Milton, M. and Coyle, A.

Lesbian and Gay Affirmative Psychotherapy: Issues in theory and

Practice, Sex and Marital Therapy: The Journal of the British Association for Sexual and
Relationship Therapy, 14(1) 43-60

Lesbian and Gay Affirmative Psychotherapy: Issues in Theory

and Practice.
Abstract: This paper is structured into four sections, each considering issues that are
relevant to the thinking of therapists when working with lesbians and gay men.
Firstly, several observations are made about the psychotherapy literature and the
approaches that it takes to lesbians and gay men. Secondly, recent relevant research
on psychotherapy with lesbians and gay men which was undertaken for the Division
of Counselling Psychology of the British Psychological Society is summarised. The
third section reports preliminary findings from research into the nature of lesbian and
gay affirmative psychotherapy. The final section considers the issues that this raises
for therapists in terms of their training and personal development. It is hoped that this
paper will raise awareness of some of the issues in the broad field of affirmative
psychotherapies and stimulate debate.

Lesbian and Gay Affirmative Psychotherapy: Issues in Theory

and Practice.
Introduction
Research has consistently highlighted the considerable stress that lesbians and gay
men experience in a society where hostility is often aimed at these groups (Herek,
1998; Snape et al., 1995) and legal structures limit the human rights of people on the
basis of their homosexuality (Sherrod and Nardi, 1998; Strand, 1998). There is
significant evidence to suggest that, due to these social stresses, lesbians and gay men
experience higher rates of emotional distress (Coyle, 1993; DiPlacido, 1998) and that
this group has an increased suicide risk (Bridget, 1995; DAugelli and Hershberger,
1993; Rotheram-Borus et al., 1994; Trenchard and Warren, 1984). These difficulties
are increased when one considers the pathologising stance that has influenced much
psychotherapeutic treatment. In recent years the need for psychotherapeutic practice
to offer an affirmative experience for lesbians and gay men has become evident in the
literature and the research, as have efforts to reconsider the basic faulty assumptions
that underpin much therapeutic thinking in this area. This paper provides an overview
of some of the issues involved in theory and practice when taking an affirmative
stance towards work with lesbian and gay clients, rather than a pathologising stance
which has been evident in much literature and therapeutic practice.
Firstly, this paper will make several observations about the psychotherapy literature
and the stances that are evident in relation to lesbians and gay men. Secondly, recent
research undertaken for the British Psychological Society (BPS) Division of
Counselling Psychology (DCoP) is summarised. This research was commissioned to

explore British Psychologists' views on working with lesbian and gay clients in
psychotherapy. The third section of this paper outlines preliminary findings from
current research undertaken by the authors into the nature of lesbian and gay
affirmative psychotherapy, drawing upon the experiences of both clients and
therapists. Thus the findings must be taken as tentative and it is not yet possible to
outline a comprehensive theory of affirmative therapy. However, this paper is timely
in that the preliminary findings do raise issues that are important for research and
practice. The final section considers many of these issues, particularly in terms of
therapeutic training and personal development. In this paper, the argument is made
that developments are necessary in the areas of literature, training, personal
development and practice if we are to provide a truly affirmative therapy to lesbians
and gay men.
The literature on working with lesbian and gay clients.
Much of the literature that has existed historically on psychotherapeutic work with
lesbian and gay clients has tended to be problematic in two ways. The first deficiency
is particularly evident in psychoanalytic literature, where homosexuality is defined as
a perversion or as pathology. This can be observed in the way in which lesbian and
gay sexualities are seen as examples of incomplete development or as indicators of
psychological immaturity (Freud, 1977). This is not just an historical phenomenon as
current theorists such as Limentani (1994), Rayner (1986) and Socarides (1978) still
publish theory that advocates this perspective, despite the fact that as long ago as
1973, the American Psychiatric Association formally removed homosexuality from its
list of diagnostic categories.

There is another problematic literature, which ignores lesbian and gay experience as
having distinct qualities. This is evident in both cognitive behavioural and humanistic
appeals to a universal methodology. The method of practice inherent in these models
is, in cognitive behavioural training, to learn the methods correctly (Beck, 1976), or in
humanistic models to develop the ability to provide the core conditions (Rogers,
1951) - the implication being that these skills can then be applied in the same way to
all clients, a claim which is debatable. In addition, this view is inherent in what has
been described as a woolly liberal stance (Kitzinger and Perkins, 1993) taken by
many in the frequently heard cries of psychotherapists, Im not prejudiced, I treat
everybody the same. By taking this stance difference can be ignored and the distinct
experience of the other is denied.
There is a growing literature that discusses lesbian and gay affirmative psychotherapy
(Davies and Neal, 1996; Gonsiorek, 1985; Greene and Herek, 1994; Hitchings, 1994;
Milton, 1996; Ratigan, 1995). This is a recent development and has only become
evident in the past two decades in the USA and in the last decade in the UK (Rivers,
1997). As with the literature mentioned above, two distinct viewpoints can be
discerned in this body of work. The first, which is less frequently encountered, is that
lesbian and gay affirmative therapy is a distinct way of working, with particular
stances that must always be taken (Davies, 1996). These stances include therapists
being comfortable with their own homosexual feelings, having the explicit agenda of
raising experiences of oppression to consciousness, deprogramming and undoing
negative conditioning associated with negative stereotypes of lesbians and gay men
(Clark, 1987).

