ETHICAL ISSUES in Counseling Gay or Lesbian Individuals and Families

1. ETHICAL ISSUES in Counseling Gay or Lesbian Individuals and Families By Jeffrey T. Bornstein, MS, LPCC, and Benjamin M. Lasky, Ph.D.

2. Declaration • We hereby declare that we have no financial or proprietary interests in giving this presentation. • Some of the matters here are aspirational while others are mandated by State and Federal Laws. • Each attendant should adhere to rules and regulations provided by their licensing boards.

3. Goals and Objectives • Explain how Heterosexism and Homophobia account for Discrimination • Impact of Staying Closeted or Coming Out • Cass Stage Model of Developing Gay Identity • Obstacles to Developing Gay Identity • Models to Treat LGBT Clients

4. Heterosexism, Homophobia and Discrimination • LGBT individuals live in a predominantly heterosexual environment marked by HOMOPHOBIA (the fear and hatred of gay and lesbian people) and • HETEROSEXISM (the perceived superiority of heterosexuality over nonheterosexuality). • These attitudes can translate into destructive and violent actions toward the gay or lesbian individual.

5. Types of Discrimination Individual Discrimination • GLBT individuals are subjected to verbal and physical attacks. For example, one study of Gays and Lesbians age 15-21 found that 80% had experienced verbal attacks, 44% had been threatened with violence, 33% had objects thrown at them, and 31% had been chased or followed, and 17% had been physically assaulted. • LGBT teens are 5 times more likely to miss school after being bullied due to sexual orientation because they feel unsafe. • Adult LGBT individuals also face discrimination. One study found that 42% of LGBT adults felt that they experience discrimination due to sexual orientation on a day-to-day basis

6. Types of Discrimination Institutional Discrimination – the policies and laws • During the cold war, the federal government enacted policies and procedures to effectively ban LGBT individuals from gaining employment in civil service and intelligence agencies. LGBT individuals would not be hired because it was presumed they posed a security risk. The premise was that enemy forces could blackmail these individuals to divulge secrets. • This discrimination carried into the private sector and the LGBT population was effectively barred from 20% of the nation’s jobs.

7. Types of Discrimination Institutional Discrimination • 1993 a Michigan Court of Appeals held that sexual orientation was not protected, so, workplace discrimination based on a person’s sexual orientation was not prohibited. • In 29 states, it is fair to be fired for being LGBT or denied promotions, in 38 states, you can be fired for being transgender. • If they are in a career that is homophobic or heterosexist, they may decide they need a new career. Wherever they work, they should become aware of what protections exist under the law. - Many states currently have proposed amendments to ban same sex marriage (e.g., Prop 8 passed in California in 2008 election).

8. Types of Discrimination • Cultural Discrimination – Most present in religions of society. Very few religions are accepting of homosexuality, so, a place where one usually turns to for support often treats the LGBT individual as if he/she is not worthy or evil. • Families of origin can struggle to tolerate and accept that they have an LGBT family member at varying degrees. • Church’s that support gay marriage include progressive Christian denominations (eg., Episcopalian, Evangelical Lutheran) conservative and reform Judaism, Liberal Hinduism, Progressive Muslims, and Native American Religions • Lesbians and Gays often choose to lead closeted lives to avoid these types of discriminations

9. Staying Closeted or Coming Out • If an LGBT individual decides to stay closeted, this can lead to internal conflict between his/her natural homosexual urges and his/her desire to fit into the mainstream. This can lead to mental and physical issues such as Major Depression, Anxiety, Eating Disorders, and Substance Abuse, and Gastrointestinal Discomfort. • This can also lead to guilt and shame over having to keep a secret

10. Deciding To Come Out • If the person comes out, he or she must face the prevailing heterosexist and homophobic attitudes associated with this behavior. This hatred often leads to Internalized Homophobia (self-hate). • Self-hate interferes with developing healthy, long term relationships, intimacy issues and other mental health issues

11. Deciding To Come Out • The out individual also may face issues with his or her family of origin. Even in families that accept, there are no rituals (e.g., weddings, birth of grandchildren, etc.) in mainstream society that bond gay and lesbian children to their family. • LGBT culture also does not have rituals that include heterosexual people with the exception of P-Flag (Parents and Friends of Lesbian and Gays). • These are issues counselors must be aware of when seeing LGBT clients.

