Tag Archives: LGBTQ Issues

LGBTQ Issues

Counselor considerations for disclosing LGBTQ+ identity

By Benjamin Hearn June 2, 2020

The question of what is appropriate to disclose about ourselves to clients is one that all counselors face, whether it be about an upcoming vacation, an emotional reaction to a client or how our own past struggles may parallel those of a client. Beyond these more common self-disclosures, we also may choose to disclose aspects of our identity that are not inherently visible, such as our sexual orientation, gender identity or even religious beliefs.

These invisible aspects of the self differ from others such as race in that there may be incongruence between how these identities are perceived by the client and experienced by the counselor. At times, disclosure of such identities may be beneficial for clients, but we must proceed both with caution and intentionality prior to taking that step. Although I will be discussing LGBTQ+ identity disclosure for the remainder of this article, it is my hope that all counselors will benefit from engaging in the process of deciding when and what is ethical to disclose to our clients.

I first became aware of the utility of disclosing my sexual orientation in practicum, during which time I needed to obtain group hours. The only active group at my site was a women’s anxiety group facilitated by my supervisor, who was also a woman. My supervisor was intent on my gaining group experience and asked the women whether they would be comfortable having a male co-facilitate sessions. Most of the group was hesitant until one of the members spoke up and said, “That’s fine, but only if he’s gay.” Her statement was met with concurrence by the rest of the group, and I was allowed to co-facilitate after sharing that I was indeed gay. My supervisor thought this was a strange contingency, but I was not surprised. I have a long history of seeing people interact differently with me once they learn I am gay.

My initial experiences self-disclosing LGBTQ+ identities demonstrated that it could be used to enhance client trust and perhaps provided greater autonomy to clients by allowing them to find a counselor with whom they “fit.” However, after reflecting, obtaining supervision and exploring the literature on self-disclosure, the concept of appropriately disclosing LGBTQ+ identities became much murkier for me. Compounding the issue was the fact that the literature also described risks to the concealment of an LGBTQ+ identity.

Overall, the consensus from these sources was that disclosure is a choice rather than a rule and needs to be addressed on a case-by-case basis. Factors that influence the choice span a wide range and may include characteristics of the client, the counselor and treatment settings. The remainder of this article explores these issues within the context of the counseling profession’s values and ethical principles, professional literature, and theories that my colleague Kelli Hess and I developed and presented at an American Counseling Association Conference.

Professional values and ethical principles

Whenever considering whether a course of action is ethical, counselors should turn first to the 2014 ACA Code of Ethics and the Practitioner’s Guide to Ethical Decision Making, a white paper developed by Holly Forester-Miller and Thomas Davis in collaboration with ACA. While neither of these documents provides concrete answers to the question “Is it ethical to disclose my LGBTQ+ identity to my clients?” they do offer a good starting point to assess the question. So, let’s begin by outlining applicable ethics standards and professional values and principles so that they can be kept in mind and later applied.

The preamble to the ACA Code of Ethics states that the promotion of social justice is one of the core professional values of the counseling profession. In the glossary of terms for the ACA Code of Ethics, social justice is defined as “the promotion of equity for all people and groups for the purpose of ending oppression and injustice affecting clients [and] counselors …”

The preamble also outlines a number of important principles that inform our topic, including:

  • Beneficence: “Working for the good of the individual and society by promoting mental health and well-being.”
  • Veracity: “Dealing truthfully with individuals with whom counselors come into professional contact.”
  • Autonomy: “Fostering the right to control the direction of one’s life.”

It is worth noting that the ethical decision-making model developed by Forester-Miller and Davis elaborates on these definitions and describes these principles in action in ways that may not be intuitive. For example, helping a client understand how their actions and values are likely to be received in the context of society promotes client autonomy.

The ACA Code of Ethics also provides several standards that are relevant to our discussion:

  • A.4.b. Personal Values: “Counselors are aware of — and avoid imposing — their own values, attitudes, beliefs and behaviors. Counselors respect the diversity of clients, trainees and research participants and seek training in areas in which they are at risk of imposing their values onto clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory in nature.”
  • I.1.b. Ethical Decision Making: “When counselors are faced with an ethical dilemma, they use and document, as appropriate, an ethical decision-making model that may include, but is not limited to, consultation; consideration of relevant ethical standards, principles, and laws; generation of potential courses of action; deliberation of risks and benefits; and selection of an objective decision based on the circumstances and welfare of all involved.”
  • I.2.c. Consultation: “When uncertain about whether a particular situation or course of action may be in violation of the ACA Code of Ethics, counselors consult with other counselors who are knowledgeable about ethics and the ACA Code of Ethics, with colleagues, or with appropriate authorities, such as the ACA Ethics and Professional Standards Department.”

Types of disclosure

Now that we have an understanding of the relevant professional values, principles and ethical standards, we can begin considering how they inform self-disclosure. We typically think of self-disclosure in terms of information that we share verbally with our clients during session. This can be broken up into “intra-” and “extra-” therapy disclosures, with the former being disclosures about the counselor’s own thoughts or feelings in session and the latter being disclosures about the counselor’s life outside of session.

Self-disclosure also takes place through nonverbal means, such as our body language, office layout and dress. The information that we disclose nonverbally is either intentionally or unintentionally shared and can also suggest or confirm an LGBTQ+ identity.

Nonverbal suggestions and confirmations

To understand how nonverbal information may suggest an LGBTQ+ identity, we must first acknowledge that human beings use stereotyping to make sense of and navigate the world. Sexual orientation and gender identity are often spontaneously assumed about an individual based on the nonverbal information they present. Some nonverbal information, such as the counselor’s mannerisms and voice inflection, are not intentionally disclosed but still may inform a client’s assumption of the counselor’s LGBTQ+ identity. A counselor may also intentionally display information, such as choice in dress or a pride flag in their office, that suggests to clients that the counselor is LGBTQ+.

Counselors may also nonverbally share information that confirms their LGBTQ+ identity to clients. This type of disclosure can take several forms and may also be either intentional or unintentional. Intentional nonverbal disclosure of this type occurs through things such as disclosing an LGBTQ+ identity on a professional biography or displaying a picture of a same-gender partner in the office. Unintentional confirmation may take place if the counselor is seen in public with a same-gender partner or if a client discovers the information through social media platforms that are not professionally oriented.

Verbal disclosure with and without prompting

In addition to nonverbal means of disclosure, we can begin to consider how and when counselors may choose to broach the topic verbally in session. In some instances, the client may ask or express something that prompts the counselor to disclose, while at other times, the counselor may disclose without prompting.

Perhaps the two most common instances that could be considered “prompts” are when a client expresses an incorrect assumption about the counselor’s sexual orientation or gender identity or when a client asks about either of these directly. Counselors may be more prone to being questioned directly or to have incorrect assumptions expressed based on the degree to which they “fall into” common LGBTQ+ stereotypes. For instance, I believe that I present few nonverbal suggestions that I am gay, and I wear a wedding ring at work. As a result, clients often ask questions about my “wife.” Another prompt to consider is the unintentional confirmation of an LGBTQ+ identity, such as the counselor being seen in public with a same-gender partner.

When it comes to responding to these questions or assertions, a counselor can always redirect the topic back to the client by asking why this information is important to them or how it would affect their treatment. The counselor may choose to disclose an LGBTQ+ identify when asked directly by a client or when correcting a client’s expressed assumption, provided that a counselor perceives minimal risk to the client and is comfortable with disclosing when prompted.

In these situations, unethical responses would be those that conflict with the principle of veracity. They would include lying about one’s LGBTQ+ identity or providing a response that affirms a client’s incorrect assumption. Such responses might damage the therapeutic relationship in the future should the client discover through other means such as social media or public encounters that the counselor identifies as LGBTQ+.

Counselors who wish for a middle ground between redirection and coming out may choose to use gender-neutral words to answer appropriate questions about themselves or their relationships. For example, “My partner and I have been married three years.”

Counselors may also wish to disclose their LGBTQ+ identity without prompting from the client for a variety of reasons, including:

1) To promote perceived similarity or relatability between counselor and client: Similarity between counselor and client identities, particularly with aspects of identity such as race, has been found to be helpful in developing rapport and with client retainment and engagement. While disclosing similarities may build rapport, counselors should be cautious of using disclosure as a shortcut for rapport or as a stand-in for mastery of LGBTQ+ competencies and expertise.