The second viewpoint is that lesbian and gay affirmative practice is a nondiscriminatory, contextually aware attitude that can be incorporated into mainstream
psychotherapy theory and practice. The challenge is thus to update our models or
develop further models that attend to the diversity of experience that exists. Where
affirmative practice is considered in this way, there are likely to be differences in how
easily it is incorporated it into different orientations. Attempts to reconceptualise
therapeutic theory are currently being undertaken within a range of theoretical
orientations. For example, there are a number of writers within existential
psychotherapy who are currently considering the nature of sexuality (Cohn, 1997;
Spinelli, 1997). Within this paradigm the implications of these developments for
practice are also evident (du Plock, 1997). Psychoanalytic practitioners have
researched the denial of access to psychoanalytic training for lesbians and gay men
(Ellis, 1994), considered how both the internal and external worlds can be taken into
account in formulation and technique (Isay, 1989; Ratigan, 1995) and offered detailed
critiques by considering constructionist theories and using these to attend to the flaws
evident in traditional psychoanalytic thinking (OConnor and Ryan, 1993). Jungian
analysts have reviewed their original writings on same sex sexuality (Hopcke, 1989)
and have developed more contemporary theoretical views on homosexuality (Hopcke
et al., 1993) as well as providing a general reworking of theory in the light of the
inter-relationship between the individual and culture (Samuels, 1993). The social
constructionist literature highlights how identity and sexual identity are socially
constructed (Kitzinger, 1987) and how this body of knowledge can be developed to
aid therapeutic practice (Simon and Whitfield, 1995; Simon, 1996).

The problematic nature of much of the available literature on working with lesbian
and gay clients was one of the influencing factors that led to the BPS DCoP study
being undertaken.
Psychologists accounts of practice with lesbian and gay clients.
The BPS DCoP commissioned a study (Milton, 1998) to explore what British
psychologists considered to be beneficial and harmful practices when providing
psychotherapy to lesbians and gay men. This research was a replication of an
American Psychological Association (APA) study which aimed to "elicit instances of
biased care as well as examples of beneficial care provided to gay men and lesbians"
(Garnets et al., 1991:965).
The research took the form of a survey that, after questions on demographic and
professional issues, posed four open-ended questions. These were to be answered only
if respondents reported knowing of instances of gay men or lesbians in
psychotherapy. The four open-ended questions were:
1. Describe any incidents where a therapist provided biased, inadequate or
inappropriate care to a gay or lesbian client in psychotherapy. For each incident,
indicate your source of information (e.g. 'A friend told me about it', 'I was the
client', 'My client told me', 'I observed it').
2. Describe any incidents where a therapist provided care demonstrating special
sensitivity to a gay or lesbian client in psychotherapy. For each example, indicate
your source of information, as in Q1.

3. In your opinion, what professional practices are especially harmful in

psychotherapy with lesbians and gay clients?
4. In your opinion, what professional practices are especially beneficial in
psychotherapy with lesbians and gay men?
Twenty five per cent of BPS members who were on the register of Chartered
Psychologists and who were members of the Divisions of Clinical Psychology or
Counselling Psychology were surveyed in order to yield a workable sample within the
available resources. Of the 578 surveys sent out, 192 (33.2%) were completed and
returned. Of these 96 (50.0%) respondents said that they had some personal
knowledge of the psychotherapy experiences of lesbians and gay men. It is this group
that the study focused upon. While the response rate was relatively low, it is not
unusually low for a postal study on a sensitive topic (Fife-Schaw, 1995). However, it
may indicate that those who did respond held particular views that drew them to
complete the survey.
The responses to the open-ended questions were subjected to thematic content
analysis. This involved identifying themes and patterns across responses and selecting
exemplars of these themes from respondents' comments, while at the same time
attending to the range and diversity of their experiences. As with the American study,
the goal:
"was not to chart the frequency of particular types of bias or to identify the
most common types of beneficial or harmful practices. Rather we sought to
identify the full range of possibilities, to categorise both harmful and
beneficial practices, and to illustrate these with concrete examples" (Garnets,

et al., 1991:966).
These results are reported in full elsewhere (Milton, 1998; Milton and Coyle, 1998),
and so here we will focus on examples of practices which were considered harmful in
working with lesbian and gay clients and those that were seen as beneficial. In the
illustrative quotations, where material has been omitted, this is indicated by empty
square brackets. Material added for clarification appears within square brackets and a
period of silence present in the participants speech is indicated by a series of three
full stops.
Harmful practices.
The first theme concerned therapists viewing homosexuality as pathology. As
described above, this view has been a focus of considerable debate in the literature,
and was evident in the responses. For example, a psychodynamic therapist said, I
think that an analytic view of arrested development or incomplete development is
harmful, inaccurate and offensive.
The second related theme considered efforts to change sexual orientation and clinical
and personal examples were provided. One example was provided where a training
course required a lesbian therapist to question and change her orientation and
lifestyle, despite the fact that she had been in a committed relationship for 15 years.
Overemphasising the role of lesbian and gay sexual identities was a phenomenon that
the psychologists believed would result in harm to lesbian and gay clients.
Participants suggested that it is unhelpful to foreground the issue of lesbian or gay
sexuality too much. This was evident when respondents suggested that as therapists,
we should not be assuming everything in their life is a result of their sexual

preference. When discussing this issue, participants suggested that this focus might
be related to the sexual identity of the therapist. One therapist said

clients

sometimes state that 'straight' therapists constantly ask them about sexual
relationships/activity when this does not relate to their problem. This same therapist
continued by giving an example of two lesbian friends seeing different therapists,
several times confirmed being asked questions or offered comments which they felt
would not have been addressed if they had been heterosexual, e.g. 'If we explore your
relationship with your mother we might be able to understand your sexuality'. Neither
friend sees her sexuality as a problem".
The term heterosexist indicates that the framework is based on the assumption that
heterosexuality is superior to, or more natural or healthy, than other sexualities
(Davies, 1996, p.24). Respondents noted that harm might be caused to lesbian and gay
clients if therapists work within such a heterosexist framework. It was suggested that
this can stem from the mindsets of individual practitioners, where space is not
provided to consider the diversity of their clients or assumptions are made that lesbian
and gay experiences and relationships will mimic heterosexual ones (Kitzinger and
Coyle, 1995). Some participants also noted another dimension that was the role of the
organisational context in maintaining such a view. Two particularly disturbing
comments were I dont know how many lesbians and gay men I have seen because I
work in the Child and Family Specialty, and I see very few gay and lesbian clients
since I am working with older people. The fact that lesbian and gay identities
overlap with identities as parents, children, families and older people is not
recognised here.
Making unwarranted assumptions about lesbian and gay sexualities and not

