Outline

Introduction to LGBTQ Concepts

Case Study- Jon and Brian
Cultural Considerations for Counseling
Understanding LGBTQ Culture
Issue One: Coming Out
Issue Two: Introduction of Significant Other
Theoretical Considerations
Narrative Therapy
Narrative Clinical Techniques
Individual
Group, Family and Couples
Ethical and Professional Practices
Lawsuits
Resources

What does LGBTQ stand for?

Lesbian
Gay
Bisexual
Transgender
Queer or Questioning

Terms to Know
Coming out- refers to the process in which one acknowledges and accepts ones own
sexual orientation. It also encompasses the process in which one discloses ones sexual
orientation to others. The term closeted refers to a state of secrecy or cautious privacy
regarding ones sexual orientation. (American Psychological Association, 2011)
Curative Therapy therapeutic interventions meant to return a homosexual person to
a homosexual orientation.
Gender - the attitudes, feelings, and behaviors that a given culture associates with a
persons biological sex. Behavior that is compatible with cultural expectations is referred
to as gender-normative; behaviors that are viewed as incompatible with these
expectations constitute gender non-conformity. (American Psychological Association,
2011)
Gender expression refers to the ...way in which a person acts to communicate
gender within a given culture; for example, in terms of clothing, communication patterns
and interests. A persons gender expression may or may not be consistent with socially
prescribed gender roles, and may or may not reflect his or her gender identity
(American Psychological Association, 2011)

Terms to Know
Gender identity - ones sense of oneself as male, female, or transgender When ones
gender identity and biological sex are not congruent, the individual may identify as
transsexual or as another transgender category (American Psychological Association,
2011)
Sex - a persons biological status and is typically categorized as male, female, or
intersex (i.e., atypical combinations of features that usually distinguish male from
female). There are a number of indicators of biological sex, including sex chromosomes,
gonads, internal reproductive organs, and external genitalia. (American Psychological
Association, 2011)
Sexual orientation - the sex of those to whom one is sexually and romantically
attracted. Categories of sexual orientation typically have included attraction to members
of ones own sex (gay men or lesbians), attraction to members of the other sex
(heterosexuals), and attraction to members of both sexes (bisexuals). In addition, some
research indicates that sexual orientation is fluid for some people; this may be especially
true for women (American Psychological Association, 2011)

Case Study: Jon and Brian

Case Study- Jon and Brian

Jon 44
Lived as a heterosexual male until age 30 (engaged to a woman at age 29)
Raised in: The South- Traditional
Family Initial Reaction: Not Accepting (father)
History:
- Several heterosexual relationships during late teen and early adult years
- Left the state to live freely as an openly gay man
- Dropped out of law school following the death of his first same-sex partner
- Meets Brian
- First 8 years of relationship Jons father refuses to meet or accept Brian
- Sister and Mother were accepting, but mother was concerned
- Mother experiences grief
- After many years, he becomes accepted by his father after they realize his
happiness, health and overall well-being has improved significantly

Case Study- Jon and Brian

Brian 40
Lived as a heterosexual male until age 14 (after dating females)
Raised in: The North- Liberal
Family Initial Reaction: Accepting
History:
- Came out at 14
- Family reacts with love and acceptance
- Family was open and accepting of significant others
- Parents welcomed Jon immediately
- Jons fathers failure to accept relationship is a relationship stressor
- Brian encourages Jon to force his father to accept the relationship
- Jons father accepts the relationship and stress between the couple
dissipates

General Cultural Considerations

Israel et al., (2007) conducted research of helpful and
unhelpful therapies for the LGBT population and found:

Needs
Transgender participants were more likely
to seek therapy for gender identity than LGB
clients were to seek therapy for sexual
orientation (p. 297).
Might prefer private practice counselors over
agency appointed counselors so that the
individual can pick their counselor based on
preferences and referrals from other individuals in
the LGBTQ community (Joint Commission, 2011).
Counselor should have (or try to have) nongender specific bathroom facilities and
should have non-gender specific and gender
neutral language in paperwork and signage
in the counseling office (Joint Commission,
2011).
Use the preferred choice of language used by the
client when talking about sexual orientation
and/or significant partner (Joint Commission,
2011).

