Competent and Ethical Counseling of

1. Competent and Ethical Counseling of LGBTQ Persons Presented by: Traci Hill, LPC

2. Human Development and the Development of ‘Coming Out’… Predominance (per the Williams Institute, UCLA School of Law – 2011) • There are more than 8 million adults in the US who are lesbian, gay or bisexual, comprising 3.5% of the adult population.

3. Human Development and the Development of ‘Coming Out’… Predominance • In total, their study suggests that approximately 9 million Americans – roughly the population of New Jersey – identify as LGBT. • 1.8% identify as bisexual • 1.7% identify as lesbian or gay

4. Human Development and the Development of ‘Coming Out’… Predominance • Estimates of those who report any lifetime same-sexual behavior and any same-sex sexual attraction are substantially higher than estimates of those who identify as LGB. • There are nearly 700,000 transgender individuals in the US • 19 million Americans (8.2%) report they have engaged in same-sex sexual behavior. • Nearly 25.6 million Americans (11%) acknowledge at least some same-sex sexual attraction.

5. Human Development and the Development of ‘Coming Out’… The Stages of Coming Out The Cass Model (1979): 1. Identity Confusion 2. Identity Comparison 3. Identity Tolerance 4. Identity Acceptance 5. Identity Pride 6. Identity Synthesis

6. Human Development and the Development of ‘Coming Out’… The Stages of Coming Out The Cass Model (1979): 1. Identity Confusion • Sees self as member of mainstream group. Denial of inner feelings. • Who am I? • Am I different?

7. Human Development and the Development of ‘Coming Out’… The Stages of Coming Out The Cass Model (1979): 2. Identity Comparison • Begin to come out of the "fog." • Maybe I am gay. • I'm alone. • What are gay people like?

8. Human Development and the Development of ‘Coming Out’… The Stages of Coming Out The Cass Model (1979): 3. Identity Tolerance • Encounter someone or something that breaks through the denial system. • I accept the possibility that I may be gay. • Where are other gay people?

9. Human Development and the Development of ‘Coming Out’… The Stages of Coming Out The Cass Model (1979): 4. Identity Acceptance • Exploring subculture activities, readings, etc. • I am gay. • Am I okay? • I can come out to some people.

10. Human Development and the Development of ‘Coming Out’… The Stages of Coming Out The Cass Model (1979): 5. Identity Pride • Feel arrogance/pride in new identity and deep rage toward majority culture. May adopt/heighten stereotypical behaviors or characteristics (i.e. "I'm different and proud of it!".) May isolate self from mainstream values and activities. • I am proud to be gay. • I don't (and won't) pass for straight.

11. Human Development and the Development of ‘Coming Out’… The Stages of Coming Out The Cass Model (1979): 6. Identity Synthesis • Acceptance and integration of new identity. May go through five stages of grief to let go of old identity and all advantages of heterosexual privilege. Internalize pride/positive feelings about identity. Typically is "out" (with friends, family, at work). More at peace with self. • I am an okay person who happens to be gay.

12. PASSING COVERING IMPLICITLY OUT EXPLICITY OUT Lying Censoring Truth without LGBT labels Affirming LGBT identity I assume you do not know. I assume you do not know. I assume you know, but Iam not sure. I know you know. You know I know you know. See me as heterosexual Do not see me as LGBT You can see me as LGBT if you want to See me as LGBT Human Development and the Development of ‘Coming Out’… The Stages of Coming Out Identity Management (Griffin, 1992)

13. Human Development and the Development of ‘Coming Out’… Coping with Family/Social Reactions (Handbook of Counseling and Psychotherapy with LGBT Clients, 2nd editon, Bieschke, Perez, Debord) There are two different aspects to coming out. 1. Acceptance of one’s non-heterosexual identity Coping with internalized homophobia 2. Disclosing ones identity to others An affirmative counselor can model a positive response that can facilitate the client’s movement toward self-acceptance. Conversely, a counselor who reinforces negative social messages can thwart this process or cause additional distress.

14. Human Development and the Development of ‘Coming Out’… Coping with Family/Social Reactions Coming out is a life-long process… LGBT individuals have to do it over and over… • Family • Work • Friends • Others…

15. Human Development and the Development of ‘Coming Out’… Coping with Family/Social Reactions Factors which mediate impact of family reaction: (Coming Out and Internalized Homophobia, C. House) • Strength of religious values • Family values regarding traditional gender roles • Family’s view of itself in relation to the community

16. Human Development and the Development of ‘Coming Out’… Stages of Adjustment For Families 1. Subliminal Awareness • A non-heterosexual orientation may be suspected because of specific behaviors, same sex-friends, not dating heterosexually, dress and language use, changes in communication (not addressing certain subjects)

17. Human Development and the Development of ‘Coming Out’… Stages of Adjustment For Families 2. Impact Occurs when the truth is made apparent The revelation crisis: the negotiation of new family roles • Experience of loss of the member’s previous family role • Feelings of guilt/failure (for “abnormality”) • Siblings may react with anger/confusion, experienced as stranger despite shared childhood