10

acknowledging diversity was said to provide an unhelpful experience for lesbian and
gay clients because by being ignorant of the diversity that exists, therapists might be
imposing particular stereotypical identities on lesbian and gay clients or silencing
other possible forms of lesbian and gay identity.
Deficient practice concerning lesbian and gay relationships was addressed in two
distinct areas, where the therapist holds inaccurate assumptions, or where the therapist
does not think about the experience of lesbian and gay relationships. Participants
suggested that inaccurate assumptions included the assumption that the relationships
are purely sexual. A lack of thought about the nature of lesbian and gay
relationships was evident where my colleagues did not fully consider implications to
the gay partner of their partners diagnosis of dementia. I think my colleague would
have involved the partner more if they had been a typical heterosexual couple.
To illustrate the theme of deficiencies in knowledge and expertise, one therapist said
they have heard therapists say 'I don't see gays'. This was from a feeling of lack of
expertise rather than antagonism". Others felt that training would have been useful on
particular aspects of working with issues around sexuality, such as uncertainty or
coming out.
Issues of technique were addressed in terms of generally deficient practice. Here it
was noted that, as is the case with any client, poor timing can be harmful. Reflecting
on his practice, one participant described "challenging gay/homosexually active client
too early. Client was male, having sex with men, denying he was gay. Therapist
challenged this perception. Client left therapy".
Therapists sexuality and personal reactions to the clients material was a focus of

10

11

participants responses in this study, but as this is discussed at length later in the
paper, it is sufficient to note that these issues might well make therapy difficult.
Accounts of beneficial practice
In this study, psychologists also provided examples of what they considered to be
beneficial practice with lesbian and gay clients.
It was suggested that the therapist needs to be able to accept lesbian and gay sexual
identity as one variation of a range of normal, natural and healthy sexual identities
and allowing that sexual orientation may be irrelevant to the problem. In addition
to this, it was suggested that it is not enough just to accept a clients sexual identity,
but in order to provide beneficial experiences, therapists need to engage actively in
the clients search for their identity. A psychodynamic therapist observed: I think it
is most helpful to discourage the idea that one either is or is not gay, as the anxiety
about being

irrevocably in a socially stigmatised category may prevent some

[people] from exploring.

While it may seem obvious to therapists to ask for clients specific perceptions and
experiences of life, this was considered by respondents in a way that appeared almost
as an antidote to some of the difficulties mentioned earlier, in particular an antidote to
overemphasising the sexual identity of the client. As one therapist put it, gay clients
should be treated as if their sexual choice were not the issue, which doesnt prohibit a
focus on [ ] special problems that being gay may bring.
When considering stances towards lesbian and gay relationships, the modality of
therapy was discussed and one respondent suggested that it was important that people
were able to be seen as a gay couple. This respondent continued by outlining the

11

12

thinking behind this view by saying this can help clients cope with hostility from
their own families". Respondents suggested ways to counter the tendency to focus too
much on the gender of the partner and the mechanics of the relationship. The
suggestion was to avoid this by focussing on the qualities of the relationship
described.
Respondents appear to challenge traditional thinking about therapeutic practices,
particularly in light of the therapists own sexuality. One example given was that
"disclosure of own sexual orientation might be more relevant for gay/lesbian
[clients]". It was also mentioned that thought needs to be given to the therapeutic
benefits that might be available with a therapist of a similar or different sexual
identity. One respondent recommended open recognition of issues around client and
therapist orientations and exploration with each individual client of the
appropriateness of seeing a therapist with the same sexual orientation or not.
The relationship of social and political issues to therapy was considered with a view
to incorporating an overt acknowledgement of these contexts into therapeutic practice
as when one therapist noted how important it had been to have an awareness of the
difficulty a gay man had functioning as a secondary school teacher due to verbal
abuse from pupils and a lack of support from professional colleagues.
This research is currently being extended and an outline of this work in progress is
now given.
Lesbian and gay affirmative psychotherapy: Further research.
The authors are currently undertaking further research into the nature of lesbian and
gay affirmative psychotherapy. This interview-based study uses a grounded theory

12

13

approach with a sample of therapists (n = 14) and clients (n = 17). As with the
previous studies, this research did not need ethical committee approval. Departmental
approval was given on the basis that there was very limited risk to participants, the
sample were all adults and all self selected, no deception was involved and the
procedures were made clear to the participants before they agreed to take part. While
the sample of the DCoP study were overwhelmingly heterosexual men and women,
lesbian and gay male clients are represented in the sample, as are heterosexual female
therapists and lesbian and gay male therapists. In this study no heterosexual male
therapists responded to calls for participants. This is a limitation of the study as there
is no way to elicit accounts from these therapists which would support or contrast the
accounts provided by clients whose therapists were heterosexual man. This is
unfortunate as lesbians and gay men may encounter heterosexual male therapists and
it would have been useful to consider their accounts of lesbian and gay affirmative
practice. As this group of participants did not come forward it is difficult to know
exactly what their reservations were. While it would be possible to hypothesise
reasons for this lack of response, for example, that heterosexual men do not feel that
their practice is lesbian and gay affirmative, that the absence is an indication of antilesbian and gay prejudice, or that heterosexual male therapists misunderstood the call
for participants, any such considerations can only be speculative. However this
absence highlights one of the difficulties facing researchers in this area the difficulty
recruiting a comprehensive sample. Five themes have been selected as they exemplify
the most conceptually coherent thematic clusters so far and they also have obvious
implications for practice.

