Welcome to Edition 264 of Institute Inbrief! In this edition’s featured article we’ll explore three key issues and concerns mental health professionals may encounter when working with sexual and gender minorities. These include: using inclusive and appropriate language, clients “coming out” during session, and counsellor cultural competency.
Also in this edition:
- AIPC’s Community Services Courses
- Ways Practitioners Build Resistance in Clients
- What Does Resilience Look Like?
- Practical Prioritising Tips
- Social Media Updates & Much More!
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Working with Sexual and Gender Minorities: Key Issues
To come into relationship with the notion that one is – and probably has always been – different from the “norm” of heterosexuality is for many individuals a terrifying experience, bringing with it a plethora of social, interpersonal, intrapersonal, employment, and sometimes religious and legal issues. Once the dawning of awareness has happened, however, few feel like it is possible to go back to the pre-dawn consciousness of attempting to engage life as before. Most wish to continue the journey of authenticity, finding out how to be in life as their inner identities dictate. Many will desire assistance from counsellors, psychotherapists, and psychologists for this journey. Yet how many mental health helpers are prepared (as in: qualified, skilled, experienced, and willing) to work with this population?
Research over the past decade, say Evans and Barker (2010), has consistently confirmed that the majority of therapists are ill-equipped to work with lesbian, gay, and bisexual clients. Most therapists have had little training on the subject of sexuality and often express lack of knowledge about this group of clients. One study found that a third of gay men, 25 percent of bisexual men, and over 40 percent of lesbian women had negative or mixed reactions from mental health professionals when being open about their sexuality (DOH, 2006). Another study found that 17 percent of therapists had, in the past, attempted to help their clients reduce their “homosexual feelings” – with 4 percent reporting that they would still try to change their client’s sexual orientation (Bartlett, Smith, & King, 2009); such therapeutic thrusts are now deemed unethical by the American Psychological Association and the American Psychiatric Association (GoodTherapy.org, 2014).
Yet those of gender minorities often desire professional assistance; they are some of the most disadvantaged groups in society. Here are some telling statistics relating to the ongoing marginalisation and stigmatisation in multiple life domains that many experience.
In terms of mental health:
- Results from the Longitudinal Study of the Health of Australian Women showed that 38 percent of lesbian respondents aged 22-27 had experienced depression compared to 19 percent of heterosexual female respondents (Hillier, de Visser, Kavanagh, & McNair, 2004).
- Nearly 75 percent of the 5500 (sexual minority) participants in the Private Lives Survey (Pitts, Smith, Mitchell, & Patel, 2006) reported some experience of depression in the past, with half of the men and 44 percent of the women having a major depressive episode.
In terms of employment:
- According to the 2008 General Social Survey in Australia (in Amnesty International, 2014), 42 percent of lesbian, gay, bisexual, and transgender (LGBT) people have experienced at least one form of employment discrimination during their lives.
- The National Transgender Discrimination Survey showed that 90 percent of transgender people were harassed, mistreated, or forced to hide who they are at work to avoid job loss or mistreatment (Grant, Mottet, Tanis, Harrison, Herman, & Keisling, 2011). 26 percent of those surveyed said that they had lost a job simply because they are transgender.
In terms of substance abuse:
- Problematic alcohol use is occurring for some members of LGBT communities. Results from the Longitudinal study of the Health of Australian Women showed that 7 percent of lesbian respondents aged 22-27 engaged in risky alcohol use compared to 3.9 percent of heterosexual female respondents in the same age bracket (Hillier et al, 2004).
- According to the Private Lives Survey (Pitts et al, 2006), 37 percent of LGBT Australians used tobacco more than five times in the previous month compared to 24 percent of the general population.
In terms of legal issues:
- In nearly 80 countries around the world, consensual same-sex conduct remains criminalised (National LGBTI Health Alliance, 2013d).
- In Australia, same-sex couples cannot marry and overseas marriages are not recognised (Lekus, 2014).
- Gender minorities in Australia and abroad are a diverse group of individuals. They have unique sexual orientations, perspectives, and life issues. They are connected at least in terms of the ongoing stigmatisation and marginalisation they experience from the heterosexual mainstream culture and any counselling for them must take these factors into account.
In the introduction to their book on issues in therapy with LGBT clients, editors Neal and Davies (2000) state that their approach of “gay affirmative therapy” (p1) is basically person-affirmative therapy, and that therapists do not need a separate body of techniques and skills in order to work with members of LGBT communities. What they do need, insist the editors, is a level of self-awareness and comfort with sexuality: homosexuality in particular.