2) To increase client autonomy or comfort: Disclosure of LGBTQ+ identity may also serve to promote client autonomy. Many clients “shop” for their counselor, and early disclosure, such as on a professional biography, may aid clients in making their selection. In addition, as I described earlier regarding my experience with a women’s group, disclosure of LGBTQ+ identity may serve to promote client comfort. While the situation I described was prompted, counselors may also find that disclosure promotes comfort when clients are reluctant to broach certain issues that may be related to the counselor’s gender identity.

3) To assist in resolution of a client’s internal values struggles.

4) To model a healthy LGBTQ+ identity.

To understand how disclosure might assist a client’s internal values struggles, we’ll return to the professional value of autonomy. Forester-Miller and Davis suggest that disclosure might serve to help clients understand how their actions and values are likely to be received in the context of society. An illustration of this could be a client who is experiencing distress at work due to difficulties with a new LGBTQ+ employee and is unaware that their counselor has an LGBTQ+ identity. The counselor may choose to disclose their LGBTQ+ identity in such an instance should the client not be at risk for self-harm or in crisis and should the therapeutic relationship be strong enough to withstand the disclosure. A counselor taking this approach should consider how they will maintain their focus on the client and manage any significant ruptures to the relationship.

Disclosure of the counselor’s own LGBTQ+ identity may also work to model a healthy identity to clients who have less-developed identities. Models of LGBTQ+ identity development suggest that comfort in disclosing LGBTQ+ identity is indicative of a healthy identity. Given this, counselors may use self-disclosure as a means to explore the reasons behind clients’ own discomfort with disclosure, such as internalized homophobia.

Additionally, instances in which cisgender, heterosexual counselors feel at ease to disclose may also work to model a healthy LGBTQ+ identity and may be viewed as an act promoting social justice. To illustrate this point, consider a community counseling clinic in which some cisgender, heterosexual clinicians display family pictures. An LGBTQ+ counselor who chooses to display similar pictures that illustrate nontraditional family structures promotes equality and raises awareness about such families.

Such seemingly small acts are important to help LGBTQ+ counselors feel comfortable in their work settings because these counselors may also experience fear of client, peer or supervisor judgment and thereby be less effective in their roles. Peer or supervisor judgment may seem unlikely, but I have met many LGBTQ+ counselors who have felt ostracized within their agencies, been told to lie to clients about their sexual orientation or gender identity, or even been fired for their disclosure to clients. Concerns such as these may be indicative of issues related to multiculturalism and diversity within the agency or wider culture but also may be related to the counselor’s unresolved issues regarding internalized homophobia. In such instances, LGBTQ+ counselors may seek their own counseling services.

To illustrate these concepts, consider this vignette: Thomas is a counselor working at a group practice in a moderate-sized city with an established client, Jared. Jared has been voicing increased complaints about his work, particularly concerning a new co-worker who is openly gay and inappropriately discusses his sexual relationships in the workplace. Jared exasperatedly states, “I just can’t stand gay people. They’re all like this. Why can’t they just keep that stuff to themselves?”

As a counselor who displays few nonverbal suggestions about his own sexual orientation, Thomas assumes that Jared believes he is heterosexual. Thomas believes disclosing that he is gay might help Jared, but he first considers the strength of his therapeutic alliance with Jared and what other services would be available to Jared were disclosure to cause irreparable damage.

Thomas decides that Jared would likely be able to process this information in a healthy way and chooses to disclose his sexual orientation in the next session when Jared once again complains about people who are gay. Jared is surprised by Thomas’ disclosure. Jared discusses stereotypes he has about gay people and why he didn’t suspect that Thomas was gay. This process allows Thomas to model a healthy LGBTQ+ identity to Jared while also dismantling unhelpful stereotypes. Jared is now able to see his co-worker’s behavior originating from poor interpersonal boundaries rather than from his sexual orientation.

Choosing not to disclose

Although it appears there may be benefits for clients, counselors and the larger LGBTQ+ population when counselors choose verbally to disclose their LGBTQ+ status, there are also times when counselors should refrain from doing so. In arriving at this decision, counselors should carefully consider:

  • Whether their disclosure is relevant to the client’s issue
  • The purpose of and motivation for disclosure
  • The client’s immediate needs
  • The strength of the therapeutic relationship

In many, if not most, cases, the counselor’s LGBTQ+ identity is irrelevant to the client’s presenting issue, and prompts for disclosing may not arise. Should the counselor still feel an urge to disclose, the counselor should consider their purpose and motivation in disclosing to ensure that disclosure is not used to meet personal needs such as client approval.

Counselors may also refrain from disclosure in instances in which the client has poor interpersonal boundaries, the client is in crisis, or there is a real risk that the therapeutic relationship may not withstand disclosure. Building on this last point, counselors should also consider what additional resources are available to the client should the client refuse to work with an LGBTQ+ counselor. This is particularly important in underserved areas or in agencies that assign counselors to clients or that have long waiting lists.

Here is a vignette to illustrate an instance in which a counselor may choose not to disclose: Janine is a heterosexual trans woman who consistently “passes” in social settings. She is providing mental health counseling services in a rural school-based setting to high school students and receives a referral for a new client, Jamil. Jamil is a junior who has recently been withdrawing from his friends. He has also been experiencing increased conflict with his family after beginning to wear his older sisters’ clothing to dinner and disclosing to them that he often wishes he were a girl.

Jamil presents in the initial session with his mother, who expresses prejudice and disdain toward the LGBTQ+ community. She states, “I was shocked. I’ve seen them in the news, and I won’t have my son being one of them.”

Janine keeps her composure throughout the intake and processes her thoughts and feelings later in supervision. She expresses that the mother’s comments did upset her and caused her to be distracted because of her own family history. She believes that Jamil would benefit from knowing someone else in the LGBTQ+ community. Janine considers this possibility with her supervisor but decides disclosure of her identity as a trans woman to Jamil at this point is too risky. She reasons that Jamil’s mother might pull Jamil from services with Janine, and there are no other readily available providers in the surrounding rural setting.

Janine collaborates with her supervisor to develop ways to bracket her discomfort with respect to the mother’s comments and Janine’s desire to build rapport with Jamil through disclosure. During the treatment planning session, Janine works with the family to develop rapport. She uses her training and education, rather than her personal experience, to explain the myriad difficulties faced by gender-nonconforming individuals and the importance of family support. Janine, Jamil and Jamil’s mother develop a plan aimed at increasing family cohesion by using small, incremental steps that will allow Jamil greater ability to express his gender identity.

Wrapping up

Counselors who identify as LGBTQ+ are faced with the unique challenge of determining whether to disclose this identity to clients and how. Myriad factors influence this decision, making it not unlike many other decisions related to self-disclosure. Counselors can begin considering the issue using an ethical decision-making model and taking into account the professional principles of beneficence, autonomy and veracity alongside relevant ethical standards.

Counselors may find themselves in a position of disclosing more or less often based on their own nonverbal attributes and behaviors, which clients may consider as suggestions that the counselor is LGBTQ+. Clients may use these attributes or behaviors in creating a prompt for the counselor to disclose their LGBTQ+ identity, or counselors may broach the topic themselves when appropriate. 

Counselors should consider verbal disclosure on a case-by-case basis, taking into account knowledge of the client’s presenting issue and needs, the strength of the therapeutic relationship, and other available resources. Counselors should refrain from disclosing when disclosure would pose an immediate risk to clients. LGBTQ+ counselors may look to their heterosexual or cisgender peers for more immediate norms on self-disclosure.

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Benjamin Hearn is a first-year doctoral student at the University of Cincinnati, where he is developing approaches for the counseling profession to use psychedelic-assisted therapies for mental health and substance use disorders. He is also interested in the integration of spirituality to counseling and is an active member of the Association for Spiritual, Ethical and Religious Values in Counseling. He has practiced in a variety of settings, including school-based mental health, private practice and wilderness therapy. Contact him at hearnbg@mail.uc.edu.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Affirming all shades of the rainbow

By Laurie Meyers May 27, 2020

Licensed professional counselor (LPC) Laura Brackett’s specialties include counseling LGBTQ+ individuals. A frequent complaint she hears from her clients is that those outside of the LGBTQ+ community — including some mental health practitioners — see it as one big, happy family that shares all of the same problems and concerns.

This is, of course, not the case. “There can be deep and painful divides between the various groups that make up this community,” says Brackett, an American Counseling Association member who practices and is the director of community engagement at Change Inc. in St. Louis.