13

14

The sexuality of the therapist

This is a theme that arose frequently within the data, and with quite a degree of
complexity. While some held the view that the sexuality of the therapist is an
important aspect of the therapy, others disagreed. These views were expressed with
particular certainty when participants were drawing upon their own experience. For
example, one person said it would be good to have another gay man, as youve got
that feeling, well, hes the same as I am, therefore you can open up to him because he
understands, while another said the therapists sexuality shouldnt be an issue
really. Participants were less definite when they thought about other peoples
therapeutic needs and the role of the therapists sexuality.
The participants raised issues here for all practitioners who aim to work in a lesbian
and gay affirmative manner. Questions were posed in relation to the sexual identity
of the therapist. For the lesbian or gay therapist a question was: is the lesbian or gay
therapist out, i.e. do therapists identify as lesbian or gay themselves and are they
known as lesbians or gay men in their different worlds? Participants also considered
what it might mean to be a closeted lesbian or gay therapist, i.e. someone who is not
open about their sexuality. One participant had a definite view on this and said I
dont think its possible to be a gay affirmative therapist if you are gay and not out.
If the therapist is out, a number of anxieties were mentioned specific to lesbianlesbian or gay-gay therapeutic dyads, particularly concerning how sexual feelings will
be dealt with: this is considered below. In addition, the question was raised as to how
the client can trust that the gay therapist is not just validating the client because he
would, wouldnt he, on the basis that they could share some similar identity. One
client put it this way. If I knew he was gay, would that detract from everything he

14

15

was saying? Yeah, because then youd be biased, youd be saying Gay is
wonderful.
It was also suggested that there are advantages in having a lesbian or gay therapist,
particularly the ability that might exist to understand shorthand. By this participants
referred to a therapists ability to understand and use language specific to lesbian and
gay experience and culture. Reflecting on this issue, one participant said [an
affirmative gay therapist] would be able to read what I said, vis a vis my cultural life,
my social life, correctly. I mean not to make misinterpretations I might be able to
go into things more, sexual things. Participants also felt that lesbian and gay
therapists would be more likely to appreciate a stigmatised experience, appreciate the
experience of oppression and have an ability to model something good about being
lesbian or gay.
Regarding the sexuality of the heterosexual therapist, questions arose regarding the
nature of the views that a heterosexual therapist can have of lesbian or gay
experience. In this regard the experience of relationships is a common area of anxiety.
One client said I had an open relationship and I think I got a vibe that her feeling
was that our relationship was insubstantial.
Another question appears to be about the degree to which clients feel that the
heterosexual therapist will be able to overcome the heterosexism and anti-lesbian and
gay prejudice present in a heterosexual society. As one client said I didnt believe
that a straight therapist would be able to understand my experience of my sexuality,
and accept it, and really understand what is happening for me. An additional view
was that heterosexual therapists are useful in that they bring the issue of prejudice into
discussion, regardless of the degree to which they are anti-lesbian and gay. One

15

16

participant stated that if a heterosexual therapist was experienced in providing lesbian

and gay affirmative therapy it gives hope that the qualities can happen in society
with other people. Thus, by virtue of the therapists heterosexuality, the prejudice of
the wider world was seen to be brought into the therapy where it could impact
positively or negatively upon the therapeutic endeavour.
Existential issues
Existential issues may be present in any therapy, but appear with regularity in
participants views on lesbian and gay affirmative therapy. For the purposes of this
paper the term existential is defined as referring to fundamental aspects of Being
such as meaning. Participants spoke specifically about the meanings of sexuality.
Participants questioned whether therapists hold fixed, essentialist understandings of
homosexuality, or whether therapists accept and appreciate the multiple meanings that
these terms have. A constructionist understanding depends on who speaks of these
meanings, when they are spoken and to whom they are spoken. Thus, in the same way
that it is evident in the literature, it was suggested that it is important that therapists
consider the implications that both essentialist and constructionist views might have
for therapeutic work. In this regard, when thinking about his practice, one therapist
considered constructionist notions when he said the starting point needs to be, What
does being a lesbian or gay man mean for this person? I mean, I have an idea of
what being a gay man is, but thats my idea.
In line with existential psychotherapy, participants highlight the need for clarification
of a persons actual experience. They noted the dangers that might exist should we
move from a phenomenological stance - one that bases our understandings in the
experience of the client - and fall into an attempt to mould our clients into a

16

17

therapists personal or theoretical view of what an acceptable gay man or an

acceptable lesbian woman might be. This has been described as the danger of
demanding or searching for the good enough homosexual (Denman, 1993). The
issue of feedback also arose when participants discussed clarification. Direct feedback
was seen as important in therapy as long as it was respectful of the validity of the
clients rights and was based in sound and accurate knowledge of the context of the
particular clients.
Another issue that is frequently addressed in the existential literature is that of
Isolation and this was raised by participants. It was suggested that gay and lesbian
clients would almost inevitably have experienced a sense of isolation and this was
illustrated when one therapist reflected on the pain of a client who in his teens had
had a boyfriend, and the boyfriend [died] and no one knew. Isolation is problematic
if it occurs again in the therapeutic context - a risk that can arise from some of
deficient practices outlined earlier, such as a failure to acknowledge the distinctive
nature of aspects of the lesbian and gay experiences.
Human qualities were also mentioned, or what have been termed the Being qualities
of the therapist (Spinelli, 1994). It was felt that these are the qualities that enhance
lesbian and gay affirmative therapy. One therapist felt that his training had repressed
these aspects of himself and said that [The course] can be so rigorous that [ ] it took
us ages to regain our kind of natural skills, [ ] The more natural bits [ ] are often the
bits that are [thought of as] potentially most suspect. This therapist suggested that
his practice is better since he has been able to allow himself to be human with his
clients once again.
Other aspects of being human that were mentioned were self disclosure, acceptable