12. Stresses of Coming Out • Coming out is a lifetime process and not a one time event. • Out individuals must develop their gay identity and come to terms with individual, institutional, and cultural discrimination. The gay or lesbian individual has to shift from the socially accepted heterosexual identity to the socially denigrated nonheterosexual LGBT identity. • LGBT individuals may have difficulty forming relationships with other LGBTs due to lack of opportunities in their environment.

13. Cass Stage Model of LGBT Identity Development • A stage development model that describes the identity development of LGBT individuals. This helps therapists predict some of the developmental issues that LGBT individuals have to face. • The Cass Model was developed in 1979 by Vivian Cass and is a 6 stage model. The model does not account for race, religion, culture, gender, and ability.

14. Cass Stage Model of LGBT Identity Development Stage 1 Identity Confusion • Person’s first awareness of gay or lesbian thoughts, feelings, and attractions (‘could I be gay?’). The person usually feels confused and has turmoil. In this stage, they may deny their homosexuality (e.g, ‘just experimentation,’ ‘it was the alcohol’). • Oftentimes, they keep emotional involvement separated from sexual involvement. • During this stage, the person may need permission from the therapist that it is OK to explore sexual identity.

15. Cass Stage Model of LGBT Identity Development Stage 2 Identity Comparison • Person accepts that they might be LBGT and becomes aware that this has wide implications. Often in this stage, the LGBT person feels alienated which can lead to isolation. • At this stage, they may compartmentalize their own sexuality, but maintain a heterosexual identity (e.g., my gay feelings are only temporary, I am just in love with this one particular man/woman). • The therapist must discuss the implications of loss of heterosexual life expectations, provide community resources, and help them overcome isolation.

16. Cass Stage Model of LGBT Identity Development Stage 3 Identity Tolerance • The individual acknowledges LGBT identity and seeks out other gay and lesbians to combat isolation. They start to realize that they are not the only one going through this. Internalized homophobia is often seen during this stage. • They are more willing to understand that being LGBT is permanent and to look for others to end isolation. They may try out a variety of stereotypical roles. • The therapist needs to provide support in exploring self-shame feelings derived from internalized homophobia and heterosexism and make sure they are aware of the community resources available to them.

17. Cass Stage Model of LGBT Identity Development Stage 4 Identity Acceptance • The individual feels positive about being LGBT and increases contact with LGBT culture. Oftentimes, individuals in this stage have less and less contact with the heterosexual community. They usually are more comfortable coming out and being seen with LGBT individuals and groups. They are more comfortable ‘coming out’ and do so more frequently. • The therapist continues to help LGBT people deal with internalized homophobia and helps them better understand when it is appropriate to ‘come out.’

18. Cass Stage Model of LGBT Identity Development Stage 5 Identity Pride • LGBT individual compartmentalizes the world into heterosexuals and homosexuals and has an ‘us vs. them’ political/social viewpoint • At this stage, therapists need to help them explore their anger and issues of heterosexism. For example, an LGBT person in this stage may need to be told to have patience with family members, as they have just learned that this person came out, while the person who came out had been working on the issue their entire lives.

19. Cass Stage Model of LGBT Identity Development Stage 6 Identity Synthesis • The individual integrates sexual orientation identity with all aspects of self and sexual orientation becomes only one aspect of self rather than entire identity. • At this stage, therapists need to continue to be mindful that LGBT individuals will always face heterosexism and homophobia and there is always a chance they could regress to an earlier stage.