Risks
At risk for depression and anxiety, substance
abuse, and suicidality
(Israel, T., Gorcheva R, et al., 2007 p294)
Also chronic stress more than
heterosexual peers (Israel, T., Gorcheva
R, et al., 2007 p. 294)
May have limited support system within family
and community. LGBT youth are subject to
bullying, harassment, threats, and violence
(Joint Commission, 2011).
Youth may also experience higher rates
of smoking, alcohol use, substance abuse,
HIV and other STD infections, anxiety,
depression, suicidal ideation and
attempts, and eating disorders (Joint
Commission, 2011).

Understanding LGBTQ Culture

The Process of Coming Out

Many of the emotional and physical risk factors for LGBT individuals are most
prominent during the process of coming out

Coming out is also a period of continually deciding whether or not to disclose this
information to specific friends, family members, and coworkers. These decisions
are motivated by the desire to validate one's own lifestyle and to establish
authentic interpersonal relationships, while always balancing the potential costs of
such disclosures (Pelton-Sweet, L., Sherry, A., 2008 p.170).

This is a time when confusion about identity lessens but feelings of alienation and
social difference often increase (Pelton-Sweet, L., Sherry, A. 2008 p. 171).

Pelton-Sweet & Sherry (2008) conclude that stage models dont accurately reflect
the coming out process which can take a lifetime (p. 171). Support is given to
potential biological, psychological, sociocultural, and historical factors in
understanding the coming out process.

All information taken from Pelton-Sweet & Sherry, 2008 (Formal citation listed on Reference slide)

Understanding LGBTQ Culture

How to Assist in the Coming Out Process:

Potential Hardships
of Coming Out:

Honor individuals own process and pace with the entire coming
out process, both to self and to family and friends (Thomas &
Schwarzbaum, 2011).

Counselor should assist individual in planning the entire

process of coming out to the family and/or introducing the
significant other. Most individuals in the LGBTQ community do
not have role models within the family or even society to look
up to in regards to such occasions and circumstances.

Rejection from
family, friends,
community

Possible
homelessness

Social isolation

Safety concerns
for self, family,
and possibly
significant other

Possible negative
feelings towards
self and others

Address possible issues individual may have with self such as

self-loathing, disgust, or denial (Thomas & Schwarzbaum,
2011, p. 315).
Assist client in overcoming certain myths about sexual
orientation, seek role models, and learn coping strategies for
the potential of homophobic behaviors from others (Thomas &
Schwarzbaum, 2011).
Provide resources that could be of potential assistance to the
client outside of therapy such as online community boards and
LGBT community centers in the area.

Understanding LGBTQ Culture

Introduction of Significant Other to Family of Origin:

Behaviors may not align with the self-identification of the individual and this could
be true for family members as well.

Counselor should understand that family members will have numerous questions
regarding coming out individual and how this affects their lives. Parents may
feel upset that their child is not normal and will not have the life that they once
believed them to have (Thomas & Schwarzbaum, 2011).

Counselor should help the individual assess whether introducing the significant
other is a wise decision - is it safe? Is the significant other out as well, could
this be a problem for the other individual in the relationship? How will this affect
the family and the relationship of the two individuals? (Thomas & Schwarzbaum,
2011)

As with the individual coming out process, counselor should assist in timing,
planning, and anticipation of reactions from family members and how to dea with
those reactions (Thomas & Schwarzbaum, 2011).

Previous Theoretical Considerations

Homosexuality was believed to be a mental disorder with diagnostic criteria

included in the DSM I and II

Homosexuality could be changed through curative therapy

Therapeutic interventions included:
Aversion Therapy
Electroshock (as aversion and punishment)
Use of nausea inducing drugs