17

18

touch and allowing feelings to be experienced between the therapist and the client
without the need either to deny them or act on them. Regarding self disclosure, one
client said Its been very useful to work with [my therapist] [ ] and to have access to
his life experience which he will disclose if appropriate.
The place of sexual feelings in the therapy
Sexual feelings were raised in relation to the sexuality of the therapist but they also
constituted a specific area of thought and concern. Some felt that they would not be
able to bear having sexual feelings for their therapist if there was a chance (even
theoretical) that these could be reciprocated. One client reflected that obviously he
was the same gender as me, and the same sexual orientation and it would almost be
as if it were too near the knuckle.
Another view expressed was that there needs to be some degree of sexual feeling for
the therapist from the client if the client is going to benefit from therapy. A participant
felt that the client has to Find your therapist [ ] physically attractive. This
participant continued by saying that the client doesnt know its sexual. This is
subconscious for the client. The suggestion was that these are important feelings to
be experienced and discussed. This participant was careful to point out that he did not
feel that acting on such sexual attraction was a useful outcome but rather, he felt that
it is important to Change it and let it create what it wishes of itself within the
relationship.
These views raise questions for all practitioners: how able are we to accept the
clients sexuality on a very real and present basis? Could practitioners accept it if a
clients desire for the therapist was felt in this palpable manner? Can therapists

18

19

engage with this in a non-sexualised manner? Respondents to the DCoP study

appeared to feel that sexual feelings from same sex clients were difficult for the
therapist. One of the respondents said, In dealing with transference and countertransference issues, [it] could be stressful [for a] heterosexual therapist to experience
erotic transferences from a same sex client.

While this raises the issue of

supervision, it may also highlight issues that need to be considered when selecting
candidates suitable for therapeutic training.
The role of theory.
While many theoretical approaches to therapy were discussed, psychoanalysis
attracted most debate as might be expected given its tradition of pathologising views
of lesbian and gay sexualities and its association with oppressive practices. This
debate was related to issues in the literature and the media in recent years, e.g.
research into the denial of psychoanalytic training to lesbians and gay men (Ellis,
1994). One client provided an account that supported this research, by explaining that
he had been rejected for training on the basis of his sexuality. He said, I applied to
train at the (prestigious training institute in London) on two occasions. [ ] the second
time I was accepted and then turned down, [ ] because I wasnt sexually mature, [ ] I
wasnt heterosexual. A therapist also talked of difficulties in analytic training. He
described having to end his initial training analysis as his analyst would not entertain
passing him until he was more mature, and again heterosexuality was seen as the
benchmark for maturity.

One approach that practitioners described and which appeared to solve the dilemma of

19

20

being a psychodynamic and lesbian and gay affirmative practitioner was to separate
theory from practice. This strategy of inattention to problematic aspects of
psychodynamic theory has also been observed in female psychoanalytic practitioners
accounts of their positions as both women and psychoanalysts (Chodorow, 1996).
Participants felt that psychodynamic theory was almost inevitably going to
pathologise lesbians and gay men. This is evident in some of the current literature
discussed earlier that overtly formulates homosexuality as a perversion (Limentani,
1994; Rayner, 1986; Socarides, 1978). These participants tried to reject aspects of the
theory that they found problematic while embracing such psychodynamic approaches
to practice as free associative and interpretational techniques and the use of silence.
Through this strategy of selectivity, a psychodynamic approach can be rendered
consistent with an affirmative stance.
Other theoretical approaches were considered in relation to the strengths they offer
the lesbian and gay affirmative therapist, and these included humanistic approaches
such as client centred and gestalt therapies, cognitive behavioural therapy, neurolinguistic programming and systemic therapy. Eclecticism was also discussed, as was
the usefulness of fields other than psychotherapy, e.g. the sociological literature.
Many of these approaches, it was felt, were free to some degree of explicit theory on
sexuality. One therapist said, I think [cognitive therapy] assists because it has pretty
much a value neutral, pragmatic rather than a dogmatic stance, and because it
doesnt have much to say about early developmental processes. This line of thinking
advocates the usefulness for lesbian and gay clients of the universal methodology
approach to theory and training. It does this by suggesting that attention to such
universal processes as the impact of cognitions upon emotion may enable the therapist
to avoid some of the more pathologising theories that exist in relation to lesbian and
20

21

gay clients.
Client centred and existential approaches to therapy were also considered, not just
because of something that they lack, i.e. a central and elaborated theory of
development, but also because of what they add to a therapists understanding. One
therapist suggested that humanistic therapies have a very strong anti-discriminatory
value embedded in its core philosophy, I mean its absolutely crystal clear, and so
theres a real commitment there.
This does not mean that clients are guaranteed a lesbian and gay affirmative
experience from any specific approach. The values and prejudices of individual
practitioners and of the social and historical contexts in which they are embedded
affect all therapies. To illustrate this, one lesbian and gay affirmative practitioner
described her behavioural training as including electric shocks as aversion therapy to
realign clients sexual orientation.
Overall, participants felt that the therapist has a responsibility to take a critical stance
towards theory of any kind and to consider the theory and other influencing factors
before developing clinical formulations. While this may appear straightforward, it is
important to note that the ability to remain critical is difficult when immersed in a
culture where status, power and financial rewards are attached to particular
knowledge sets and practices (Foucault, 1961; Parker et al., 1995).

21

22

The role of gender in therapy.