That is especially true for marginalized communities within the LGBTQ+ population. For example, American society has made significant progress in accepting differences in sexual or “affectional” identity but remains distinctly uncomfortable with alternate gender expressions such as transgender and nonbinary, says ACA member Christian Chan, an assistant professor in the Department of Counseling and Educational Development at the University of North Carolina Greensboro. People can generally grasp (even if in some cases only reluctantly) being gay, lesbian or bisexual as being about whom one chooses to love. However, the idea of someone being assigned the wrong gender at birth or a person rejecting that they must choose the binary of either male or female undermines deeply held notions of what constitutes a person’s identity, explains Chan, whose research interests include intersectionality and issues affecting queer people of color.

Even the LGBTQ+ community tends to prioritize affectional identity over gender identity, says Chan, a member of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of ACA. For too long, there has been a hierarchy of whose needs matter, he asserts, and transgender people — particularly women of color — have been at the bottom.

“Mental health providers are not really culturally responsive to the needs of [diverse] communities — particularly communities that have multiple identities,” he says. Even counselors who are affirming of LGBTQ+ clients don’t always take the time to consider clients’ intersecting identities and how those identities affect their mental health needs, Chan adds.

When transitioning is not an option

LPC Jessica Jarman Hayes says the transgender clients she counsels are often not out and almost “sneaking themselves into therapy.” Hayes, whose Columbia, South Carolina, practice specializes in LGBTQ+ issues, explains that being transgender anywhere in the surrounding area is just not accepted. If anyone in the communities where her clients live learned that these individuals are struggling with their true identity as a transgender woman or man, her clients would lose everything, she says. If married, their spouses would leave them and take their children. Their families, friends and neighbors would reject them, leaving them with no social support. The need for secrecy is so great that it can be challenging for these clients to even schedule appointments with Hayes.

Other of Hayes’ clients live out in isolated areas of South Carolina’s Low Country. They cannot easily get to her office, so their only option is teletherapy, sometimes from a car in the parking lot of a grocery store because they have no safe space available to them at home.

“It reminds me a lot of when I was working in domestic violence,” says Hayes, who is also a volunteer at the Harriet Hancock LGBT Center in Columbia. “You just have to be there to support them, sometimes for years, when they finally reach a place in which it [denying their identity] is no longer acceptable, and then come up with a plan to get out of Dodge.”

Violence is an ever-present threat for people who identify as transgender and gender nonconforming or “nonbinary.” According to the Human Rights Campaign report “Violence Against the Transgender and Gender Non-Conforming Community in 2020,” at least 26 individuals who were transgender or gender nonconforming were murdered in 2019. Most of the victims were African American women.

As the report notes, “These victims were killed by acquaintances, partners or strangers, some of whom have been arrested and charged, while others have yet to be identified. Some of these cases involve clear anti-transgender bias. In others, the victim’s transgender status may have put them at risk in other ways, such as forcing them into unemployment, poverty, homelessness and/or survival sex work.”

Hayes says the fear of violent retribution is another reason, in addition to fear of losing family and friends, that her transgender clients feel unable to express their identities in any way. One client hid underwear in a wall in the house, and their spouse gave them a severe beating when they discovered it, Hayes says.

There is no protection for the abused in these cases because the local police do not take such incidents seriously, according to Hayes. This lack of concern is present even when a juvenile is involved, she says, recounting the story of a suicide hotline call from a transgender teen that got routed her way. The teenager was actively suicidal and in danger. The father had found girls’ clothing and had severely beaten the teen. Hayes called the police and made it clear this was a domestic violence incident involving child abuse and a victim who was actively suicidal.

“The police went in there and teamed up with the dad,” Hayes says. “They said, ‘If you would just stop pretending to be a girl, your dad wouldn’t have to do this.’”

For a time, the girl was able to maintain touch with Hayes by using a self-wiping app on her cell phone to avoid being detected. Hayes called the police repeatedly, but they continued to refuse to take action. Eventually, the father discovered the girl was making calls and took her phone, her computer and his computer out of the house so that she had no means of reaching out. Hayes and other volunteers at the Hancock Center have done their best to check on the teen’s welfare since losing contact but have been unsuccessful. Her school has been ordered not to give out any information, and the local police aren’t providing any help. A Columbia-area police officer has agreed to keep his ears open for any news, but thus far the Hancock Center hasn’t heard anything.

In search of support

Closeted transgender women (i.e., people presenting as men, in accordance with their assigned gender at birth, but who secretly self-identify as women) who are discovered are at risk of violence not just from spouses but, potentially, the spouse’s family, Hayes says. “This is seen as an act of great betrayal.”

Hayes recommends that all of her transgender clients use the time after their phone sessions with her (or any other time they have 15-20 minutes of private time) to connect with virtual support groups. She wants clients to find at least one “safety buddy” to whom they can reach out if they just need to talk or if something serious is going on. She also makes sure that all clients have the transgender peer support and crisis hotline number (Trans Lifeline: 877-565-8860).

Hayes also uses radical acceptance to help her clients cope with the inability to embrace their true identities. “OK,” she tells clients, “we can radically accept that this situation really sucks and is really uncomfortable, but we have to accept that we are in danger of losing a job or family, even if we never come out but someone else finds out.”

Hayes urges her transgender clients always to have a go-bag packed, but recommending places for refuge is a challenge. A few domestic violence shelters in Georgia are trans-affirming, but they are a significant car ride away. The Columbia area has some homeless shelters that will accept transgender individuals. Still, these are not always great options because some of them are run by religious organizations that require those seeking refuge to read “applicable” Bible verses. Hayes generally encourages clients to think of relatives with whom they could stay. Clients don’t necessarily need to explain the whole story of what is happening — just that they need to get away, Hayes says.

In an environment in which wearing gender-affirming underwear or painting one’s toenails can have devastating consequences, Hayes acknowledges that it is incredibly challenging to help make her clients’ situations more livable. Even so, she has found a few small ways for her transgender and nonbinary clients to explore their identities, including gaming, an environment in which having avatars of different or no fixed gender is common.

Another outlet she suggests — but only if clients believe their phones are safe from scrutiny — is the social media platform Tumblr, which is very graphics-oriented and functions a bit like a cross between Facebook and Twitter. Users can set up an account and post or follow others who share art, graphics, GIFs and other visual content. Crucially for Hayes’ clients, it’s also possible to search content without registering. Why is this an affirming outlet? Because Tumblr is a hive for many kinds of interests, including fashion, design, décor and art. Hayes tells her clients to use the platform to explore what their “aesthetic” (personal style) would look like if they had complete freedom, encompassing not just their appearance but also their surroundings. 

Hayes began her career counseling domestic violence survivors in the Miami area, where the shelters are transgender and LGB affirming and intimate partner violence between gay men or a trans woman and cisgender man is taken seriously by the legal system. Although Hayes, who considers herself a member of the LGBTQA+ community, has been in South Carolina for several years, she is still sometimes surprised by the virulence of the hatred many in the area feel toward transgender and other queer people. She echoes Chan in saying that although different affectional orientations are now more tolerated (even if sometimes grudgingly) in some quarters, alternative gender expression is still largely viewed as unacceptable. She believes there also remains significant transphobia within the LGBTQ+ community itself, which leaves her transgender clients with very few resources for social support.   

Family struggles

When ACA member Bethany Novotny moved from Pittsburgh to Johnson City, Tennessee, to begin teaching as an assistant professor of human services at Eastern Tennessee State University (ETSU), she wasn’t sure how friendly her new surroundings would be to those identifying as LGBTQ+. Novotny, who went on to start a local lesbian dine-out group, was pleased to find that Johnson City had a robust LGBTQ+ community and that it and the university were a haven among the surrounding Appalachian towns for queer young adults.

Over time, Novotny, who is an LPC in Pennsylvania, found that students viewed her as a safe and sympathetic person to talk to. That rapport, her desire to help transgender and nonbinary students, and Novotny’s friendship with staff at the campus counseling center led to her taking over ETSU’s transgender support group, now called ASPECTS — Aligning Support, Pride, Education and Community for Transgender Students. The group originally included only students who had been referred by the campus counseling center. But Novotny opened it up to all transgender and gender-nonconforming students because she feels they have unique challenges apart from the rest of the queer community. “People are more afraid [discussing alternative gender expression] than they are when we talk about sexual orientation,” she notes.