18. Human Development and the Development of ‘Coming Out’… Stages of Adjustment For Families 3. Adjustment • Involves the family’s initial attempt to adapt to the non-heterosexual family member • Role clarification and adjustment

19. Human Development and the Development of ‘Coming Out’… Stages of Adjustment For Families 4. Resolution • The family discards the fantasized heterosexual identity for the non-heterosexual identity of the family member • Family members begin to examine their own values about non-heterosexuality and modify them in light of new and often intimate knowledge of non-heterosexual persons

20. Human Development and the Development of ‘Coming Out’… Stages of Adjustment For Families 5. Integration • Family adjusts values in order to incorporate the non-heterosexual identity into the family • Family members learn to de-emphasize the small part of the non-heterosexual family member’s identity that is different and retain the majority of the person’s known and loved attributes

21. Human Development and the Development of ‘Coming Out’… Gay Adolescence • Identity Pride (Stage 5 of The Cass Model) • Recommended for review: ‘Does Your Gay Age Match Your Chronological Age?’ at www.joekort.com • Typical behaviors and impacts… and issues seen in counseling at this stage?

22. Human Development and the Development of ‘Coming Out’… Developing Healthy Social Support and a Chosen Family Identity Acceptance (Stage 4 of The Cass Model) • Ex’s, Mentors, and other Accepting Individuals Provide a lifetime of emotional support from people who understand them in a way that straight family never will. • “Family of Choice”, “Gay Family” (this may include ex-partners)

23. Compounding Issues / Impact Themes LGBTQ? Can I accept myself? Will others accept me? Family or Origin Issues/Trauma Organic/Genetic: mood disorders, anxiety, etc.

24. Compounding Issues / Impact Themes LGBTQ? Can I accept myself? Will others accept me? • Mental Health • Recommended for review: • ‘New Data on Lesbian, Gay and Bisexual Mental Health’, DeAngelis, APA, Vol. 33, No.2 • ‘Prevalence of Mental Disorders, Psychological Distress, and Mental Health Services Use Among Lesbian, Gay, and Bisexual Adults in the United States’, Cochran, Sullivan, and Mays, Journal of Counseling and Clinical Psychology, 2003, Vol. 71, No. 1 • And regarding the possible development of Axis II symptoms… ‘Personality Disorders in Gay, Lesbian, Bisexual and Transgender Chemically Dependent Patients’ by Grant, Flynn, Odlaug, and Schreiber

25. Compounding Issues / Impact Themes LGBTQ? Can I accept myself? Will others accept me? Substance Use/Abuse Recommended for review: Healthy People 2010, Substance Abuse Report (CDC)

26. Compounding Issues / Impact Themes LGBTQ? Can I accept myself? Will others accept me? Overcompensation / Overachievers – self-esteem and worthiness issues “The Gay Tax” Recommended for review: “Another Consequence of Homophobia: Overcompensation”, by Dr. Anthony Grollman, 2013. “The Best Little Boy in The World,” by Andrew Tobias

27. Cultural Concerns The LGBTQ Community / “Gay Culture” • The flag and other symbols • Terms / language / code • Subcultures • Small communities • “Gayborhoods” • Gathering places • “Gaydar” • OKC / Oklahoma LGBTQ Culture • Boundaries

28. Cultural Concerns Spiritual Considerations • In Oklahoma • Books that may be helpful: • The Lord is my Shepherd and He Knows I’m Gay by Troy Plummer • Stranger at the Gate by Mel White • Christianity, Social Tolerance and Homosexuality by John Boswell • The Alchemist by Paula Coelho • We Were Baptized Too by M. Alexander and J. Preston • Also helpful to family members: • “Letter to Louise” by Bruce Lowe

29. Cultural Concerns LGBTQ AND: • Native American… the “two-spirit people”… • 2-Spirit Organizations: Native Out – www.nativeout.org, Central Oklahoma Two Spirits Society • Asian… “…a failure of the parents and a rejection of family and culture” (Bieschke, Perez, Debord) • The Gaysian, The Gay Asian’s Lifestyle Guide – includes a list of resources and organizations supportive to gay Asian-Americans • Latino… possibly ok if in “the active or insertive role…” (Bieschke, Perez, Debord) • Llego’, The National Latino/a LGBT Organization: 202-544-0092 • African American… “The Down Low / DL” • The National Black Justice Coalition, see website or call: 202-319-1552

30. Cultural Concerns LGBTQ AND: • Aging… risk of social exclusion / importance of community… • “I do not want to be looked after by someone who dislikes me because I am a lesbian.” Sheila, age 57 • For more info see: Working with Older Lesbian, Gay and Bisexual People, a Guide for Care and Support Services” by the Stonewall organization • SAGE (Services and Advocacy for LGBT Elders) – Tulsa Chapter – SAGE@Okeq.org • Outt Late – a support group for lesbians that came out later in life – Cimarron Alliance, OKC