Walker, writing the forward to the book, adds that the volume takes a needed step forward in informing and challenging therapists – both those who identify as members of sexual minorities, and those who do not – to extend their knowledge and skill bases. The dearth of good literature, claims Walker, has prevented therapists from gaining an awareness of the complexity of the issues faced by sexual minorities as they attempt to reconcile observations of their difference with a desire for acceptance by the wider society.
In this article, we’ll explore three key issues and concerns mental health professionals may encounter when working with sexual and gender minorities. These include: using inclusive and appropriate language, clients “coming out” during session, and counsellor cultural competency.
Language: inclusive and appropriate
The paperwork and the waiting room
The language a counsellor/therapist or other mental health practitioner uses begins before the client ever walks through the door. Health, medical, and counselling clinics often have information sheets for new clients to complete before seeing the practitioner. Something as simple as asking marital status with the sole options of “single”, “married”, or “divorced” immediately tells an LGBT client that he or she does not belong. A lesbian client coming with the presenting issue of depression because her long-standing relationship has finished will feel more included if she can answer “significant other” rather than married or single and “relationship dissolved” as opposed to “divorced” (Shallcross, 2011). Areas for further action here may include advocating for appropriate language usage on other official forms, such as voter census surveys or Centrelink or other welfare agency paperwork.
Back in the waiting room, therapists and other practitioners can ask themselves whether the literature in evidence welcomes sexual minorities. For example, are there “Safe Zone” stickers posted? Is reading material from LGBT groups in the community included in the waiting room choices? Are there other things letting people know that they are accepted?
How to call them: taking a cue from clients
At some stage in the session, you will probably need to refer to the group with which the client identifies, so asking clients how they self-identify is a good idea. This allows counsellors to learn and use the same language that clients use to describe themselves. It makes sense that, as intelligent beings, we attempt to place incoming stimuli into categories that are meaningful for us: for example, the irritating screech that goes into the “helping” category when we determine it is ambulance noise, the email that gets filed with other reminders for appointments, and the sight of a berry in the bush whose shine tells us it is in the poisonous group. With respect to social considerations, we have been socialised to observe men and women dressing, speaking, and behaving in a certain way. When we work with members of sexual minorities, however, we need to be prepared to challenge preconceived notions – some of which we may not even realise we have had – about sex, gender, and relationships, opening to words of self- and other-reference which are in categories very different to what we might use (Shallcross, 2011).
History-taking in session: Letting sexuality take part
Once the (first) session gets going, the counsellor needs to be sensitive to language used in making the assessment of the client, and every effort needs to be made to minimise heterosexual bias. All clients should be asked whether they are in a sexual relationship and how they identify, but this important area is often left out. A thorough evaluation should include assessment for spirituality, sources of social support, history of violence or abuse, sexual history, sexual orientation, level of internalised homophobia, intimate partners, and high-risk behaviours for sexually transmitted disease and substance abuse. Many counsellors omit some of these areas due to their own discomfort, but they are areas that should be explored with any client and particularly with sexual-minority clients (Shallcross, 2011).
Coming out: It may happen in session
The reality about LGBT and other sexual minorities, however, is that, because acceptance by the wider society is a fraught and sometimes painful process, clients may turn up in your rooms who have barely acknowledged their sexual orientation or gender identity to themselves, let alone the rest of the world. That coming-out process may happen in your rooms, and if so, you need to be prepared to deal with it. A number of studies have highlighted the significance of coming out in the development of LGBT identity (Davies, 1996; Clarke, 2007; Plummer, 1995).
Plummer deemed it the “critical life-experience” during the 1970s and 1980s, although less so in the 1990s. He traces how increasing acceptance of gays and lesbians, and to some extent bisexuals, placed the coming-out story of the 1980s centre stage as a primary medium not only for LGBT individuals to understand themselves, but also to facilitate the understanding of them by others in their lives (Plummer, 1995).
Coming out: An ongoing process
Researchers into LGBT psychologies stress that coming out is not a single event; rather, it is an ongoing process as new people enter the coming-out person’s life. For some it is a fairly simple, straightforward process, while for others it is protracted and painful: a cataclysmic event requiring professional assistance to manage the emotional turmoil (Clarke, 2007; Franke & Leary, 1991). Thus it makes sense here to flag it as a key concern of LGBT people, and to chart how the process of coming out in therapy may unfold, and what, if any, strategies may facilitate it – or inadvertently block it. Obviously, coming out is an issue not only for LGBT people, but also the people in their lives. Thus, the four-step model we use includes others, in ever-widening circles.