Novotny supervises while students lead the group, which meets once a week. The students share practical information such as where they can go to receive hormone therapy and find affirmative health care providers. Obtaining these services usually requires traveling to either Knoxville, Tennessee, or Asheville, North Carolina, which is a challenge, especially for those students who don’t have cars. Novotny says the group often works together to make sure members get rides when necessary.

Not surprisingly, acceptance is a constant topic in the group, Novotny says. The students feel safe — many for the first time in their lives — at ETSU, but they still have to navigate family and community attitudes when they go home on breaks.

“We would talk about coping skills [before breaks],” Novotny says. “Sometimes they would choose to stay with a friend or another family member. I would remind them to have a crisis plan — making sure if things got bad, they knew what to do.” A crisis plan resembles a suicide safety plan, with a list of local and campus resources, shelter locations and the number for the national suicide hotline.

Once, a student who had started taking hormones decided that they should come out to their family on break. The group talked it through for several weeks beforehand, Novotny says. The student’s parents did not take the coming out announcement well, and the student was forced to seek shelter with a cousin. The cousin turned out to be very supportive and even helped the student come out to their grandmother, which they never thought possible, Novotny recounts. All too often, however, students would return to school without getting any affirmation from their families.

Although revealing oneself as transgender is particularly challenging, coming out to family and friends isn’t easy for anyone in the LGBTQ+ community. Even among families who want to support and affirm their loved ones, the coming out process can be a difficult transition, Brackett says. Some family members — often parents in particular — grieve letting go of the future they had envisioned for their loved one, she adds. “That’s not to say that they reject their family member’s future as an LGBTQ+ person, simply that they may need to adjust the specifics of what that future may be. Maybe the vision was of a son who [would have] a wife and children, and now that vision needs to be adjusted to [having] a husband instead of a wife,” Brackett says.

In other cases, families fear their loved one will become an entirely different person, she says. Brackett explains to families that although changes in expression and personality are very likely, it isn’t a foregone conclusion that in coming out, their loved one will undergo a complete transformation.

“Even when there are substantial changes, I try to remind families that the person they knew was possibly more of a mask than they want to accept,” she explains. “This person is now trying to discover who they really are, and that process will take time. It’s important to be patient, be curious, be respectful, and [for families to] find their own support.”

Novotny says many of her group members have parents who struggle because they perceive the transition of their child’s gender expression — from the one the student was assigned at birth to their true gender — as an alteration that has transformed their child into someone they don’t recognize. This comes in part from a lack of exposure to and understanding of what being transgender means.

One student’s mother couldn’t even grasp the concept, telling her child, “You have a penis, so you’re a boy,” Novotny recounts. “The student was trying to communicate to [their] mom, ‘I’m still the same person. I’ve actually been this person the whole time, and you don’t see that. I am trying to share something scary and vulnerable with you.’” At the student’s request, Novotny helped them talk to their mother.

“I always respond first with empathy,” Novotny says. “I know that what they [parents] are going through is difficult, and I don’t want to minimize or dismiss their feelings. It’s all about meeting them where they are, even though sometimes I want to shake them and scream at how horrible they are being. I also worked to affirm the love and support that it took for mom to show up in my office that day. The fact that she was there was huge. She was willing to talk even though she didn’t understand, and I wanted both mom and my student to recognize what a big step that was.”

Novotny listened to the mother’s concerns and helped correct misinformation by inserting “tidbits of information that might help mom put the puzzle pieces together. I did this very gently and only where appropriate because I did not want to come off as though I was lecturing her,” Novotny says. “As an educator, I know how important it is to plant seeds. We may not always see that come to fruition, but it is so important to plant those seeds gently. … I also try to communicate to parents that they don’t need to fully understand to provide support, love, affirmation and acceptance.”

In some cases, the family conflict isn’t rooted in a lack of understanding but something more fundamental. Brackett, like Novotny, tackles these struggles with understanding and empathy.

“I seek to understand what their resistance or hostility is connected to and move from there,” she says. “Working with a family that has deeply rooted religious beliefs that condemn sexual or gender minorities is drastically different from working with a family that is afraid of the changes that may occur within their family system. At times it can be necessary to have these discussions without the LGBTQ+ family member present in order to not only protect them from hearing this process in its most raw form, but also to allow the family space to be open about what they are feeling. Additionally, recommending outside support groups or resources can help alleviate some of the misinformation and isolation the family may carry.”

Families also fear the treatment their loved one might experience in the outside world. “Will they be bullied or ignored or even physically hurt or killed?” Brackett says about some of the common concerns families voice. “Will they suffer mental anguish and be at higher risk for addiction or suicide?” 

“It’s important for families to remember that a huge protective factor for members of the LGBTQ+ community is the presence of a supportive family,” Brackett asserts. “When working with family members in this place of fear, I try to highlight for them the power they have in creating a safe and loving environment for their loved one. While a mother can’t make the world safe for her gender-nonconforming child, she can at least work to ensure that she is safe for them.”

The process of coming out

In some cultures, such as those Hayes’ clients live in, as well as other racial and ethnic communities, coming out may be dangerous to the LGBTQ+ individual and perhaps to their family. Or an LGBTQ+ person may have some family members who would support their coming out but others who would not be affirmative or accepting. Some individuals choose to honor both their LGBTQ+ identity and their familial or cultural identity by coming out only to certain family members or friends.

“I frame coming out as an ongoing process and remind my clients that the need for a grand unveiling isn’t necessary unless it’s important to them,” Brackett says. “Often, I see my clients come out by degrees, starting with the safest people or environments first to gain support. By identifying safe people and thinking through the possible outcomes of coming out, the client can begin to amass protective factors they need as they go through the process. Deciding not to come out to people they identify as unsafe or unnecessary doesn’t have to be framed as a betrayal to their identity, though it’s an understandable reaction. It can also be framed as a means of protecting themselves. They are not required to disclose information that puts them at risk.”

With any major life change, there is grief at whatever is lost, and this is very true in people who are negotiating the ways in which they want or don’t want to be publicly out, Brackett continues. “Being rejected by a family member or important institution like a religious community or friend group can be devastating,” she says. “Gentleness, empathy and nonjudgmental discussions are important in allowing clients the freedom to connect with the impact coming out is having on them. Holding the grief is important, but so is guiding them toward creation of a new life and support system: ‘Yes, this is horrible and heartbreaking. Is there someone who has acted differently or where you’ve felt acceptance?’”

Counselors can help clients build a new support system by working with them to change their concept of family, says ACA member Leah Polk, a licensed clinical social worker and clinical director at Change Inc. in St. Louis. Clients are not limited to their families of origin; they can assemble ones of their own choosing, she emphasizes. So, even though their families of origin may have set a priority on traditional scripts or rituals, the families they choose can be inclusive and view each member as inherently valuable, says Polk, whose specialties include LGBTQ+ issues. 

“The important part here is that the client gets to spend time identifying what is most important and valuable to them as it relates to family,” she explains. “They are able to map out how they establish family and gain reliable reflections that emphasize what they like about themselves.”

Peer support for transgender youth and young adults

Laura Boyd Farmer, an LPC whose specialties include affirmative LGBTQ+ counseling, helped found a peer group for youth and teenagers 10 years ago in the Roanoke, Virginia, area. She and other area professionals saw a need among the area’s LGBTQ+ youth, who were frequently ostracized and bullied and had little family support. “Our intention was to create a safe and supportive space,” says Farmer, a member of ALGBTIC. Farmer and others sat with teens in the area and asked them what they needed and what kind of support would be helpful. The result was Youth SAGA (Sexuality & Gender Alliance) of Roanoke.

“The kids created the name,” Farmer says. “They were very passionate that they wanted this to be a group for queer-identified kids, but also for anyone who was affirming of gender and sexuality diversity.”

SAGA meets twice a month, and there are always two leaders with mental health experience (Farmer and three volunteers take turns serving as the two leads). Meeting times are posted on Facebook, and the group gathers in public spaces such as coffeehouses, libraries and bookstores so that teenagers who are not out to their families will have a ready-made excuse to drop in.

The group follows two basic rules: Respect participants’ chosen identities, names and pronouns, and give everyone time to talk. Group members are also asked not to talk about what goes on at meetings outside of SAGA. All of the participants are so invested in preserving a place where they can find and give support that there has never been an issue with breaking confidentiality, according to Farmer.

