Welcome to Edition 278 of Institute Inbrief! LGB clients often experience great adversity in their life, therefore their mental health workers need to be informed and prepared to support this population. This edition’s featured article aims to extend your understanding of the issues faced by individuals who identify as LGB.
Also in this edition:
- 2017 Mental Health Super Summit
- Mindfulness Meditation vs Stress
- The Importance of Teamwork
- Social Media Updates & Much More!
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If you’re a mental health practitioner or student, the 2017 Mental Health Super Summit is a must-not miss event. This is your opportunity to join thousands of your peers in one of the most exciting and innovative mental health events ever held in Australia.
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Here’s a snapshot of the 2017 Mental Health Super Summit:
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This is a rare opportunity to learn from some of the most influential leaders in mental health of modern times, and help raise over $150,000 to help children and families in need.
Working with LGB Clients: Key Issues and Concerns
Individuals who identify as lesbian, gay, or bisexual experience a number of social, interpersonal, intrapersonal, employment, and sometimes religious and legal issues. Coming to terms with their sexuality and how this plays a part in their lives is often challenging and many will require assistance from counsellors, psychotherapists, and psychologists for this and other issues in their life. As a mental health professional, it is important to note that all of your clients are unique and carry with them their own unique combination of these issues. LGB clients often experience great adversity in their life, therefore their mental health workers need to be informed and prepared. How prepared (i.e. qualified, skilled, experienced, and willing) are you to work with this population?
This article aims to extend your understanding of the issues faced by individuals who identify as LGB. Once you are aware of the areas of concern confronting non-heterosexual individuals you will be more competent at applying your existing counselling skills to the unique individual sitting in front of you in the therapy room. Moreover, you may be able to see areas of action you could take supportively to help diminish the marginalisation from the larger society endured by such clients.
First we look at the use of gay affirmative psychotherapy. We then discuss the correct use of language and history-taking in session. Moving on we introduce the concept of coming out and how this can impact on your clients.
Gay affirmative psychotherapy
Gay affirmative psychotherapy is a form of psychotherapy for non-heterosexuals, specifically gay and lesbian clients, which focuses on client comfort in working towards authenticity and self-acceptance regarding sexual orientation. It does not attempt to "change" the individual to heterosexual, or to "eliminate or diminish" same-sex "desires and behaviours".
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 LGB communities. What they do need, insist the editors, is a level of self-awareness and comfort with sexuality, and 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 LGB and those who do not – to extend their knowledge and skill bases.
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 LGB 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. Culturally competent forms will have "gender", not "sex", and "relationship status" rather than "marital status". Most culturally competent practices will have a box for "other" and will allow the individual to specify.
Back in the waiting room, therapists and other practitioners can ask themselves whether the literature in evidence welcomes LGBT or other gender-diverse clients. 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, like pride stickers and posters for local support groups?
Using the right language: 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 those non-heterosexual clients 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).
We suggest an overarching shift in language used with clients. Using inclusive, non-assuming language is important with all clients. When first joining with new clients it is essential to be neutral in your language until your client chooses to define themselves to you. Allow your clients to take the lead on the language used in your sessions and be guided by them. Adopting the language of your client is respectful and an important part of building rapport.
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 clients for whom some aspect of their identity or sexuality is non-heterosexual (Shallcross, 2011).
The reality about LGB people 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 to themselves, let alone the rest of the world. The 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 LGB sexuality (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 LGB 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 LGB 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 LGB 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 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 LGB writers call "heteronormative": that is, understanding heterosexuality as the normal, or default, way of being.
People viewing sexual orientation from within that framework have a dichotomous view. They believe 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 such sexual orientation or identity as a "passing phase" and not treat it seriously (Barker, 2007; Evans & Barker, 2010).