31. Cultural Concerns LGBTQ AND: • Youth… the rate of suicide attempts among GLB youth are 20 – 40% higher than among non-GLB youth – per NAMI. • Trevor Suicide Prevention Line 1-800-850-8078 • Rainbow Youth Hotline 1-877-542-8984 • GLBTQ Youth Advocacy www.youthresource.com • Locally: YES (Youth Equality Services) • LGBTQ Support Group every Tueevening at Expressions, in Common Grounds Coffee Shop at 2245 NW 39th • Kris Williams, Coordinator 405-600-1052

32. Cultural Concerns LGBTQ AND: For Oklahoma Specific LGBTQ Community and Support Information: • The Cimarron Alliance Equality Center – 405-495-9300 At 56th and N. May, www.equalityokc.org • Oklahomans for Equality, Tulsa – Helpline: 918-743-4297 or www.okeq.org

33. The “T” (Transgendered) Overview Development / General Information • “I knew something was different at age 4,5,6…” • The Transexual Person in Your Life at www.tsfaq.info • www.Susans.org

34. The “T” (Transgendered) Overview The Tg “Umbrella” • Cross-dressing • Transvestite • Gender Queer • Transexual

35. The “T” (Transgendered) • Diagnosis • Gender Identity Disorder, now Gender Dysphoria…the criteria… • Complications: • Depression or anxiety • Poor self concept • Body image issues / obsession • Emotional distress • Feeling alone • Suicide

36. The “T” (Transgendered) Role of the Therapist Standards of Care • Dr. Harry Benjamin / The Benjamin Standards of Care … …1948, 1966, and today… • World Professional Association for Transgender Health (WPATH)

37. The “T” (Transgendered) Role of the Therapist • Family-Centered Treatment • Assisting parents, spouses/partners, children in the adjustment process… • Coping in the Community • When, how, and to whom to “come out”… • Advocacy • Education / Consultation • The “Bathroom Letter”

38. The “T” (Transgendered) Role of the Therapist • Youth and Children • Timing / case-by-case • Parents and split families • Support • Involving the doctor • When to Refer / Consult • “We shouldn’t have to educate our therapists.” -- a client in transition • Thorough evaluation • Comorbid issues

39. The “T” (Transgendered) The Transition • Social / Emotional • Self • Family • Work • Community • Physical • Hormones, hair and hips… • Medical • Hormones • Surgical Options • Local resources • Every transition is different – a “completed transition” for one may be very different than that of a another…

40. The “T” (Transgendered) Developing a Healthy Support Network • Online support/community • Local support groups / community • Cimarron Alliance – Saturdays at 5pm • Local LGBTQ-friendly churches

41. Clinical Considerations Personal Bias Heterosexism: (Handbook of Counseling and Psychotherapy with LGBT Clients, 2nd edition) • Defined as: “The ideological system that denies, denigrates, and stigmatizes any nonheterosexual form of behavior, identity, relationship or community.” • “…refers to the premise that all people are heterosexual unless and until they indicate otherwise…therapists frequently operate under this premise…”

42. Clinical Considerations Personal Bias Heterosexism: • “The client’s current identity may not be a fixed point, but rather fluid… it is important not to make assumptions based on current behavior or marital status” • Communicating openness to clients: • Promotional materials / nondiscrimination statement • Forms • Office

43. Clinical Considerations Overcoming Heterosexism: • “A critical first step that counselors need to take to avoid perpetuating heterosexism is to perform an honest self examination of their own attitudes and beliefs regarding sexual orientation,” • “Mental health professionals live in the same heterosexist society as everybody else and are subject to biases and prejudices that permeate that culture.”

44. Clinical Considerations Areas to explore: • To what degree do you consider a range of possibilities as viable? • Do you perceive a variety of equally acceptable alternatives with respect to sexual orientation, or is heterosexuality considered preferable, with other identities being acceptable but less preferable (or even unacceptable)? • To what extent do you place limits on those who do not identify themselves as heterosexual (career, parenting, etc)?

45. Clinical Considerations Areas to explore: • To what degree do you fully embrace the professional organizations’ removal of homosexuality as mental illness? • Do you view LGBT orientation as indicative of instability, regardless of the official position of your association? • What are your religious beliefs regarding the ‘shamefulness’ or ‘sinfulness’ of nonheterosexual orientations?

46. Clinical Considerations Areas to explore: • Religion can be a particularly difficult problem for LGBT individuals, often bringing them into therapy. • “Therapists need to be able to help clients address religion and spirituality in ways that are affirmative, not further condemning.” • Conversion Therapy

47. Clinical Considerations APA Practice Guidelines for LBG • Understand the effects of stigma • Understand these orientations are not mental illnesses • Understand that same sex attractions feelings and behavior are normal variants of human sexuality

48. Clinical Considerations Boundaries • Can we install and maintain the same boundaries with LGBTQ clients as we would with heterosexual clients? Or is there an ‘extra wall’?

49. Clinical Considerations Confidentiality • Do we maintain the same level of confidentiality for nonheterosexual clients, or are some things just too juicy not to share (even without names)? • Small communities…

50. Clinical Considerations Informed Consent • Being open and ready to inform clients of how much experience we have with their particular population / issue