The structure of each meeting depends on the size of the group. If only a few teens are present that week, the session is relatively informal, with group members simply discussing what is going on in their lives. With larger groups, leaders pass out pieces of paper so participants can write down any topics they would like the group to cover. The group leaders put all the pieces of paper in a bowl, which is then passed around. Each person removes a piece of paper and reads out the topic for discussion.

Topics range from concerns such as “My parents don’t want me to transition and I don’t know what to do” and “I don’t know how to come out to a family member” to the practicalities of expressing gender identity. The group has covered logistical questions about the physical and hormonal aspects of transition, as well as ways that youth can present themselves in a way that affirms their gender expression when their families are not letting them transition. The teens also ask each other about how to find good chest binders and affordable makeup.

Dealing with bullies and finding allies are also common topics, Farmer says. She recounts an approach to bullying that she thought was particularly effective: “This trans youth shared that he found the best way to deal with bullies was to choose a direct statement to respond with and to use it repeatedly,” Farmer explains. “For example, when a bully would say to this youth that he was really a ‘she’ and just confused, the youth would reply, ‘That sounds like a you problem.’ This kid also had his friends use the same response when they heard anyone say anything unkind about him or toward him. I loved this approach because it puts responsibility back on the bully to educate themselves, like holding up a mirror for them to see that whatever mean things they are saying are actually about them, not the person they are trying to bully.”

Sometimes the group features outside speakers. For example, because the intersection of religion with sexual and gender identity is a common concern in southwest Virginia, Farmer had a pastor lead a discussion on how spirituality and sexuality intersect. The pastor also talked about what the Scriptures actually say (and don’t say) about the topic and gave the group recommendations for discussing the topic with family.

Farmer emphasizes that SAGA is not a therapy group but rather peer-based support. Because discussions about sexual and gender identity sometimes include topics such as trauma that can be triggering for others, she and her co-leaders have developed a signal that group members can use if they are being triggered. If someone puts a hand on their heart, it is a signal for the leaders to gently and respectfully move the discussion away from the current topic. Farmer and the other leaders are careful to check in afterward to see whether the teen who brought up the topic wants to continue the discussion privately.

“The beauty of this group is that I don’t have to know the answers,” Farmer says. “The kids are sharing their wisdom with others. It’s a beautiful thing to witness.”

Providing affirmative counseling

Even professional clinical counselors who have experience with the LGBTQ+ community may have biases and blind spots, say the practitioners Counseling Today interviewed for this article. Brackett and Polk offer some suggestions for counselors who want to make sure they are offering affirmative counseling to LGBTQ+ clients.

“The first thing I recommend is self-reflection on how you are connected to the LGBTQ+ community outside of being a clinician,” Brackett says. “Understanding your own involvement and comfort within the LGBTQ+ community will help you be present with these clients in an authentic way.”

She suggests that counselors ask themselves the following:

  • Are you a member of the LGBTQ+ community? If so, what elements do you connect to versus what elements do you find yourself separated from? Are there parts of the queer community that you (consciously or unconsciously) avoid or dislike? If so, why? Do you feel like you “belong,” and how does that impact your willingness to connect with others in the community? How do your opinions change if the race, ethnicity, income, gender or gender presentation of the person changes?
  • If you don’t consider yourself part of the LGBTQ+ community, how open and connected are you to people within it? Do you seek out or seek to avoid places or events that are heavily attended by the queer community? How comfortable do you feel when you are in those spaces? How do your opinions change if the race, ethnicity, income, gender or gender presentation of the person changes?

“Remember that there are generalized experiences, and then there are your client’s experiences,” Brackett continues. “Trust your client to tell you their reality. It may align with your own experiences or general narrative you have of the LGBTQ+ community, but it may not. Your goal is to be present with them where they are, as they are.”

Polk has some additional suggestions:

  • Allow the client to determine the pace. It is not the counselor’s job to set an agenda for coming out or transitioning.
  • Frequently reassess goals in therapy. What the client needs when they enter therapy is often not the same as what they need after eight to 10 sessions have taken place.
  • Monitor for clients’ sense of safety and agency. For example, ask them how their relationships are and how they experience safety in an environmental context (e.g., employment, social events, political environment).
  • Continue to scan and assess for co-occurring disorders such as substance abuse. Individuals who identify as LGBTQ+ tend to have a disproportionate number of stressors that could lead to comorbid emotional and mental health concerns.

“Additionally, I would suggest some form of participation in LGBTQ+-affirming communities,” Polk says. “For example, attend a support group, view LGBTQ+ art [and] film, or read literature written by queer authors. Ask to interview LGBTQ+ counselors, or seek out LGBTQ+-specific supervision and psychotherapy training. Finally, perform a self-assessment of your own attitudes and biases of LGBTQ+ people to determine your growing edges in counseling.”

Brackett offers a closing thought: “If you find that you are uncomfortable with LGBTQ+ clients or are concerned about your ability to work with this population, seek out clinical supervision, and engage in your own therapy.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Affirmative Counseling With LGBTQI+ People edited by Misty M. Ginicola, Cheri Smith and Joel M. Filmore
  • Casebook for Counseling LGBT Persons and Their Families edited by Sari H. Dworkin and Mark Pope
  • Group Counseling With LGBTQI Persons by Kristopher M. Goodrich and Melissa Luke

Continuing Professional Development: LGBTQ (aca.digitellinc.com/aca/specialties/137/view)

  • “Transgender — Moving From Awareness to Advocacy” with Becca Smith
  • “Affirming Counseling Practice With Queer People of Color: From Margins to Center” with Adrienne N. Erby and Christian D. Chan
  • “Resiliency Factors of Trans-College Students: Implications for Professional Counselors and Higher Education Professionals” with Jane E. Rheineck and Matthew Lonski
  • “Lesbian, Gay, Bisexual, Transgender and Queer Youth: Family Acceptance and Emotional Development” with Julie Basulto
  • “The Counseling Experiences of Transgender and Gender Nonconforming Clients” by Rafe Julian McCullough, Lindy K. Parker, Cory Viehl, Catharina Chang, Thomas M. Murphy and Franco Dispenza

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/self-care-resources)

  • LGBTQ
  • Grief and loss

Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (algbtic.org)

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

The use of evidence-based practices with oppressed populations

By Geri Miller, Glenda S. Johnson, Mx. Tuesday Feral, William Luckett, Kelsey Fish and Madison Ericksen December 3, 2018

Therapy must always be tailored to the individual; there is no one-size-fits-all model. However, certain approaches have been empirically verified for use with a variety of clientele. It is critical that all counselors, especially those working with client populations that are oppressed, have both an overview of evidence-based practices and specific techniques related to these approaches in their clinical toolboxes to help them provide the best counseling services possible.

Counselors are frequently required to use evidence-based practices and need to know how to use them effectively in counseling clients who are oppressed. Specifically, the unique development of the therapeutic relationship between oppressed clients and privileged clinicians must be understood and addressed. Multicultural counseling experts Derald Wing Sue and David Sue maintain that the dynamics of oppression shift the influence of the therapeutic relationship. Thus, counselors must alter their application of evidence-based practice techniques.

Solution-focused brief therapy and low socioeconomic status

Take a moment to think about what the basic needs of your own life are. What is impossible for you to live without? For many of us, our basic needs are continually met. Therefore, they often go unnoticed — they are woven into our everyday lives and ways of being in the world.

For others, questions such as “Will I eat today?” or “Will I have a safe and warm place to sleep tonight?” are asked daily. Often, the answer is “no.” Concerns such as clean drinking water, access to hygiene products and finding adequate shelter affect an inordinate number of individuals in the United States. School counselors and licensed professional counselors have a moral and ethical obligation to address these matters, with the intention of removing barriers and cultivating a safe space for clients in both the therapeutic relationship and the environment beyond our office walls.

Glenda Johnson (one of the co-authors of this article) worked as a school counselor and an advocate in a school system in which the majority of students came from low socioeconomic status (SES) backgrounds. Many of the students were on free or reduced lunch plans because their families’ financial resources were severely limited. At the core of Johnson’s work was the intent to ensure that every child’s basic needs were met while they were at school. She emphasized the importance of working collaboratively with other school staff members to build a team and a foundation for connecting these students and their families to resources.

It is also vital to assess an individual’s behaviors, emotions and reactions through a holistic, biopsychosocial approach rather than focusing only on the school context. Learned behavior concerns, inattention, difficulty with emotion regulation (anger), sadness and loss of hope are often the result of a lack of resources. Johnson recalls that if a student acted out, one of her first questions would be, “Did you have breakfast this morning?”