The important thing to note here is that all individuals have a right to experience their sexuality in whatever way is true to them. This may be fixed over time for some and this may be fluid for others. As counsellors our role is to help clients create comfort in their own experience, and not to impose another way of being on them. As mental health professionals, we have a responsibility to the wider community to support clients in a way that provides them with an overarching sense of belonging.
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, Petersen, & 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 coming out in counselling sessions of LGB 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 orientation 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 orientation 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 sexual orientation 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 LBG 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 orientation 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 LGB 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 LGB 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 LGB cultures? 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. Cross defined such competence as "a set of congruent behaviours, 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).
Cultural competence is really important for working with LGB people and a number of things will be discussed under this heading. These include: valuing diversity, having the capacity for cultural self-assessment, being conscious of the dynamics inherent when cultures interact, having institutionalised culture knowledge, and having adaptations to service delivery reflecting an understanding of cultural diversity.
1. Valuing diversity
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 LGB communities is how to discuss questions of sexuality and sexual orientation. 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 LGB 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).
2. Having the capacity for cultural self-assessment
As a counsellor/mental health practitioner, are you aware of how the sexual orientation of hetero-normative culture shapes the systems of care that are offered to LGB 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? Whatever your approach is, be sure to remember there is no one right way to do this. However, we do recommend taking a person-centred approach when doing so. Be congruent, empathic, and offer unconditional positive regard.
3. 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).
4. Having institutionalised culture knowledge
As a counsellor/mental health practitioner, are you able to access accurate knowledge about the culture of LGB people, 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).
5. 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 orientations 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).
6. Organisational Level: what can your organisation do?
We recommend counsellors invite LGB professionals into your workplace to present and talk to your workers. Invite these professionals to conduct cultural competency training for your staff and to allocate champions for your organisations. Champions are people appointed to drive change within an organisation. They are responsible for attending professional development and network meetings on behalf of the organisation. They report to the organisation about current trends and participate in ongoing improvement processes. There are many different bodies across Australia that your organisation can connect with and we recommend you research what is available within your state.
This article was adapted from Mental Health Academy’s “Counselling LGB Clients” professional development course.
Barker, M. (2007). Heteronormativity and the exclusion of bisexuality in psychology. In V. Clarke & E. Peel (Eds.), Out in psychology: Lesbian, gay, bisexual, trans and queer perspectives (pp 95-119): John Wiley & Sons, Ltd.
Center for Substance Abuse Treatment. (2000). Substance Abuse Treatment for Persons with HIV/AIDS. Chapter 7—Counseling clients with HIV and substance abuse disorders. Treatment Improvement Protocol (TIP) Series, No. 37. Rockville, Maryland: Substance Abuse and Mental Health Services Administration (US). Retrieved on 3 June, 2014, from: hyperlink.
Clarke, C.M. (2007). Facilitating gay men's coming out: An existential-phenomenological exploration. In E. Peel, V. Clarke & J. Drescher (Eds.), British lesbian, gay and bisexual psychologies. The Haworth Medical Press.
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. Buckingham Philadelphia: Open University Press.
Evans, M & Barker, M. (2010). How do you see me? Coming out in counselling. British Journal of Guidance and Counselling, 38(4), 375-391.
Franke, R., & Leary, M.R. (1991). Disclosure of sexual orientation by lesbians and gay men: A comparison of private and public processes. Journal of Social and Clinical Psychology, 10 (3), 262-269.
Galgut, C. (2005). Lesbians and therapists: the need for explicitness. Counselling and Psychotherapy Journal, 16(04), 285.
Knox, Hess, Petersen, & Hill. (1997). A qualitative analysis of client perceptions of the effects of helpful therapist self-disclosure in long-term therapy. Journal of Counseling Psychology, 44, 274-283.
National Center for Cultural Competence. (2004). Curricula enhancement module series: Definitions of cultural competence. A project of the National Center for Cultural Competence. Georgetown University, Washington D.C.: Center for Child and Human Development. Retrieved on 29 May, 2014, from: hyperlink.