Marvin R. Goldfried

CLINICAL ISSUES IN WORKING WITH LESBIAN, GAY, AND BISEXUAL CLIENTS

This article discusses some of the key clinical issues for therapists to consider when working with lesbian, gay, and bisexual (LGB) clients. After a discussion of the biases that can influence psychotherapy, guidelines are given for conducting LGB-affirmative therapy that avoids these biases. Issues that therapists need to be familiar with in working with LGB clients include LGB identity development; couple relationships and parenting; LGB individuals as members of families; the unique stressors faced by individuals who are underrepresented in the LGB research literature (e.g., older LGB individuals, ethnic minorities, religious LGB individuals, bisexual individuals); and legal and workplace issues. An examination of the published literature is offered with particular emphasis given to the available empirical research. Lesbian, gay, and bisexual (LGB) women and men utilize therapy at rates higher than the general population (Bell & Weinberg, 1978; Liddle, 1996; Morgan, 1992; National Lesbian and Gay Health Foundation, 1988), and nearly all therapists report seeing at least one LGB client in their practices (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991). Yet, the mental health professions have historically demonstrated heterocentric and homophobic beliefs, prejudices, and practices against LGB individuals, placing the burden of distress on the client and his or her possession of an illness (Goldfried, 2001). Indeed, some professionals continue to promote cures for homosexuality (Nicolosi & Nicolosi, 2002). Even when homosexuality is not viewed as pathological, mental health professionals need to consider the distress that antihomosexual bias can cause LGB individuals. Disregarding such factors may lead to erroneous and unfortunate attributions of the sources of distress in an LGB person who is seeking therapy. There is a dearth of systematic research on the unique therapy experiences of LGB individuals. Although theoretical work on the nature, etiology, and consequences of LGB identities abounds, little exists in the way of empirical studies on these issues. Thus, it comes as no surprise that when working with LGB clients, we as therapists are often inadequately equipped in our training to handle issues that are unique to LGB individuals (Phillips & Fischer, 1998). As a consequence, LGB clients have a right not only to be skeptical of our competence in handling their LGB-related issues but also to expect that we gain proficiency in handling any such issues that may arise in the therapeutic context. Although guidelines for conducting psychotherapy with LGB clients exist (American Psychological Association, 2000), there is a need for work that explicates these guidelines with the intent of making them more useful for clinicians. Important issues in the lives of LGB clients include LGB identity development, romantic relationships, family relationships, and parenting. There are a number of additional issues and considerations that are important to consider when working with certain members of this population (e.g., specific issues of concern to bisexual, ethnic minority, and older LGB individuals). The primary purpose of this article is to provide an overview of many of the issues we need to know about as therapists when working with LGB clients. As will be seen, some of these issues are based on clinical impressions and some on research findings. We first consider the ways that heterocentrism and homophobia affect LGB individuals and some of the potential therapeutic biases that may arise when working with LGB clients. Toward the goal of encouraging an LGB-affirmative approach to therapy, several of the specific issues confronting our LGB clients are then discussed.

The working alliance: A comparison of two therapies.

Alliance ratings of single significant sessions of cognitive-behavioral and psychodynamic-interpersonal therapies were compared using the observer form of the Working Alliance Inventory (WAI-O). Eighteen cognitive-behavioral and 13 psychodynamic-interpersonal therapists, nominated by experts in the field, participated in the study. Results indicate significantly higher total alliance scores for cognitive-behavioral sessions, and greater variability in alliance for psychodynamic-interpersonal sessions. In addition, SCL-90 scores were negatively correlated with the alliance solely in psychodynamic therapy, indicating that more symptomatic patients may have greater difficulty with the work required in this kind of therapy.

Faulty thinking patterns in two types of anxiety

This study examined the cognitive characteristics of an unselected clinical population to determine the extent to which two current conceptions of faulty thinking, irrationality and negative self-statements, were differentially associated with pervasive and situation-specific forms of anxiety. Subjects were 25 male and 33 female adults requesting therapy at a community clinic. They were assessed on two indices of anxiety, the Social Avoidance and Distress Scale and the Fear of Heights Survey, and on two measures of faulty thinking, the Irrational Beliefs Test and the Situations Questionnaire. Results indicated that the pervasive form of anxiety, social anxiety, is significantly correlated with only irrational thinking, while the situation-specific form of anxiety, acrophobia, is significantly correlated with both irrationality and negative self-statements. Several additional relationships were identified, notably, the greater tendency of phobic than socially anxious subjects to emit negative self-statements and, for phobic subjects, the greater tendency to emit negative self-statements than to think irrationally. The implications of these findings for cognitive behavioral theory and therapy are discussed.

Resistance and Clinical Behavior Therapy

The concept of resistance rarely if ever arose in the early literature on behavior therapy. Most of the original descriptions of behavior therapy conveyed an underlying assumption that, apart from their presenting problems, clients were totally “rational” beings who readily complied with the intervention procedures set forth. As behavior therapists began applying their procedures to unselected cases and were confronted with a wide variety of complex clinical problems, it became strikingly evident that the simple application of the appropriate technique was not always successful. Although the therapist might have been clear about the determinants associated with any problem behaviors, and may also have felt confident that certain therapeutic techniques had a good chance of bringing about the needed change, the clarity of the clinician’s thinking was not always matched by the client’s desire or ability to comply with the intervention procedures. It has been in the face of such instances of therapeutic noncompliance that the topic of resistance has come to the fore in behavior therapy.

