"Gay-Positive" Therapy Is Not Good Enough

By Jeff Levy and Bruce Koff

Reprinted from In The Family Magazine, Volume 7, Number 2, Fall 2002, pp. 8-11.

"You don't need any special training to work with gays and lesbians, but it is essential to be 'gay friendly'." So read the August, 2001 issue of Psychotherapy Finances, quoting the opinion of an openly gay therapist in Minneapolis. The article, entitled "Niche Marketing: Open Your Doors Wider for Gay and Lesbian Clients," suggested that "sensitivity" to "special issues" and a few well-placed gay/lesbian magazines in the waiting room are all a therapist needs to work competently with lesbian and gay clients.

Our own experiences suggest that a great deal more is required. One of our colleagues, Marie, recently called us with a request to consult with her and one of her clients. Marie is a well-respected heterosexual social worker with a thriving practice in the Chicago area. Dave, her client in question, was a 40-year-old single man whom she had been seeing for several years. She and her client felt stuck, she said. He'd made a great deal of progress in their work together, but he was still struggling with relationship issues. Dave met with one of us and echoed Marie's sentiments. He felt stuck, despite having made a great deal of progress in his work with Marie. Dave was asked to discuss his relationship history as part of the consultation interview. No assumption was made about his sexual orientation. Though Dave described himself as bisexual, all his relationships had been with men and he reported feeling primarily attracted to men. The initial consultation was followed with a phone conversation with Marie. We discussed some of what we perceived as the presenting issues and possible directions for therapy. "Well, " Marie said, "I don't think we can go much further until Dave addresses his gender identity issues."

We were surprised by Marie's description of what she thought was Dave's primary issue. We respect Marie and have referred many clients to her in the past. It became clearer to us that our competent, caring and well-meaning colleague was conflating gender identity and sexual orientation. Though gender may have been part of Dave's struggle, he was more "stuck" in issues regarding his sexual orientation. Specifically, he struggled with shame about his attraction to men and perhaps was constrained by a therapist who was confused by concepts and language.

We struggle with how to gently but assertively respond to well-intentioned therapists whose foundation skills are outstanding, but who lack knowledge to adequately address queer clients.

A decade or two ago, it was not uncommon to hear LGBT people sharing horror stories about therapy with straight clinicians who attributed their sexual orientation to over-involved mothers or under-involved fathers. These therapists tried to convert them to heterosexuality; dismissed their sexual orientation as being "just a phase"; or agreed to parents' requests to have them committed to mental hospitals to be treated for their "perversion." While there are fewer of those horror stories now, there are still many subtle and overt ways that straight therapists operate out of ignorance and misguided ideas about what their LGBT clients need. For example, one client shared with us her recent experience seeking couples therapy. She said that she'd talked with a number of straight therapists about their experience and opinions about working with non-heterosexual couples. She reported that several of the straight therapists had said things like, "Relationship issues are relationship issues," and that "most of the relationship issues that arise in same sex couples are the same as those that arise in heterosexual couples."

Our heterosexual colleagues who believe that "relationship issues are relationship issues" in same-gender and opposite-gender partners may feel quite confident that they can help their LGBT clients. But we strongly suspect they are missing some of the underlying issues that significantly affect same-sex relationships. For example, how have each of the partners learned to manage a stigmatized identity and how might those coping patterns affect couple dynamics, such as dealing with conflict or expressing emotion? What if the partners are at vastly different points of "outness" in their lives? How well have they managed to integrate their relationship with families of origin, with work, and with community? To what extent might gender role socialization shape interactions differently with same-sex couples? Consider, too, the questions raised by many therapists, including Suzanne Slater in The Lesbian Family Life Cycle, about whether closeness in a lesbian couple is always a form a pathological "fusion," or can it in fact engender greater warmth, intimacy and support? Psychologists Robert-Jay Green, Michael Bettinger and Ellie Zacks raise a similar question in Lesbians and Gays in Couples and Families, about whether non-monogamy in a gay male couple is always some form of betrayal or "disengagement," as one might presume in a heterosexual couple, or can it represent a high degree of differentiation and intimacy gained through fairness and acceptance? Other LGBT and straight-ally therapists have been asking deeply relevant questions that every therapist needs to explore with queer clients, including how might racial/ethnic/cultural differences between the partners affect their approach to integrating their relationship with their families? What sort of legal and social supports are available? These and other vital questions are evidence of a distinct and unique framework for working with LGBT individuals and their families that is different from that which may apply to work with a heterosexual population.

Maybe the question of who should and shouldn't work with which clients misses the mark. Therapy is often a process of bridging differences, whether the difference is between a male therapist with a female client, a gay therapist and a straight client, or a childless therapist with clients who are parents. In fact, even an LGBT therapist must question whether he/she is competent simply by virtue of being LGBT. Each client presents unique and discreet issues among and between these various categories with which even the most seasoned therapist may be unfamiliar.

We've come to believe that a body of knowledge and skills does exist pertaining to LGBT clinical practice that is substantively distinct from other clinical theory. Armed with this extra component, we find that clinicians, gay or straight, become significantly more effective in working with LGBT individuals and their families. What we ALL need to define is a basic level of competence for working with LGBT individuals and their families.