Previous DSM Criteria for Homosexuality

DSM-II:
302 Sexual deviations
This category is for individuals whose sexual interests are directed primarily toward objects other
than people of the opposite sex, toward sexual acts not usually associated with coitus, or toward
coitus performed under bizarre circumstances as in necrophilia, pedophilia, sexual sadism, and
fetishism. Even though many find their practices distasteful, they remain unable to substitute
normal sexual behavior for them. This diagnosis is not appropriate for individuals who perform
deviant sexual acts because normal sexual objects are not available to them
DSM-III
302.00 Ego-dystonic Homosexuality
The essential features are a desire to acquire or increase heterosexual arousal, so that heterosexual
relationships can be initiated or maintained, and a sustained pattern of overt homosexual arousal that
the individual explicitly states has been unwanted and a persistent source of distress.
This category is reserved for those homosexuals for whom changing sexual orientations is a
persistent concern, and should be avoided in cases where he desire to change sexual orientations
may be a brief, temporary manifestation of an individuals difficulty in adjusting to a new awareness
of his or her homosexual impulses
Diagnostic criteria for Ego-dystonic Homosexuality:
A. The individual complain that heterosexual arousal is persistently absent or weak and
significantly interferes with initiating or maintaining wanted heterosexual relationships.
B. There is a sustained pattern of homosexual arousal that the individual explicitly states
has been unwanted and a persistent source of distress.

Many theories are based on the idea that heterosexism is the

norm (Adams, Jaques & May, 2004).

The problem should not be focused entirely within the

family, but on the broader social context we exist in (Adams,
Jaques & May, 2004). .

Affiliative orientation- the involuntary experience of

romantically falling in love. Many view homosexual
relationships as a derivative of sexual behavior, not romantic
love (Adams, Jaques & May, 2004). .

Theoretical Considerations

What is Narrative Therapy?

Purpose : To help individuals and families look for ways to change their lives
through deconstructing and re-authoring their own life story.
Role of the Counselor: Active through understanding
I am not the expert of your life, you are the expert of your life.
The counselor actively helps the client navigate through new ideas and
viewpoints, but is not looking to fix the client.
Goals and General Approaches :
You are not the problem, the problem is the problem.
Narrative therapy turns away from the process of pathologizing people and
relationships to creating an empathic and supportive therapeutic context for
people to call forth other ways of knowing themselves and their lives in order
to bring change. (Saltzburg, 2007)
Puts problems into a socio-cultural context.

Narrative Clinical Techniques

Deconstruction - breaking down stories and ideas that define a person by looking
at them from a different vantage point (Saltzburg, 2007).
Examining the absoluteness of the stories and exploring other possible outcomes,
challenging those stories that are used to immobilize, and dissembling unhelpful
stories (Saltzburg, 2007).
Externalizing - You are not the problem, the problem is the problem.
The client takes a relational stance to the problem. The counselor asks questions
that serve to figure out what type of impact the problem has on the client and what
the client is thinking that adds power to the problem.
When the problem is externalized, the power goes back into the hands of the client and
possibility can be established (Saltzburg, 2007).

Re-authoring - writing a new story that holds better outcomes and different
possibilities.
The counselor asks questions that help the client recognize unique outcomes (
when things turn up different from what their story says it should have), and
recognize their system of support.

Individual Techniques
Jon in Individual Therapy:
Jon speaks to his counselor about stressors in his life stemming from non-acceptance
and a lack of support. Brian is caught in the middle of Jons family as well as about
other factors that affect his life.

Externalization of the Problem: homophobia, the conflict, Malcolm-ing

Deconstruction: As their stories are being told, the counselor listens for gaps in
reasoning and for problem saturation (Payne, 2006). The counselor also makes sure
his or her interpretation of the clients problem is accurate. The counselor asks
questions about the story to draw out unique outcomes for the client.

Re-authoring- The counselor works with the client to think about how they would want
life to be, they explore things the client left out of their story to show the client how
things operated without the problem and how these things meant and felt to the client
(White, 2007). The client is made aware of the social context of the problem and decide
who they would like to keep in their lives as characters in their story (re-membering).

Couples, Family and Group

Techniques
Jon and Brian in Couples Therapy:
Jons family stressors center around his parents lack of acceptance of his life style.
Brian gets caught in the middle which creates stress for the couple.

Jon and Brian externalize their problem together and speak about it as if it is
outside of themselves.

They are more open and honest and comfortable about speaking.

They each examine their future stories separately and then they examine how those
stories interact together.