Four steps to coming out
Plummer (1995) suggests these four critical stages in coming out:
- Coming out to oneself in a self-conversation
- Coming out privately to a carefully selected few friends and family
- Coming out publicly to more people (and where others may take control of the “outing” process)
- Coming out politically to further LGBT rights and causes
The willingness to come out depends chiefly on the degree to which a person is concerned about other people’s reactions, with fear of rejection being uppermost. Feelings of self-hatred and doubt may accompany the process, as well as relief at (finally) being authentic and the opening up of potentials not previously realised (O’Connor & Ryan, 1993, in Evans & Barker, 2010). Evans and Barker (2010) note that some young people may be more likely to experience their sexual identity as fluid; they may not even regard it as the most central aspect of themselves. Beyond that, coming-out processes are usually impacted by the fact that most people must still operate in an atmosphere of homophobia, enduring taunts and even hate crimes.
Because the developed world, at least, no longer criminalises and pathologises LGBT individuals for their sexual orientation/identity, some authors have argued for a broader understanding of sexual identity/orientation: one which would include not only self-identity and sexual behaviour, but also attractions, fantasies, and emotional and social preference and lifestyle (Garnets et al, 1991, in Evans & Barker, 2010). Ultimately, however, the individual presenting to you for counselling assistance will be doing so in a society that is what LGBT writers call “heteronormative”: that is, understanding heterosexuality as the normal, or default way of being.
Most people viewing sexual orientation or identity from within that framework have a dichotomous view, believing that a person is heterosexual or homosexual; there is not even room for bisexuals, who, because they do not fit neatly into either camp, are viewed with suspicion by not only the wider society, but also by both gay and “straight” communities. For many people, including some professionals, there is the further temptation to view membership in a sexual minority as a “passing phase” and not treat it seriously (Barker, 2007; Evans & Barker, 2010).
Counsellor sexual orientation: To disclose or not
While the preceding paragraphs have flagged many possible scenarios, in the final analysis your deep, non-judging attention to the client will bring forward their particular concerns. The client may even “try out” coming out with you (in order to have a sneak preview of what it could be like with people in his/her life). Regardless of what presenting issues come up, you have the additional question of whether you disclose your own sexual orientation. It is partly an ethical question, and while there has been much controversy on the matter, there is no clear-cut answer. Some studies (Galgut, 2005; Knox, Hess, Pertersen, & Hill, 1997) suggest that it can improve the client/counsellor relationship and others find that it undermines the therapeutic relationship (Audet & Everall, 2003; Wells, 1994), with clients feeling the need to protect the counsellor. Yet other studies (Mair, 2003) have suggested that clients do not find the orientation of the therapist to be of importance at all.
A study by Evans & Barker (2010) explored the perceptions and experiences of sexual coming out in counselling sessions of LGB people (i.e., no transgendered people) and parents of LGB children. It incorporated considerations of the coming out of both the client and the counsellor, whether or not they actually disclosed. It also looked at whether clients felt that self-disclosure (or not) had impacted on the counselling relationship and process.
Results suggested that, while sexual identity was relevant to the counselling process for most of the 62 participants (who were either LGB people or people with an LGB family member, and all of whom responded to a questionnaire about their counselling within the last five years), the sexual identity of the counsellor was not generally perceived as important. A corollary finding was that the majority of participants did not view disclosure as vital. Most participants did, however, assume the sexuality of the therapist if it was not disclosed, and non-disclosure led to distress in some cases, especially for those who had a preference for either an LGB or heterosexual therapist.
What follows are the main factors named by participants as engendering what two-thirds of the participants deemed to be a satisfactory or good counselling experience. You may be able to take a cue for what is important to your sessions with LBGT people from the experiences of these participants:
- That the counsellor would not find the LGB sexual orientation to be a problem
- That the counsellor would be non-judgmental and welcoming
- That the counsellor would not downplay/minimise the clients’ LGB experiences
- That the agencies at which the counsellors worked were geared up to expect LGB clients (see notes, above, on language and written materials of inclusivity in the waiting and therapy rooms)
- That the counsellor would not be defensive or uncomfortable talking about sex
- That the client would not have to educate the counsellor about LGB issues
- That the counsellor would be aware of the effects of growing up LGB in a heteronormative society
- That the counsellor would be sensitive to the implications and intricacies of coming out, both for their clients and for themselves, and that the counsellor would have considered how to negotiate both similarities and differences in sexual identity between themselves and their clients (Evans & Barker, 2010).