Johnson shares an anecdote that highlights the powerful act of providing a safe, therapeutic space for students to identify and voice their emotions openly with peers. As a school counselor, she infused the identification of various emotions into a game of musical chairs, and what transpired was completely unexpected. A student identified a “sad” emotion and explained that their father recently had lost his job. The student was experiencing fear about not having enough food to eat during this time. Then, other students began to share similar stories without prompting. The game of musical chairs transformed into a collaborative and touching experience as the students identified common ground and connected on deeper levels of understanding and empathy.

When providing services to individuals from a low SES, counselors may find it helpful to use a strengths-based therapeutic approach. The evidence-based practice of solution-focused brief therapy (SFBT) zeros in on the therapeutic relationship and the clinician’s way of being. In this relationship, there is an acknowledgment of reality but also an emphasis on solution-focused thought and reframing. Focusing on strengths, the counselor and client work together to identify and move toward making small changes in any area because a small change in one area often leads to change in another area.

SFBT often introduces the “miracle” question: “Suppose that when you go to sleep tonight, a miracle occurs that solves your problem, but because you were sleeping, you did not realize what happened. When you wake up in the morning, how will you realize a miracle happened? What will you notice that you are doing differently?” These questions enhance and expose glimpses of solutions that an individual may struggle to identify in everyday life situations.

Additionally, SFBT places great value on successes. The counselor and client celebrate achievement and may use scaling to note the client’s progress. When working in a school system, the counselor could develop a creative and motivating way for children to rate themselves and their progress toward goals. For example, Johnson created a rating scale, complemented by the colors green, yellow and red, for kindergartners and first-graders. Green identified a completed goal, yellow identified progress toward a goal and red identified room for improvement. Similarly, she used a rating scale of 1-5 for students in second through fourth grades. Under this scenario, a student could check in with a rating, such as, “I am at a 3 and working toward a 5.” The counselor might respond, “What would it take to get to a 3.5?” The scale provided a visual for children to identify, track and celebrate their successes.

In SFBT, the counselor acknowledges client strengths and walks alongside these clients as they create and work toward their goals and future successes. “Flagging the minefield” is another technique counselors can introduce to help clients generalize and apply what they learn in counseling to future situations. Flagging the minefield is a particularly important facet of SFBT because it assists individuals in recognizing potential obstacles or barriers that will appear in their lives. The counselor and client work together to identify tools and resources the client can apply in other settings and relationships.

When working with students living in poverty, counselors should introduce a strengths-based approach and identify and gather resources to assist students and their families in removing barriers and meeting basic needs. Cultivating a safe, therapeutic relationship with students that focuses on solution building can assist them in building a stronger sense of self.

Motivational interviewing, SFBT and rural adolescent substance abusers

Adolescence is a vulnerable time and a critical period for developmental outcomes. During this stage of life, adolescents are exploring and forming their peer relationships and personal identities while beginning to distance themselves from family. Experimentation with substances often begins during this time. In 2012, Tara Carney and Bronwyn Myers found a correlation between the early onset of substance use and an elevated risk for later development of substance use disorders. Additionally, because early substance use may impact the growth of the adolescent brain, it has the potential to heighten one’s risk for delayed social and academic development.

Adolescents living in rural areas are marginalized in multiple ways. Children are an underserved minority population, as are rural populations. Sheryl Kataoka, Lilly Zhang and Kenneth Wells (2002) found that among youth with a recognized mental health need (estimated at 10 million to 15 million people), only 20-30 percent receive specialized mental health care. Rural communities are more likely to have fewer clinicians or require a long drive to see those clinicians, making it more difficult to obtain care. These disadvantages are exacerbated by the tumultuous nature of adolescence.

Motivational interviewing and brief interventions are two evidence-based practices particularly suited to this population because these approaches are generally influential in their therapeutic role while also being cost-effective. Motivational interviewing facilitates behavior change through exploration and resolution of ambivalence, and it focuses on being optimistic, hopeful and strengths-based. It uses principles of empathy, discrepancy, self-efficacy and resistance, and offers specific techniques such as OARS (Open questions, Affirmations, Reflective listening, Summarizing). SFBT emphasizes solutions, changes clients’ perceptions and behaviors, helps clients access their strengths and uses techniques such as exception to the problem, specification of goals and the miracle question.

Individual interventions with the use of the same interventions for multiple sessions are ideal, and research suggests that the earlier the intervention, the better the outcome. Early intervention shows better results than both preventive measures and later interventions because it reduces the need for more specialized interventions and provides applicable and useful tools and tactics for adolescents as they enter into various student, peer, familial and professional roles.

Challenges certainly exist when working with children and adolescents, particularly because many biological, environmental and social shifts occur organically during this time. As children and adolescents rapidly transition on a continuum of development, they become “moving targets.” Interventions that prove effective for those ages 11-12 often cease to be effective by ages 13 or 14. It is vital that counselors remain aware of this across the life span. Although adolescents are beginning to distance themselves from their caregivers, familial relationships and parental involvement remain crucial during this period.

To appropriately and competently involve the families of rural adolescents, some understanding of cultural values is necessary. In 2005, Susan Keefe and Susie Greene identified core Appalachian values, including egalitarianism, personalism, familism, a religious worldview, a strong sense of place and the avoidance of conflict. In the Appalachian region, assuming authority without demonstrating an authoritarian attitude is important. Language tends to be simple, direct, honest and straightforward. Family is extremely important, exemplified by the adage “blood is thicker than water.” Individuals’ relationship to the land is complex, and it can be beneficial to explore how clients view economic deprivation. In 2016, Sue and Sue also pinpointed some tendencies of rural clients, including having a “street-smart” attitude and way of being, depending on systems due to living in poverty and valuing survival at all costs.

As a result, subtle techniques such as stages of change, motivational interviewing and SFBT may be useful for this population. In stages of change, the intervention is matched to the stage of the client’s readiness to change (precontemplation, contemplation, preparation, action, maintenance, termination). Motivational interviewing facilitates an invitation to engage, and its strengths-based, hopeful tone can be helpful for clients living in an environment populated by deficits such as poverty and lack of education. The practical nature of brief therapy fits well with the no-nonsense worldview of clients coming from rural backgrounds.

Unfortunately, published rural studies often focus on specific regions or populations. Few interventions have been tested in rural settings, and the evidence from systematic reviews is often too general and not specific to the rural context. Ideally, rural communities could review interventions tested with various target populations in a range of settings. Such information is not usually available, however, and the strength of evidence is unlikely to be the only factor considered in choosing an intervention. The research on rural adolescent populations is limited, and little consistency exists across studies related to measurement tools. Furthermore, disseminating evidence-based practices to schools, families and community settings in rural areas is difficult due to the lack of resources.

However, it is important to note that there have been great improvements in substance abuse treatment and prevention with children and adolescents who live in rural areas. A 2016 Monitoring the Future survey of eighth-, 10th- and 12th-graders by the National Institute on Drug Abuse found the lowest ever reported rates of use for all illicit drugs, including alcohol, marijuana and nicotine. As further research is conducted, it will be important to delve into this information to identify what is already working with these individuals and what can be improved to better serve them moving forward.

Evidence-based practices with transgender clients

Transgender individuals face discrimination on multiple fronts. Many experience familial rejection, unequal treatment, harassment and physical violence during daily living. The rate of substance abuse within the transgender community is three times higher than that of the general population. There is a profound lack of competent health care for transgender individuals, and the care that is available may be inaccessible to a majority of the transgender population. The rate of unemployment within the transgender community is also three times greater than that of the general population, due in part to factors such as workplace discrimination, poverty and homelessness. Transgender people also face discrimination and mistreatment in shelters.

With high rates of homelessness, substance abuse and mistreatment, transgender people also have frequent interactions with law enforcement, where they can be subject to police brutality and discrimination. Within the criminal justice system, a high rate of physical and sexual assault is perpetrated against transgender individuals, and they are often denied medical treatment while incarcerated or detained.

Poor health outcomes for transgender people correlate with risk factors such as economic and housing instability, lower educational attainment, lack of family support and other intersectional factors such as race, ethnicity, immigration status and ability.

According to the 2015 U.S. Transgender Survey, 18 percent of transgender people who sought mental health services experienced a mental health professional attempt to stop them from being transgender. This correlated with higher rates of serious psychological distress and suicide attempts and an increased likelihood of running away from home, homelessness and engaging in sex work.