As with the therapists sexuality, the issue of the therapists gender was characterised
by some complexity. For some, the gender of the therapist was irrelevant in therapy,
as when one therapist said, It doesnt matter. For others, it was an important aspect.
As one client put it I think gender is a big one, for me anyway. For some clients,
the gender of the therapist was a key criterion in choosing a therapist, in the same way
that for some the core criterion had been the sexual identity of the therapist.
Views were expressed about male therapists and about female therapists. Men were
described as sometimes a bit harder and ah, brittle, um and less allowing of human
frailty perhaps or better able to withstand some of the material that the client might
bring to therapy. In this regard, a client said, I felt I could perhaps talk a bit more
openly with a man, and uh, talked about my homosexuality more to a man, than I
could to [a female therapist]. Women therapists were seen in terms of
stereotypically feminine qualities to some degree, as when a client said Well, I
suppose women are supposed to be sympathetic and warm conventionally.
When these views were tied to sexual identity, there was a range of opinion, but the
overwhelming view was that lesbian and gay therapists of your own gender are most
likely to understand and respect you as a lesbian or gay client. Heterosexual men were
not evaluated favourably as (potential) lesbian and gay affirmative therapists. This
might be affected by the fact that, as was mentioned earlier, while some of the clients
had experienced therapy with a heterosexual man, no heterosexual male practitioners
operating in a lesbian and gay affirmative way responded to calls to participate in the
research.

22

23

Training and personal development.

Many of the participants raised issues regarding the training of therapists. All of the
therapists interviewed acknowledged the lack of attention that was paid to lesbian and
gay experiences in their training. One therapist said, I actually realised that that
wasnt part of the course and thats what hit me quite clearly.
Participants felt that absence of attention to lesbian and gay concerns in training has
taken the form of not teaching about the distinct experiences of lesbian and gay
clients, and also of not supervising client work in a way that allows for alternative
sexualities to be discussed. This can be viewed as an absence, but equally by
providing such deficient training, courses may be seen as silencing the lesbian and
gay voice (Coyle et al., 1998; Kitzinger, 1996). This absence may lead to a difficult
experience for clients, when their lesbian and gay experience is not acknowledged or
accepted. Also there are difficulties when therapists feel ill equipped to work with
lesbians and gay men as it limits lesbian and gay clients access to therapy in which
their experiences can be acknowledged and understood. As long as this situation
persists, those who train therapists are failing to produce professionals who are
equipped emotionally, cognitively and linguistically to work with a complete diversity
of experience. When lesbian and gay issues were addressed in training, participants
talked about having experienced a sense of disgust or horror when issues of same sex
sexuality were discussed, because these discussions often drew upon pathologising
discourse. One therapist talked about one quite appalling lecture, all of our sexual
health lectures were just dreadful. Another gave a specific example when a lecturer
told the class in the early 1990s, In order to cure yourself of AIDS, youve got to stop
being gay. In thinking of these issues, power was invoked as an important dynamic.

23

24

For the people who mentioned this, their dilemma related to how the trainee conveys
to the eminent professor that the teaching provided is offensive, outdated and/or
prejudice dressed up as theory. One participant noted that when trainings silence
lesbian and gay concerns it makes it more unspeakable, you know it makes it more
unthinkable, its either seen as [ ], something you simply cant ask, because its too
appalling to ask.
The research projects described above support Annesley and Coyles (1995)
contention that where therapists report being comfortable with their practice with
lesbian and gay clients, it has very little to do with training and instead is generally
ascribed to personal experience. Personal experience of being lesbian or gay, personal
experience of having lesbian or gay relatives or lesbian or gay friends was represented
as central to being comfortable when working with lesbian and gay clients.
Conclusion
Various conclusions concerning the nature and promotion of lesbian and gay affirmative
practice can be drawn from the literature and research presented in this paper. Perhaps
the most important conclusion is that lesbian and gay affirmative practice cannot be
considered to be a therapeutic approach analogous to psychodynamic, person-centred or
cognitive behavioural approaches, for example, which are grounded in elaborated
theories of human development, well-being and distress. Lesbian and gay affirmative
approaches are instead grounded in certain concepts, skills and qualities of being (most of
which would characterise good practice with any client group), underpinned by a
fundamental belief in the normality and value of lesbian and gay sexualities and a
thorough understanding of the nature, dynamics and challenges of these sexualities. The
extent to which such a stance can be easily incorporated within the various schools of

24

25

therapeutic theory and practice will vary according to the core assumptions of these
schools, with some requiring more significant amendment than others in order to
accommodate the principles of affirmative practice.
This is a potentially problematic issue because the greater the change that is required, the
greater the likelihood of it being resisted, not only because of anti-lesbian and gay
prejudice but also because fundamental change may be seen as eroding the very basis of
a particular therapeutic tradition. This has been witnessed in attempts to reformulate
psychodynamic theories and approaches in order to take account of feminist theory have
led to debates about whether the end products can still be considered psychodynamic
(Schoenewolf, 1997). In addition, queries have been raised over whether these attempts
can really be said to have addressed the problems that led psychodynamic approaches to
be seen as colluding with and reinforcing women's subjugation (Hollway, 1989; Frosh,
1994). Similarly, it is easy to imagine a situation where disagreement would arise over
whether a particular theoretical approach has changed too much or too little in an effort to
be lesbian and gay affirmative. These are issues that affect the wider field of affirmative
therapy as a whole, not just when working with lesbians and gay men. If affirmative
practice is considered to be worth striving for, change is unavoidable and such change
needs to start with a critical analysis of the core assumptions of every therapeutic
tradition. The analyses offered in this paper reveal that even the most apparently open
and accepting traditions are founded upon assumptions that can prove problematic when
practitioners are aiming to work affirmatively with lesbian and gay clients. The lessons
learned from the development of feminist therapeutic practice may prove a valuable
resource in directing and negotiating this process of change (Brown, 1994; DuttonDouglas and Walker, 1988; Enns, 1997).

