagogues, or mosques, to discuss their experiences with trainees.
  • Assess whether training interventions improve trainees’ attitudes toward sexual minority individuals, affirmative counseling self-efficacy, and beliefs about affirmative practice.
  • Expose students to the American Psychological Association’s Practice Guidelines for LGB Clients:


Training and education in regard to sexual minority issues should not end with graduate studies (Alessi, 2013). Discrimination and prejudice by health care professionals may negatively influence service utilization and affect treatment outcomes among sexual minority individuals (Institute of Medicine, 2011). Therapists should make concerted efforts to learn about sexual minority identities as well as diversity in the LGB community. Despite the remarkable progress made by the LGB community over the years, sexual identities that do not conform to heteronormative standards continue to be marginalized. Thus, therapists must be adequately trained to help sexual minority clients cope with the effects of living in such an environment.

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Cite This Article

Alessi, E. J. (2016, January). Training graduate students to work with sexual minority clients: Affirmative and culturally competent psychotherapy. [Web article]. Retrieved from:


Alessi, E. J. (2013). Acknowledging the impact of social forces on sexual minority clients: Introduction to the special issue on clinical practice with LGBTQ populations. Clinical Social Work Journal, 41, 223-227.

American Psychological Association. (2014). The “Conscience Clause” in professional training. Retrieved from

Anastas, J. W. (2013). Policy, practice and people: Current issues affecting clinical practice. Clinical Social Work Journal, 41, 302-307.

Bieschke, K. J., Eberz, A. B., Bard, C. C., & Croteau, J. (1998). Applying social cognitive theory to the creation of GLB-affirmative research training environments. The Counseling Psychologist, 26, 735-753.

Crisp, C. (2006). The Gay Affirmative Practice Scale (GAP): A new measure for assessing cultural competence with gay and lesbian clients. Social Work, 51, 115-126.

Davies, D. (1996). Towards a model of gay affirmative therapy. In D. Davies & C. Neal (Eds.), Pink therapy: A guide for counsellors and therapists working with lesbian, gay, and bisexual clients (pp. 24-40). Buckingham, England: Open University.

Edwards, L. L., Robertson, J. A., Smith, P. M., & O’Brien, N. B. (2014). Marriage and family training programs and their integration of lesbian, gay, and bisexual identities. Journal of Feminist Family Therapy: An International Forum, 26, 3-27.

Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press.

King, M., Semlyn, J., Killaspy, H., Nazareth, I., & Osborn, D. (2007). A systematic review of research on counselling and psychotherapy for lesbian, gay, bisexual, and transgender people.Retrieved from

Martin, J. I., Messinger, L., Kull, R., Holmes, J., Bermudez, F., & Sommer, S. (2009). Council on Social Work Education—Lambda Legal study of LGBT issues in social work. Retrieved from

Perez, R. M. (2007). The “boring” state of research and psychotherapy with lesbian, gay, bisexual, and transgender clients: Revisiting Barón (1991). In K. J. Bieschke, R. M. Perez, & K. A. DeBord (Eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients (pp. 399-418). Washington, DC: American Psychological Association.

Sherry, A., Whilde, M., & Patton, J. (2005). Gay, lesbian, and bisexual training competencies in APA accredited graduate programs. Psychotherapy: Theory, Research, and Practice, 42,116-120.


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