The Stimulus Value of the TAT

Abstract Ratings of all 30 TAT cards were obtained from 34 male and 40 female college students on the following 10 bipolar, adjectival scales: accepting-rejecting, aggressive-passive, dependent-independent, happy-sad, hopeful-hopeless, impulsive-controlled, pleasant-unpleasant, safe-dangerous, severe-lenient, and sexy-sexless. The results of the ratings indicate that the cards vary considerably as to their ambiguity, i.e., the number of scales which consistently describe the picture. Further, the stimulus properties of some cards are such that it is likely they will “pull” negatively-toned stories. It is suggested that in evaluating stories given to the TAT cards, the interpretation should be made only in light of the stimulus value of the particular card.

Transtheoretical Ingredients in Therapeutic Change

As part of my interest in understanding more about how people change and the specific psychotherapeutic processes involved in such change, I have become increasingly involved in building bridges. Not, obviously, architecturally, but more in an ecumenical sense. The assumption that I have operated under in trying to find common themes associated with therapeutic change across the different orientations is as follows: To the extent that there exist commonalities across different approaches to therapy, then what we are likely to find in such commonalities are probably robust phenomena, in that they have managed to emerge despite the theoretical biases inherent in each specific orientation (Goldfried, 1980).

Clinical Behavior Therapy and the Male Sex Role

Men rarely present themselves for treatment because they have identified problems associated with their roles as men. Yet such problems may often be at the core of the difficulties they do present with: difficulties they are experiencing in their marriages, problems with excessive use of alcohol, sexual dysfunctioning, stress-related problems, as well as the full array of psychological difficulties one is likely to encounter clinically. Behavior therapy, while having relevance to an increasingly more diverse set of clinical phenomena, has had little to say directly about problems centered around men’s issues. However, behavior therapy does have a history of flexibility in areas of application, as it provides the clinician with more of a technology than a direction for specific areas of applicability. Behavioral procedures originally developed for one specific purpose have often later been applied to a wide variety of other clinical problems. The newly emerging field of “behavioral medicine” has drawn extensively on behavioral intervention methods for purposes of dealing with various physical disorders. And assertion training, while originally developed with no thought whatsoever as to its utility in dealing with problems associated with the female sex role, has nonetheless been used to help women become more instrumental in their functioning.

Thoughts on the Resistance Chapters

I must confess to having experienced considerable resistance in writing my comments on the psychoanalytically oriented chapters. Although initially I was very enthused over the prospect of reading about the thoughts and experiences of Basch, Schlesinger, Dewald, and Blatt and Erlich on the topic of patient resistance, the actual task proved far more difficult than I had anticipated. In reading and then rereading these chapters, I found it very difficult to point to anything specific that I could comment on. I looked closely for guidelines on how to deal with patient resistance, but was unable to find any that I could readily comprehend. Not surprisingly, my first reaction was to attribute the cause of this difficulty to the individuals who wrote these chapters. It took very little reflection to realize, however, that to do so was not appropriate, as the authors could in no way be faulted for their clinical sensitivity, experience, or sophistication. I then began to blame myself for being obtuse in not being able to comprehend what a group of experts in psychoanalytically oriented therapy had to say about resistance. On further reflection, however, I had to remind myself that my original training was psychoanalytically oriented and that I still retained some familiarity with the relevant writings of Freud, Reich, and Fenichel. My interest and motivation were not a factor either, as I have recently become more involved in the search of common therapeutic principles that cut across all theoretical orientations (Goldfried, 1980, in press).

Methoden der Verhaltensbeurteilung

Nachdem wir einige Kernfragen der verhaltenstherapeutischen Diagnostik umrissen haben, konnen wir uns nun der Ubertragung dieser Prinzipien auf konkrete klinische Erhebungsverfahren zuwenden. Die Verhaltensanalyse wird in der Praxis der klinischen Verhaltenstherapie meist mit Hilfe von Interviewdaten, Verhaltensbeobachtungen in der naturlichen Umwelt oder in simulierten Situationen, schriftlichen Fragebogen oder einer Kombination dieser Erhebungsmethoden erstellt.

Ausgewählte klinische Probleme

Mit Ausnahme der wenigen Falle, in denen das Problem des Klienten relativ klar und einfach strukturiert ist (wie z. B. bei einer Hundephobie) lauft der Entscheidungsprozes auf seiten des Therapeuten bei weitem nicht so gradlinig ab, wie es nach der Lekture verhaltenstherapeutischer Literatur scheinen mag. Normalerweise mus man an die Schwierigkeiten des Klienten mit verschiedenen Verfahren herangehen, die von den Variablen abhangen, die wahrscheinlich das in Frage stehende Problem kontrollieren. So wird man, wie weiter unten ausfuhrlich dargestellt wird, z. B. Personen, die durch starke Angste handlungsunfahig sind, ganz unterschiedlich behandeln, je nachdem, welche Faktoren nach Meinung des Therapeuten ihrer Angst zugrunde liegen. Das folgende mag sehr wie eine Suche nach „zugrundeliegenden Ursachen“ anmuten, wie das also, was Verhaltenstherapeuten irrtumlichen Unterstellungen zufolge ganzlich vernachlassigen. Tatsachlich ist es aber so, das der Verhaltenstherapeut, ebenso wie andere Forscher in den angewandten Wissenschaften, nach den Variablen sucht, die den starksten Einflus haben, und viele dieser Variablen sind nach einer nur fluchtigen Untersuchung des vorliegenden Problems eben nicht deutlich erkennbar (Bandura, 1969; Davison u. Neale, 1974; Goldfried u. Pomeranz, 1968; Lazarus, 1965).