As you can see, this named list of principal factors mirrors high-calibre counselling of any sort. The concern for safety is pervasive throughout the factors.
Counsellor cultural competency
We have been speaking about LGBT communities. They, like communities anywhere, have established cultural norms and accepted ways of behaving, speaking, thinking, and relating to one another. So do “straight” (heterosexual) communities. The challenge for mental health practitioners comes when they are asked to be with a client from a different culture: in this case, possibly, the LGBT culture.
If that comes to be you, how do you know whether you are responding appropriately? How do you be supportive and avoid offending? What might it take to gain cultural competency in the sexual minority culture? Seminal work, now classical, by Cross et al in 1989 offered five essential elements which contribute to an institution’s, agency’s or (we add) individual’s ability to operate with cultural competence, which Cross defined as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency or among professionals and enable that system, agency or those professionals to work effectively in cross- cultural situations” (National Center for Cultural Competence, 2004).
We note the five elements below, and add comments to “translate” to the situation of a heterosexual counsellor learning to become competent in the culture of sexual minorities.
We can say that counsellors value diversity when accepting that people they serve come from different backgrounds and make different choices based partly on culture. As human beings, we all have a basic set of needs; what varies is how we go about meeting them. A particular concern in providing culturally appropriate care to members of sexual minorities is how to discuss questions of sex and sexuality. In many cultures of the world, people avoid discussing sex because such discussions seem disrespectful. Some health providers believe that some health problems faced in LGBT communities arise because of members’ inability to speak directly about safe sex practices, risky behaviours, and homosexuality. Even in some recovery/treatment settings, sex and sexuality are overtly avoided (Center for Substance Abuse Treatment, 2000; National Center for Cultural Competence, 2004).
Having the capacity for cultural self-assessment
As a counsellor/mental health practitioner, are you aware of how the sexual majority mainstream culture shapes the systems of care that are offered to LGBT clients? Upon becoming aware, it will be easier for you to choose modalities and techniques which minimise cross-cultural barriers. For instance, are you aware of how many boundaries you may cross with some cultures by merely asking about things such as sex, dying, or substance abuse? How might you be able to gain needed information without being offensive? One idea is to broach such topics less directly than you normally would. Another is to apologise in advance for what you are going to ask (Center for Substance Abuse Treatment, 2000; National Center for Cultural Competence, 2004).
Being conscious of the dynamics inherent when cultures interact
Whatever intervention you make, there is a good chance that it emanates from culturally prescribed patterns of communication, etiquette, and problem-solving. There is an equally good chance that the client’s response/reaction also arises from his or her culture. When those cultures are very different, it is easy for the client, for instance, to misjudge the communicative intent of your intervention. It is equally possible that your response to something the client says or does will misjudge what the client intended. When we add into the mix feelings on the part of either or both parties about serving or being served by someone from another culture, we gain insight into the powerful factor that we may call the dynamics of difference. Understanding these dynamics (and their origins) enhances productive cross-cultural interventions (Center for Substance Abuse Treatment, 2000; National Center for Cultural Competence, 2004).
Having institutionalised culture knowledge
As a counsellor/mental health practitioner, are you able to access accurate knowledge about the culture of sexual minorities, especially those in this country? One recommendation is to ensure that you have cultural consultants available for training and support (Center for Substance Abuse Treatment, 2000; National Center for Cultural Competence, 2004).
Having adaptations to service delivery reflecting an understanding of cultural diversity
The previous four elements build a context for a cross-culturally competent system of care and service. Both your individual approach and eventually, that of your organisation, can be adapted to create a better fit between the needs of your clients and the services available. Where there are repeated negative messages, either in the wider society or through the media, about the sexual minority(-ies) you are working with, these can be countered with messages and programs which incorporate alternative, culturally-enhancing experiences, develop clients’ problem-solving skills, and teach about stereotypes and prejudice. By implementing such programs, you will be able to institutionalise cultural intervention as a legitimate helping approach (Center for Substance Abuse Treatment, 2000; National Center for Cultural Competence, 2004).
This article was adapted from the Mental Health Academy CPD course “Counselling the Gender-Diverse Client”.
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