This should not be news. LGBT folks and straight allies have been engaged in an ongoing struggle with the mental health profession for decades over how the profession deals with sexual orientation. A groundbreaking survey by Garnets et al. of psychologists as far back as 1986 (published in September 1991 in the American Psychologist) revealed the depth of the problem, describing therapists who continue to pathologize homosexuality, fail to regard homophobia as a significant factor affecting a client's symptomatology, narrowly define homosexual orientation based solely on behavior, fail to adequately consider the possible consequences of disclosure of sexual orientation, misinterpret relationship problems or suggest interventions based on heterosexual norms and standards. So it was immensely gratifying last year to see the American Psychological Association approve "Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients," a historic document outlining the various sets of knowledge and skills required to achieve competence. Most important, the "Guidelines" call upon psychologists to "increase their knowledge and understanding of homosexuality and bisexuality through continuing education, training, supervision, and consultation."

It's fine to say that we hope our colleagues become competent therapists for their queer clients, but the reality is that taking one workshop here or there at a professional conference, or reading a book now and then that includes a chapter about gay issues is simply not enough. After Bruce Koff and colleague Barbara Kelly gave a presentation about training needs for LGBT clinical competence, they began to brainstorm about creating a whole program to train clinicians to be culturally and clinically competent in addressing the lives of LGBT people and their families. They and several other colleagues spent several years creating a clinical training program in Chicago for LGBT and straight therapists alike. [We were gratified by the support of many straight colleagues who were eager to learn more and get involved.] The program is conducted under the auspices of three collaborating agencies--Horizons Community Services, Howard Brown Health Center, and the Chicago Center for Family Health. Along with three other queer psychotherapists (Kelly, Margo Jacquot and Theo Pintzuk) we now offer a one-year, post-master's degree certificate program in clinical practice with LGBT individuals and their families. Our current effort is designed to promote standards of clinical practice and, through the provision of a certificate, assure current and potential LGBT clients and their families that their provider is well trained to work with them.

The project began with some frank discussion about our own gaps in knowledge and expertise. As queer people, we all had first-hand experiences that raised our consciousness about possible clinical issues for our queer clients, yet we quickly realized that even we were missing important themes and recurring patterns. Some of us knew more about addictions, trauma, or youth, for example, while others knew more about working with couples or dealing with diverse representations of gender. We recognized, quite honestly, that the great advantage of taking on this project would be that we would have to learn the material ourselves in order to teach it to others. We then designed and distributed a survey to 500 mental health professionals to help us determine the level of interest in and knowledge of an extensive list of topics, and were greatly encouraged to receive back 150 completed surveys. These, along with our own experience, current research, and the APA Guidelines, helped us formulate the "ideal" curriculum. While not exhaustive, we identified the key content areas as follows:

  • Historical and anthropological perspectives on sexual orientation and gender
  • Essentialist and social constructionist approaches
  • Identity development across the lifespan
  • Affirmative models of clinical practice
  • Racial, ethnic and cultural differences, including regional, urban and non-urban LGBT cultures
  • Relational issues
  • Spiritual issues
  • Parenting, including families with LGBT parents and/or children
  • Trauma, including hate violence, domestic violence, sexual assault, childhood sexual abuse, and profound social ostracism
  • HIV
  • Gender issues and transgender concerns
  • Addictions
  • Variations in sexual behavior
  • Clinical practice with special populations, including LGBT youth, seniors, chronic mentally ill and individuals with disabilities.
  • Finding and using community resources
  • Adapting existing treatment models to clinical practice with LGBT individuals and their families

Last year, we conducted 8 full-day workshops on some of these topics in order to develop and test key components of our curricula. We averaged 18 attendees per session and received invaluable feedback on how to proceed, along with a great deal of support and enthusiasm. We are now in the process of implementing the full certificate program and expanding our faculty group to include others who can address some of the continuing gaps in content. As part of the program, we will also provide ongoing case consultation and supervision in order to foster the application of theory into practice.

Although we did not survey attendees about their sexual orientation, many disclosed this information during the course of the day's training. We were pleased to note a mix among our audience, including a number of heterosexual professionals who worked in schools or agencies. Their presence and involvement reminded us that, regardless of whether or not we believe that straight therapists are qualified to treat LGBT clients, the fact is they do, and many of them recognize this and want additional training. We also noted that those clinicians in our workshops who identified as LGBT, though perhaps more knowledgeable, were equally appreciative of the depth of material.

As gay clinicians, we have been professionally humbled by this opportunity. It is indeed true that both of us are gay and have experienced social ostracism and anti-gay discrimination, have dealt with shame and powerlessness, have been affected by friends and clients with HIV, have come out to our families and friends, have had sexual partners and have life-partners. But developing, teaching, and therefore learning this extensive material made us realize more fully that none of these life experiences, in and of themselves, qualify us to treat LGBT people. There is so much more to understand--so many ways we are not prepared to competently help the client who, although gay, has experiences and perspectives that differ significantly from our own.

Our own clinical proficiencies have grown immensely since we began this project. We assess our clients differently now. We have become keenly sensitized to the impact of stigma on identity development and integration and ask pointed questions that better access this experience. We are aware of the interplay between growing up LGBT in a hostile culture and other life traumas; how LGBT identity integration impacts integration of trauma experiences and how trauma impacts the integration of LGBT identity. We have become more open to our clients' stories and constructions of their relationships, and can help them to identify patterns of adapting to a stigmatized identity that may inhibit the couple's vitality and viability. We monitor more closely the impact of our words and invite our clients to define their identities using their own words and experiences. We develop richer and more useful case formulations and intervene with greater skill and sensitivity.

For all therapists, experience and knowledge promote competent practice. When we LGBT professionals train ourselves, we inevitably set higher standards for the entire profession. "Sensitivity" is surely helpful, and being "gay-friendly" probably is a necessary condition for clinical practice with the LGBT population. But we are learning through our own experience that neither is truly sufficient.