20. D’Augelli’s Model of Lesbian,Gay, Bisexual Development (1994) • A lifespan model: 3 interrelated Variables interact for identity formation: • Personal Actions, and Subjectivities: An individual’s self-concept in relation to his/her sexual behaviors, feelings, and thoughts • Interactive Intimacies: an individual’s inner circle’s response and interactions with partners • Sociohistorical Connections: Society’s view, demographics of residence, and beliefs

21. D’Augelli Model • Exiting Heterosexual Identity: Acknowledging that feelings are not heterosexual in nature • Developing a Personal Lesbian/Gay/Bisexual Identity Status: An individual’s personal definition of being homosexual • Developing a Social Lesbian/Gay/Bisexual Identity: An individual’s homosexual identity as it pertains to peer groups and social norms

22. D’Augelli Model • Becoming a Lesbian/Gay/Bisexual Offspring: An individual’s attempt to share his/her homosexual identity with parents and its consequence • Developing a Lesbian/Gay/Bisexual Intimacy Status: The journey to find a meaningful, intimate relationship • Entering a Lesbian/Gay/Bisexual Community: An individual’s recognition of injustices and triumphs and joining the community

23. Challenges to Developing a Gay Identity • They must shift from socially accepted heterosexual identity to socially denigrated LGBT identity. • This shift signifies that they will now directly have to deal with individual, institutional, and cultural discrimination

24. Challenges to Developing a Gay Identity • LGBT individuals have realistic concerns that coming out will lead to rejection, estrangement, and mistreatment from their family of origin • Family of Origin – In one study, 50% of mothers of LGBT college sons initially reacted with disbelief or denial when finding out their sons were gay or bisexual. 50% of fathers reacted with silence or disbelief. 18% of parents reacted with intolerance, attempts to convert them to heterosexuality, and verbal threats to cut them off financially. • Most parents eventually come to accept or tolerate their child’s sexual orientation, but the above reactions can delay the ‘coming out’ process.

25. Challenges of Developing a Gay Identity • Coming out can lead to satisfaction, renegotiation of family ties, empowerment, and integration of gay and straight lives. • Coming out is the hallmark of gay/lesbian identity development. • Therapists should note that many of the mental health issues seen during the coming out process often mimic psychopathology (e.g., eating disorders, substance abuse, affective disorders, depression) and should be interpreted in the developmental context rather than a primary diagnosis. • Therapists should be aware that adolescents who recently came out are at heightened risk for suicide attempts

26. Developmental Issues • According to Erik Erikson’s Developmental Stage Model, individuals face developmental tasks or conflicts at various stages of their life. If the person resolves the conflict, they develop in a healthy manner. If they do not, they may develop issues that are rooted in unresolved conflict. • In Erikson’s fifth stage, LGBT individuals can have greater difficulty resolving Identity vs. Role Confusion during adolescence when their heterosexual peers are expected to accomplish this task.

27. Developmental Issues • LGBT individuals have a more difficult time resolving Identity vs. Role Confusion due to a lack of role models as well as the repression of their true sexual identity. • One manifestation of successful resolution of Identity vs. Role Confusion for the LGBT person is ‘coming out.’

28. Models to Treat LGBT Clients Multicultural model • Therapists must be aware their client is not part of the mainstream and understand how living in a homophobic and heterosexist culture impacts their client. • Therapists must be aware how LGBT individuals may have a negative view of their profession. For example, until 1973, the APA considered homosexuality a disorder. Now, the APA (2002) and ACA (1995) include sexual orientation and gender identity in their code of ethics and mandate that diversity of this type be respected.

29. Multicultural Model – Therapist Errors • Failing to recognize that ‘coming out’ is a major event by glossing over it. • Assuming an opposite gender when discussing a client’s romantic relationship (heterosexism). • Having assessment forms that have non-inclusive language. • Gay and lesbians have communicated they feel negative when such things occur in the counseling session which hurts rapport.

30. Multicultural Model - Suggestions • Ask nonjudgmental questions about sexual orientation. • Have inclusive language in assessment forms. • Sex/Gender: M, F, Intersex, Transgendered. • Relationship/Marital Status: Single, Married, Living Together, Partnered, Divorced). • Early self-disclosure from therapists who are homosexual. • Have textbooks of homosexuality on bookshelves. • These types of actions help build relationships.