Couples, Family and Group

Techniques
Jon in Family Therapy:
Jon and his family speak openly about their role in Jons story. They discover new ways
of understanding and re-author their own individual stories.
Unique issues in family therapy:
Loss- parents may feel they are never going to be able to see their children
have children, get married or live a fulfilling life. There is worry about AIDS in
certain situations (Saltzburg, 2007).
Isolation - parent may feel that their son or daughters sexuality will isolate
them from their friends and social groups (Slatzburg, 2007).
Estrangement- parents and siblings may feel that the individual is so different
that they will never be able to relate again (Saltzburg, 2007). The client must
work to show both parties their similarities despite their differences in sexual
orientation.
Definitional ceremonies- engages individuals to be active participants in their own lives with the
support from their friends, relatives and people important to them. This validates the client as a proud
member of their new world.
Ex: Jons family throws him a Coming Out Party, a wedding is celebrated with the family in
attendance

Couples, Family and Group

Techniques
Jon and Brian in Group Therapy:
Jon and Brian have the chance to interact with other LGBTQ individuals in group therapy.
They may choose to attend regular group therapy on an individual basis and couples
group therapy together.
Narrative group therapy may be another important component for the LGBTQ individual.
It shows:

They are not alone in their identity.

They are able to openly discuss unique struggles with others dealing with similar
issues.
They are able to actively construct their story with the help of others.

This may be something Jon and Brian may have attempted first, to help them
understand that they are not alone and that there are people qualified to be
mindful of unique LGBTQ issues that can help them . Other ways to gain support
in a group setting may be to research forums on the internet.

Ethical and Professional Practices

Israel et al., (2007) found that:

It is clear from the results of the current study that basic counseling skills are
important. Notably, the most commonly described helpful and unhelpful
situations were defined by the presence or absence of basic counseling skills and
positive therapeutic relationships. Warmth, listening, appropriateness of
interventions, focus of therapy, and therapist congruence with client values and
decisions were particularly salient to creating helpful and avoiding unhelpful
situations (p301).

The present study found that therapists who were affirming, validating, and
knowledgeable regarding sexual orientation were particularly helpful, and those
who focused inappropriately on sexual orientation or tried to persuade LGBT
clients to change or hide their sexual orientation or gender identity were
particularly unhelpful (Israel et al., 2007 p.301).

Murdock states: One thing you should be clear about is that counseling is about
clients needs and values, not yours. Part of ensuring the welfare of your clients is
respecting the diversity they present, and this diversity comes in many forms
(Murdock, N. 2013 p.22).

Value Conflicts
Within the ACA Code of Ethics there are valuable codes to remember
when treating any client that creates value conflicts for the
counselor.
ACA Code of Ethics (American Counseling Association [ACA], 2005)

Counselors are expected to be aware of their own values and avoid imposing
values that are inconsistent with counseling goals (Standard A.4.b.)
Counselors must practice only within the boundaries of their competence (Standard
C.2.a.)
if they determine an inability to be of professional assistance to clients (Standard
A.11.b.), they should facilitate a referral to another provider.

Ethical and Professional Practices

Bruff v. North Mississippi Health Services,
Inc. (2001) :Bruff would not counsel her
previous client who had returned to receive
help with her Lesbian relationship because
Bruffs religious beliefs conflicted with
homosexual lifestyles; the court upheld Bruffs
termination from her place of emplyment

can use religious beliefs as the basis for

referring LGBT clientsHowever, these cases
have potential implications that extend beyond
the narrow rulings in Bruff and Walden,
because they have challenged how counselors
are trained at public universities.
(Herlihy, B., Hermann, M., Greden,
L. 2012p.149).

The rulings in these two legal cases affirmed

that em- ployers of counselors have a legal
duty to make reasonable accommodations for
the counselors religious beliefs. How- ever,
these two legal cases affirm that counselors
cannot be inflexible when religious
accommodations are offered (Herlihy, B.,
Hermann, M., Greden, L. 2012p.149).
Walden v. Centers for Disease Control and
Prevention (2010) : counselor insisted on
disclosing her reason for referral was based on
religious beliefs about homosexuals; the court
ruled against Walden, basing its deci- sion on
the manner in which [Walden] handled the
situation rather than on Waldens religiously
based refusal to provide same-sex relationship
counseling (Herlihy, B., Hermann, M., Greden,
L. 2012p.149).