25

26

The promotion of lesbian and gay affirmative therapeutic practice is dependent upon the
provision of lesbian and gay affirmative therapeutic training. Therefore, consideration
needs to be given to training curricula. As all therapeutic practitioners may potentially
encounter lesbian and gay clients, teaching staff on basic and post-qualification
therapeutic training courses need to consider how they can ensure that they foster
competence in lesbian and gay affirmative practice among trainees. This will entail staff
developing and refining their own competence in this domain and becoming skilled in
disseminating it to trainees. It will also involve creating adequate space within curricula
to address issues relevant to lesbian and gay well-being, such as lesbian and gay
identities, lesbian and gay relationship issues and dealing with anti-lesbian and gay
prejudice and violence.
If such recommendations were to be wholeheartedly implemented, the frequency with
which lesbian and gay clients encounter the sort of deficient therapeutic practice
outlined in this paper and in other studies (Annesley and Coyle, forthcoming;
Golding, 1997; PACE, 1998; Proctor, 1994) would be significantly reduced.
Moreover, it could be argued that the likelihood of these client groups encountering
non-pathologising, validating, life-enhancing therapy would be greatly increased,
thereby facilitating the development of more satisfying ways of living, including in
the sexual and relationship domains. Surely any therapist who is concerned with
providing a high quality service to their clients would agree that this is a goal worth
striving for.

26

27

References:

ANNESLEY, P., & COYLE, A. (forthcoming) Dykes and psychs: Lesbian womens
experiences of clinical psychology services, Changes: An International Journal
of Psychology and Psychotherapy, 16

ANNESLEY, P. & COYLE, A. (1995) Clinical psychologists attitudes to lesbians,

Journal of Community and Applied Social Psychology, 5, pp 327-331.
BECK, A. T. (1976) Cognitive Therapy and the Emotional Disorders,
(Harmondsworth, Penguin Books).
BRIDGET, J. (1995) Lesbian and gay youth and suicide, Paper presented at a
conference on The needs of gay and lesbian young people (London, National
Childrens Bureau) April 28, 1995.
BROWN, L. (1994) Subversive Dialogues: Theory in Feminist Therapy, (New York,
Basic Books).
CHODOROW, N. J. (1996) Seventies questions for thirties women: some nineties
reflections, in: S. Wilkinson (Ed.) Feminist Social Psychologies: International
Perspectives, pp.21-50 (Buckingham, Open University Press).
CLARK, D. (1987) The New Loving Someone Gay, (Berkeley, CA, Celestial Arts).
COHN, H. (1997) Existential Thought and Therapeutic Practice, (London, Sage).
COYLE, A. (1993) A study of psychological well-being among gay men using the
GHQ-30, British Journal of Clinical Psychology, 32, pp 218-220.
COYLE, A., MILTON, M., & ANNESLEY, P. (1998) The silencing of lesbian and
gay voices in psycho-therapeutic texts, training and practice, Paper
presented at the British Psychological Society Social Psychology Section
Annual Conference, 21st-23rd September (Canterbury, University of Kent).
DAVIES, D., & NEAL, C. (Eds) (1996) Pink Therapy; A guide for counsellors and
therapists working with lesbian, gay and bisexual clients, (Buckingham, Open
University Press)
DAVIES, D. (1996) Towards a model of gay affirmative therapy, in: D. DAVIES &
C. NEAL (Eds) (1996) Pink Therapy; A guide for counsellors and therapists
working with lesbian, gay and bisexual clients, (Buckingham, Open University
Press)

27

28

DAUGELLI, A. R. & HERSHBERGER, S. L. (1993) Lesbian, gay and bisexual

youth in community settings: Personal challenges and mental health problems,
American Journal of Community Psychology, 21, pp 421-448.
DENMAN, F. (1993) Prejudice and homosexuality, British Journal of Psychotherapy,
9, pp 346-358.

DIPLACIDO, J. (1998) Minority stress among lesbians, gay men and bisexuals: A
consequence of heterosexism, homophobia and stigmatization, in: G. M.
HEREK (Ed) Stigma and sexual orientation: Understanding prejudice against
lesbians, gay men and bisexuals, (Thousand Oaks, CA, Sage)
DU PLOCK, S. (1997) Sexual misconceptions: A critique of gay affirmative therapy
and some thoughts on an existential-phenomenological theory of sexual
orientation, Journal of the Society for Existential Analysis, 8, pp 56-71.
DUTTON-DOUGLAS, M. A., & WALKER, L. E. A. (Eds) (1988) Feminist
Psychotherapies: Integration of Therapeutic and Feminist Systems, (Norwood,
NJ, Ablex).
ELLIS, M. L. (1994) Lesbians, gay men and psychoanalytic training,

Free

Associations: Psychoanalysis, Groups, Politics, Culture, 4, pp 501-517.

ENNS, C. Z. (1997) Feminist Theories and Feminist Psychotherapies: Origins, Themes,
and Variations, (New York, Harrington Park Press/ Haworth Press).
FIFE-SCHAW, C. (1995) Surveys and sampling issues, in: G. M.BREAKWELL, S.
HAMMOND & C. FIFE-SCHAW (Eds) Research Methods in Psychology,
(London, Sage).
FOUCAULT, M. (1961) Madness and Civilization; A History of Insanity in the Age
of Reason, (London, Routledge)
FREUD, S. (1977) On sexuality, (Harmondsworth, Penguin).
FROSH, S. (1994) Sexual Difference: Masculinity and Psychoanalysis, (London,
Routledge).
GARNETS, L., HANCOCK, K. A., COCHRAN, S. D., GOODCHILDS, J., PEPLAU,
L. A. (1991) Issues in psychotherapy with lesbians and gay men: A survey of
psychologists, American Psychologist, 46, pp 964-972.
GOLDING, J. (1997) Without Prejudice: MIND Lesbian, Gay and Bisexual Mental
Health Awareness Research, (London, MIND Publications).