31. Multicultural Model Questions for a straight therapist to ask themselves: • Are my family values inclusive of LBGT individuals and their families? • Is a healthy and happy life compatible with being gay or lesbian? • Can I let the gay/lesbian couple take the lead in determining whether a relationship is workable and healthy? • Am I ok with gays/lesbians having families and being parents? • Would I be willing to be the client of a gay/lesbian therapist?

32. Multicultural Model • Straight therapists must be ready for their client to express rage and anger they perceive as injustices from the mainstream heterosexist, homophobic world without taking it personally and acting defensively • Help their client work through the pros and cons of what coming out will mean at work, with family or origin and all of their environments

33. Rational Emotive Behavior Therapy • Unlike the Multicultural Model which posits that LGBT individuals experience psychological issues due to their environment, REBT therapists posit that LGBT individuals cause their own problems by their reactions to the environment. LGBT individuals who learn REBT redefine how they feel about themselves and how they react to their environment.

34. Rational Emotive Behavior Therapy Core Aspect of REBT Therapy • A (activating event) influences B (beliefs about event), which results in C (consequences). In reality, the person’s belief system causes the consequences. With this approach, patients learn to replace their faulty beliefs with ones that lead to positive consequences.

35. Psychoanalysis • The therapist tries to make clients’ unconscious thoughts and motivations conscious. Once aware of these unconscious thoughts, they can modify these thoughts for a healthy and significant change in their personality. • LGBT individuals are hesitant to engage in psychoanalysis due to perception that the theory condemns homosexuality or treats it as a disorder. • Freud did consider the development of homosexuality was due to arrested development of the phallic stage. • At the same time, Freud did not treat homosexuality as a disorder and believed psychoanalysis could effectively be used to treat LGBT individuals the same way he would treat heterosexuals.

36. Conversion Therapy What should a therapist do if a potential client comes to therapy to become free of homosexual thoughts and feelings? • Explain informed consent and make sure client understands the information shared is confidential. • Explain that there are no substantiated claims that therapy can convert sexual orientation. • Discuss alternatives to conversion therapy. • Be aware that client may not be comfortable discussing their homosexual feelings and may not allow exploration.

37. Conversion Therapy • If patient still wants Conversion Therapy, the therapist can provide this therapy if they feel they have a good understanding of the patient’s religion and moral value system and accept that their mode of therapy has effectiveness with a wide range of disorders. • Gay therapists should reveal their sexuality as this could have an impact if the client wants to move forward.

38. Kinsey Heterosexual-Homosexual Rating Scale The 7 Point Scale • 0 – Heterosexual 100% • 1 – Predominantly heterosexual, only incidentally homosexual • 2 – Predominantly Heterosexual, but more than incidentally homosexual • 3 – 50% heterosexual, 50% homosexual • 4 – Predominantly homosexual, but more than incidentally heterosexual • 5 – Predominantly homosexual, only incidentally heterosexual • 6 – Exclusively homosexual • In a therapeutic setting, this could be used to help alleviate concerns of someone who identifies as heterosexual but has homosexual thoughts, or someone who identifies as homosexual but is upset over heterosexual thoughts they have.

39. Kinsey Heterosexual-Homosexual Rating Scale • This rating scale was developed in 1948 to account for their research findings that showed people do not fit into neat and exclusive heterosexual or homosexual categories. • Kinsey stated, “males do not represent 2 discrete populations, heterosexual and homosexual. The world is not to be divided into sheep and goats, …The living world is a continuum in each and every one of its aspects.” • In their book, Sexual Behavior of the Human Female, the authors noted that , “it is characteristic of the human mind that tries to dichotimize in its classification of phenomena….many persons do not want to believe that there are gradations in these matters from one to the other extreme.”

40. Community Resources • Los Angeles Gay and Lesbian Center Los Angeles, CA 90028-6213. Tel: 323-993-7400, laglc.convio.net.