When counselors take such rigid positions, it

appears that courts will likely uphold the right
of employers to terminate their employment
(Herlihy, B., Hermann, M., Greden,
L. 2012p.149)

Ethical and Professional Practices

(counselors in training legal cases)
Ward v. Wilbanks (2010) : during a practicum

class Julea Ward refused to counsel a client

because providing gay-affirmative counseling
would have violated her religious beliefs An
informal review was held, in which the
counseling faculty expressed concern that Ward
was refusing to comply with program policies
and the ACA Code of Ethics (American
Counseling Association [ACA], 2005). A
remediation plan was suggested to help Ward
comply with the ACA Code of Ethics, but Ward
refused to participate in the plan. After a formal
review, Ward was dismissed from the counseling
program (Herlihy, B., Hermann, M., Greden,
L. 2012p.149).

Keeton v. Anderson-Wiley (2010) : Jennifer

Keeton condemned homosexuality so the
university put her on a remediation plan but
she refused to participate in part of it. In the
appeal, the court noted that Keeton does not
have a constitutional right to disregard the
limits [the university] has established for its
clinical practicum and set her own standards
for counseling clients in the clinical practicum
(Herlihy, B., Hermann, M., Greden,
L. 2012p.149; Keeton v. Anderson-Wiley,
2010, p. 25)

BAN on the CURATIVE THERAPY

On January 1, 2013, California became the first state to ban Curative therapy for minors who are
Homosexual. The lawsays: that no mental health provider shall provide minors
with therapy intended to change their sexual orientation, including efforts to change

behaviors or gender expressions, or to eliminate or reduce sexual or romantic attractions or

feelings toward individuals of the same sex (Eckholm, E. 2012 p. 1).

For
(Eckholm, E. 2012 p. 1)

Against
(Eckholm, E. 2012 p. 1)

Gay and lesbian leaders, along with major scientific

groups, reject such theories outright and say there is no
scientific evidence that inner sexual attractions can be
altered.

One licensed family therapist and member of the

association, David H. Pickup of Glendale, Calif., said
in a recent interview that the ban would cause harm
to many who want and need the therapy.

Reparative therapy is junk science being used to

justify religious beliefs, said Wayne Besen, the
director of Truth Wins Out, a gay advocacy group.

If boys have been sexually abused and

homosexual feelings that are not authentic later
come up, we have to tell them no, we cant help
you, Mr. Pickup said.

The California law is a milestone, but only a first step.

Mr. Besen said, because the ideas in reparative therapy
have been widely adopted by church ministries and
others promoting the idea that homosexual urges can
be banished.
Legislators in New Jersey and a few other states
have discussed introducing similar bills to ban the
use of the therapy for minors, Mr. Besen said.

Helpful responses of a therapist treating an individual who

is troubled about his or her same-sex attractions include
helping that person actively cope with social prejudices
against homosexuality, successfully resolve issues
associated with and resulting from internal conflicts, and
actively lead a happy and satisfying life. Mental health
professional organizations call on their members to respect
a persons (clients) right to self-determination; be sensitive
to the clients race, culture, ethnicity, age, gender, gender
identity, sexual orientation, religion, socioeconomic status,
language, and disability status when working with that
client; and eliminate biases based on these factors.
(American Psychological Association, 2008)

How Can I Help?

Be open about your sexual orientation
Examine your own stereotypes and prejudices concerning the LGBTQ
community
Encourage non-discrimination policies in the workplace and social
organizations
Work to make coming out safe for persons of all ages, races, and genders
Educate yourself on the issues and terminology related to the LGBTQ culture

Resource Links
It Gets Better project
http://www.itgetsbetter.org/pages/about-it-gets-better-project/
Truth Wins Out
http://www.truthwinsout.org/
PFLAG
http://www.pflag.org GLAAD
http://www.glaad.org/
Human Rights Campaign
http://www.hrc.org
American Psychological Association
http://www.apa.org/pi/lgbt/resources/index.aspx
Wake Forest- LGBTQ Center http://lgbtq.wfu.edu/

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