Research conducted in 2015 by Samantha Pflum et al. emphasized the lack of access to transgender-affirming resources and communities for individuals living in rural locations. The history of mistreatment and abuse of lesbian, gay, bisexual, transgender and gender-nonconforming clients by medical and mental health professionals must be acknowledged. Gender and sexual minority clients still face discrimination within the helping professions, and for individuals holding multiple marginalized identities, these experiences are compounded.

Even well-meaning providers are likely to make mistakes when working with marginalized clients. According to Lauren Mizock and Christine Lundquist, one of these mistakes is education burdening, or relying on the client to educate the provider about transgender culture or the general transgender experience. Resources exist to facilitate competence in these areas, and clinicians have a responsibility to refrain from placing the burden of their education on the client.

Some counselors participate in gender inflation, or focusing on the client’s gender to the exclusion of other important factors. Other counselors engage in gender narrowing, applying restrictive, preconceived ideas about gender to the client, or gender avoidance, which involves ignoring issues of gender altogether. Gender generalizing occurs when a clinician assumes that all transgender clients are similar. Gender repairing operates from a belief that a transgender identity is a problem to be “fixed.” Gender pathologizing involves viewing transgender identity as a mental illness or as the cause of the client’s issues. Finally, gatekeeping occurs when a provider controls client access to gender-affirming resources.

Acceptance of a client’s gender identity is ultimately not enough to provide competent, affirmative services. Understanding the nuances of these common mistakes will help clinicians provide a safe therapeutic environment that is affirming of these clients’ identity and humanity.

The Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (ALGBTIC), a division of the American Counseling Association, has developed competencies for counseling transgender clients (see counseling.org/knowledge-center/competencies) that focus on the following eight domains:

  • Human growth and development
  • Social and cultural foundations
  • Helping relationships
  • Group work
  • Professional orientation
  • Career and lifestyle development competencies
  • Appraisal
  • Research

Counselors can work within this framework to:

  • Promote resilience by using theoretical approaches grounded in resilience and wellness
  • Conceptualize the development of a transgender individual across the life span
  • Understand internal and external factors influencing identity development
  • Consider how identity interacts with systems of power and oppression (especially for minority transgender individuals)
  • Examine counselors’ own internalized beliefs and how those beliefs affect attitudes toward transgender clients
  • Reevaluate approaches to working with transgender clients as new research emerges

One intervention that has been identified for use with this population by Ashley Austin and Shelley Craig is transgender-affirmative cognitive behavior therapy (CBT). Transgender-affirmative CBT modifies CBT interventions to address specific minority stressors, such as victimization, harassment, violence, discrimination and microaggressions, that transgender people commonly face. This approach uses psychoeducation to help clients understand the connections between transphobic experiences and mental health issues such as stress, anxiety, depression, hopelessness and suicidality. Experiences are processed through a minority stress lens to help clients move from a pathologizing-of-self mindset to an affirming view of themselves as people coping with complex circumstances.

Clinicians are advised to affirm the existence of discrimination and to help these clients identify influences on their mental health by using the transgender discrimination inverted pyramid (see below). 

Transgender individuals internalize messages at each level, and it can be beneficial to have a visual for how these messages trickle down and influence mental health. Clinicians can empower transgender clients by assisting them in challenging internal and societal transphobic barriers. A few examples are challenging negative self-beliefs, connecting with a supportive community and advocating for self and community.

Another approach recommended for use with transgender clients by Joseph Avera et al. in 2015 is the Indivisible Self model, an Adlerian wellness model refined by Jane Myers and Thomas Sweeney that emphasizes strengths. There are five wellness factors of self in this model:

  • Creative Self: Cognitions, emotions, humor and work
  • Coping Self: Stress management, self-worth, realistic beliefs and leisure
  • Social Self: Friends, family and love)
  • Essential Self: Spirituality, self-care, gender identity and cultural identity
  • Physical Self: Physical and nutritional wellness

This model easily can be adapted to a transgender-specific lens, especially regarding the Essential Self, by exploring gender and cultural identity and how they influence client experiences and beliefs. Used in conjunction with the ALGBTIC transgender competencies, the Indivisible Self model offers helping professionals both a conceptual and practical framework for working effectively with transgender clients.

For all clients, and transgender clients in particular, intersectional factors magnify the experience of oppression. Sand Chang and Anneliese Singh recommend addressing the intersectionality of race/ethnicity and gender identity for both clients and clinicians. This involves:

  • Challenging assumptions about the experiences of transgender and gender-nonconforming people of color
  • Building rapport and acknowledging differences within the therapeutic dyad
  • Assessing client strengths and resilience in navigating multiple oppressions
  • Providing a variety of resources that are affirming to transgender and gender-nonconforming people of color

In addition, assisting clients in locating social support is advised. Social support increases healthy coping mechanisms and helps with self-acceptance, thereby reducing psychological stress related to discrimination. Social support can also help to normalize and validate emotions related to discrimination.

Conclusion

Evidence-based practices have consistently been shown to be helpful to clients, but counselors must remember that they operate within the context of a relationship. To use evidence-based practices effectively, we must hold on to our humanness. The implementation of a single technique will look very different depending on who is in the room and what they are bringing with them.

Often, the expectations for using evidence-based practices might create pressure for counselors to follow a strict formula for treatment. Process variables such as honoring the personal relationship between the counselor and the client, maintaining a “therapist’s heart” and respecting the unique aspects of the client may seem to be at odds with the procedure for using a specific intervention. A working knowledge of multicultural issues can provide some context for how to shift evidence-based practices to fit the client rather than pressuring the client to conform to a prescribed, generalized format.

Using interventions with a solid evidence base is good practice. Adjusting their implementation on the basis of the unique identity of the person sitting across from us is great practice.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Geri Miller is a professor in the Department of Human Development and Psychological Counseling (clinical mental health counseling track) at Appalachian State University (ASU) in North Carolina. She is a licensed professional counselor, licensed psychologist, licensed clinical addictions specialist and substance abuse professional practice board certified clinical supervisor. She has been a volunteer counselor at a local health department since the early 1990s. Her clientele has primarily consisted of women with little opportunity for jobs or education and who experience barriers of poverty. Contact her at millerga@appstate.edu.

Glenda S. Johnson is an assistant professor in the Department of Human Development and Psychological Counseling (school counseling program) at ASU. She is a licensed professional counselor and a licensed school counselor in North Carolina. Her scholarly focus includes school counselors delivering comprehensive school counseling programs, students who are at risk of dropping out of high school and the mentoring of new counseling professionals.

Mx. Tuesday Feral received their master’s degree in clinical mental health counseling and a certificate in systematic multicultural counseling from ASU. They are the support programs director for Tranzmission, a nonprofit organization serving the Western North Carolina nonbinary and transgender community through education, advocacy and support services. Tuesday offers training and workshops in trans cultural competence and cultural humility on local, state and national levels.

William Luckett received his master’s degree in clinical mental health counseling from ASU with a certificate in addictions counseling. He has interests in somatic therapy approaches, mindfulness, religious and spiritual topics in counseling, and substance abuse counseling. He currently provides in-home counseling to rural families in Virginia.

Kelsey Fish is a student in ASU’s clinical mental health counseling program and a clinical intern with Daymark Recovery Services in rural Appalachia. Her clinical interests include expressive arts therapy, adolescents, and gender and sexual minority issues.

Madison Ericksen is a graduate of the clinical mental health counseling program at ASU. She has specialized training and interest in trauma-informed practices that use mindfulness, eco-based and expressive art therapies as complementary treatments alongside traditional therapy. She provides strengths-based and resiliency-focused outpatient counseling for children and families.

 

Letters to the editor:  ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

Promoting LGBTQ students’ well-being in schools

By Roberto L. Abreu, Adriana G. McEachern, Jennifer Geddes Hall and Maureen C. Kenny October 2, 2018

Research shows that LGBTQ youth are disproportionately bullied (whether in person or via cyberbullying), verbally and physically harassed, and assaulted in schools by peers and staff. Such hostility has been correlated to lower school performance and psychological and emotional distress, including suicidal ideation and attempt, depression and anxiety.