28

29

GONSIOREK, J. C., (Ed) A Guide to Psychotherapy with Gay and Lesbian Clients,
(New York, Harrington Park Press).
GREENE, B. & HEREK, G. M. (Eds) (1994) Lesbian and Gay Psychology: Theory,
Research and Clinical Applications, (Thousand Oaks, CA., Sage).
HEREK, G. M. (Ed) (1998), Stigma and sexual orientation: Understanding prejudice
against lesbians, gay men and bisexuals, (Thousand Oaks, CA, Sage)
HITCHINGS, P. (1994) Psychotherapy and sexual orientation, in P. CLARKSON &
M.POKORNY (Eds) The Handbook of Psychotherapy, (London, Routledge).
HOLLOWAY, W. (1989) Subjectivity and Method in Psychology: Gender, Meaning and
Science, (London, Sage).
HOPCKE, R. (1989) Jung, Jungians and Homosexuality, (Boston, Shambhala).
HOPCKE, R., CARRINGTON, K. L., & WIRTH, S. (Eds) (1993) Same-Sex Love and
the Path to Wholeness, (Boston, Shambhala).
ISAY, R. (1989) Being Homosexual; Gay men and Their Development, (London,
Penguin Books)
KITZINGER, C. (1987) The Social Construction of Lesbianism, (London, Sage).
______, (1996) The token lesbian chapter, Feminist social psychologies:
International perspectives, (Buckingham, Open University Press)
_______, & COYLE, A. (1995) Lesbian and gay couples: Speaking of difference,
The Psychologist, 8, pp 64-69.
_______, & PERKINS, R. (1993) Changing Our Minds: Lesbian Feminism and
Psychology, (London, Onlywomen Press)
LIMENTANI, A. (1994) On the treatment of homosexuality, Psychoanalytic
Psychotherapy, 8, pp 49-62.
MILTON, M. (1996) Coming Out in Therapy, Counselling Psychology Review, 11,
(3), pp 26-32.
______, (1998) Issues in Psychotherapy with Lesbians and Gay Men: A survey of
British psychologists, (Leicester, Division of Counselling Psychology
Occasional Papers, 4, British Psychological Society).
MILTON, M. & COYLE, A. (1998) Psychotherapy with lesbian and gay clients, The
Psychologist, 11, pp73-76.
OCONNOR, N. and RYAN, J. (1993) Wild Desires and Mistaken Identities:
Lesbianism and Psychoanalysis, (London, Virago)

29

30

PARKER, I., GEORGACA, E., HARPER, D., MCLAUGHLIN, T. & STOWELLSMITH, M. (1995) Deconstructing psychopathology, (London, Sage).
PACE (Project for Advice, Counselling and Education) (1998) Diagnosis: Homophobic.
The Experiences of Lesbians, Gay Men and Bisexuals in Mental Health Services,
(London, PACE).

PROCTER, G. (1994) Lesbian clients' experience of clinical psychology: A listener's

guide, Changes: An International Journal of Psychology and Psychotherapy, 12,
pp 290-298.
RATIGAN, B. (1995) Inner world, outer world: Exploring the tensions of race, sexual
orientation and class and the internal world, Psychodynamic Counselling, 1,
pp 173-186.
RAYNER, E. (1986) Human Development: An Introduction to the Psychodynamics of
Growth, Maturity and Ageing, 3rd Edition, (London, Routledge).
RIVERS, I. (1997) Lesbian, gay and bisexual development: Theory, research and
social issues, Journal of Community and Applied Social Psychology, 7, pp
329-343
ROGERS, C. R. (1951) Client Centred Therapy, (London, Constable).
ROTHERAM-BORUS, M.J., HUNTER, J. & Rosario, M. (1994) Suicidal behavior
and gay-related stress among gay and bisexual male adolescents, Journal of
Adolescent Research, 9, pp 498-508.
SAMUELS, A. (1993) The Political Psyche, (London, Routledge).
SCHOENEWOLF, G. (1997) Towards a viable theory of female development, Changes:
An International Journal of Psychology and Psychotherapy, 15, pp 1-12.
SHERROD, D. & NARDI, P. M. (1998) Homophobia in the courtroom: An assessment
of biases against gay men and lesbians in a multiethnic sample of potential jurors,
in: HEREK, G. M (Ed), Stigma and Sexual Orientation: Understanding
Prejudice Against Lesbians, Gay Men and Bisexuals, (Thousand Oaks, CA,
Sage)
SIMON, G. (1996) Looking forward: Perspectives from a practice contexts, Paper
presented at a conference on Beyond Homophobia (Loughborough,
Association of Lesbian, Gay and Bisexual Psychologies - UK) April 14th,
1996.

30

31

______, & WHITFIELD, G. (1995) A discourse-in progress: Gay affirmative practice

and a critical therapy, Paper presented at a conference of the Association of
Lesbian, Gay and Bisexual Psychologies - UK (Loughborough, Association of
Lesbian, Gay and Bisexual Psychologies - UK) September 16-17th, 1995.
SNAPE, D., THOMSON, K & CHETWYND, M. (1995) Discrimination against gay
men and lesbians: A study of the nature and extent of discrimination against
homosexual men and women in Britain today, (London, Social and
Community Planning Research)
SOCARIDES, C.W. (1978) Homosexuality, (New York, Jason Aronson).
SPINELLI, E. (1994) Demystifying Therapy, (London, Constable).
_______, (1997) Human sexuality and existential-phenomenological inquiry,
Counselling Psychology Review, 12, pp170-178
STRAND, D.A. (1998) Civil liberties, civil rights and stigma: Voter attitudes and
behaviour in the politics of homosexuality, in: G.M. HEREK (Ed), Stigma and
Sexual Orientation: Understanding Prejudice Against Lesbians, Gay Men and
Bisexuals, (Thousand Oaks, CA, Sage)
TRENCHARD, L., & WARREN, H (1984) Something to tell you The experiences
and needs of young lesbians and gay men in London, (London, London gay
teenage group).

31