In the 2015 GLSEN (formerly Gay, Lesbian & Straight Education Network) National School Climate Survey, LGB students reported higher levels of verbal, physical and sexual violence and bullying than did their heterosexual counterparts. Specifically, 98.1 percent of LGB students heard the word “gay” used in a derogatory manner, 85.2 percent reported verbal harassment, and 34.7 percent reported being physically harassed in the past year. In addition, a 2017 meta-analysis (conducted by co-authors Roberto L. Abreu and Maureen C. Kenny) of 27 empirical studies on the effects of cyberbullying on LGBTQ youth revealed that compared with their heterosexual and cisgender counterparts, these students are disproportionately harassed online and through other technology-based means. Such harassment has been correlated to a range of behavioral and emotional difficulties, including suicidal ideation (with some studies suggesting rates as high as 40 percent among LGBTQ youth) and suicide attempts (with rates as high as 30 percent).

Many LGBTQ students identify school counselors as the one school staff member to whom they are most likely to disclose concerns related to their sexual and gender identity. Given this reality, school counselors are uniquely positioned to address myths about LGBTQ youth, to advocate for these students and to effect change.

Dispelling myths

Let’s begin by examining five myths that can have an impact on the identity, safety and well-being of LGBTQ youth. We’ll also look at specific strategies and interventions that counselors can use to address these myths and increase the safety of LGBTQ students.

Myth #1: Parents must be informed of their child’s sexual and gender identity. A 10th-grader discloses to her high school counselor that she identifies as a lesbian. Most of her friends know, but she has yet to tell her parents. She fears their reaction because she has heard them make derogatory remarks toward LGBTQ individuals in the past. Must the school counselor inform the student’s parents?

The American School Counselor Association (ASCA) National Model (2012) stresses the importance of parent and family involvement and its influence on the well-being of students. Although parent engagement is critical when working with LGBTQ youth, school counselors should consider several factors before disclosing to parents a student’s sexual or gender identity. Many LGBTQ students believe they lack parental support, and they may fear rejection, abuse and an unsafe home environment if their parents discover their sexual or gender identity.

Therefore, the counselor in this scenario should first discuss with the student her feelings about informing her parents and assess how they may react to this information. It would be important for the counselor to prepare the student for potential negative parental responses. Role-playing the conversation could be helpful for the student. It would be best to have the minor client make the disclosure to her parents with the counselor present to provide support. It is also important to have a plan in place to provide the client with a safe place to stay should the parents totally reject her and need time to adjust to the situation.

In certain instances, school counselors may have to break confidentiality. For example, what if the student also disclosed to the counselor that she was distraught over the situation and was having suicidal thoughts and feelings of hopelessness because she feared that her parents would never understand or accept her sexual and gender identity? In that situation, there would be potential harm and danger to the minor client. Therefore, the counselor would need to conduct a thorough suicide assessment, then inform the client of the legal and ethical reasons that confidentiality must be breached.

It is important for counselors to check their schools’ policies and procedures in relation to dealing with crisis situations such as suicide. School counselors can work with parents individually or in groups to foster awareness and acceptance of LGBTQ students and to promote understanding of their needs and the challenges these students face every day.

Myth #2: Gender-neutral facilities are a threat to school safety. A school district policy does not allow transgender students to use the restroom that corresponds to their gender identity. A transgender student has brought this to the attention of the school counselor, inquiring about what to do. The student says he often goes the entire school day without going to the restroom.

School counselors should use their role as staff and educators to speak to the school administration about this issue. In talking to school administrators, counselors can present research related to transgender students experiencing a lack of safety in schools and make the argument that forcing these students to use a bathroom that does not align with their gender identity only contributes to this presenting concern.

Some states have passed laws precluding gender-neutral facilities, imposing on the rights of transgender individuals to use the restroom that corresponds to their gender identity rather than their sex at birth. Some of these laws have been incorporated into school policy. The rationale given for these laws has been to protect public privacy and safety. However, there is no research evidence to support this claim.

In 2015, Media Matters for America conducted a survey of 17 school districts in 12 states encompassing approximately 600,000 students. The survey asked about cases of harassment or inappropriate behavior after transgender-inclusive policies had been passed in those districts. The survey results concluded that no incidents of sexual harassment or inappropriate behavior had been reported in those schools, debunking the myth that gender-neutral facilities are a threat to school safety.

Counselors, as social justice agents, must involve themselves in policy. This can be done at school meetings, where counselors can advocate for gender-neutral policies in schools and school districts. Counselors can inform school administrators of their interest in participating in these meetings and being involved in the decision-making process. They can volunteer to conduct information sessions for meeting participants about the academic, personal and career needs of LGBTQ youth. Counselors should actively seek to advocate for transgender youth so that these students can use the bathroom that best aligns with their gender.

Myth #3: School policies and laws protect all students. School policies and laws have focused mainly on reducing bullying but not necessarily on protecting LGBTQ youth and keeping them safe. The 2015 GLSEN report that investigated anti-bullying policies in the nation’s school districts revealed that out of the 13,181 school districts surveyed, 70 percent had anti-bullying policies. However, only 20 percent of these school districts had LGB-inclusive policies, and only 10 percent had LGBT-inclusive anti-bullying policies.

Although anti-bullying policies may be in place, LGBTQ students continue to report higher incidents of bullying and harassment than do other students. Often, these policies are not widely distributed to students and staff, and although most students and staff may be aware of district anti-bullying policies, they are not necessarily aware of LGBT-inclusive anti-bullying policies. 

Furthermore, policies and laws are often influenced by politics and societal opinions. Laws referred to as “no promo homo” involve efforts to prevent national LGBT education, mandate that administrators take a neutral stance on gender identity and prohibit providing specific services to these students. Although seven states (Alabama, Arizona, Louisiana, Mississippi, Oklahoma, South Carolina and Texas) had “no promo homo” laws as of January 2018, many states are working to develop LGBT-inclusive laws and policies that do not discriminate against these youth. For example, many states have developed LGBT anti-discrimination laws. These laws also permit transgender students to participate in sports congruent with their gender identity.

School counselors need to be proactive and work with school administrators to develop LGBT-inclusive policies. Counselors can assist in disseminating and discussing these policies regularly with students, parents and staff. Counselors should educate school administrators on bullying and “no promo homo” laws so they will better understand the detrimental effects of systemic oppression on LGBT youth.

In addition, school counselors should empower LGBTQ students to share with school staff their experiences with bullying and harassment within the school. This will open the door for school personnel to make a personal connection with these students and will help them learn more about the physical and mental health consequences of LGBTQ bullying and lack of representation.

Myth #4: LGBTQ students are safe around all school personnel. Many LGBTQ students do not feel safe at school — around either other students or school personnel. The GLSEN survey from 2015 reported that more than 50 percent of LGBTQ students heard homophobic comments from teachers and school staff. Many of these students believed that reporting harassment or assaults to school personnel would worsen the situation and that no action would be taken. Among those who did disclose bullying, harassment or assault to school staff, 63.5 percent indicated that their reports were ignored. In addition, when these incidents were reported, LGBTQ students faced harsher discipline than did their heterosexual and cisgender peers and were often blamed for the incidents (see research from Shannon Snapp, Jennifer Hoenig, Amanda Fields and Stephen Russell). This lack of support from school personnel places LGBTQ students at greater risk of being victimized.

In 2017, students in California’s San Luis Obispo High School published an edition of the student paper, Expressions, featuring LGBTQ issues. In response, a special education teacher at the school wrote a letter quoting the Bible and stating that those committing homosexual acts “deserve to die.” The school administration chose not to discipline the teacher for the action, stating that teachers as well as students “do not shed their First Amendment rights” at school. Although the teacher resigned soon after the incident, his statement remains a testament to the harassment and discrimination leveled against some LGBTQ students by school personnel.

School counselors need to advocate for and support LGBTQ students in the face of such victimization. Providing training to all students, parents and school staff is critical to reducing incidents of bullying and harassment and increasing awareness and sensitivity to the issues LGBTQ students confront in schools. A middle school in South Florida developed a monthlong program that focused on bullying prevention, including sexual and gender identity sensitivity training at various levels. At the high school level, counselors are forming LGBTQ support groups to provide outlets for these students to discuss specific issues and concerns. These groups provide one way to let these students know that they are valued and that their voices are important.

Myth #5: Sex education is inclusive of all students. Sex education that is LGBTQ inclusive is very limited or nonexistent in our nation’s schools. Often, this lack of inclusion is due to discomfort and lack of knowledge about LGBTQ sexuality on the part of school personnel, students and parents. Many teachers do not feel competent to teach on the topic.

Traditionally, sex education in U.S. schools centered on an abstinence-only curriculum. This ideology changed somewhat in the 1980s because of the AIDS epidemic, the increase in sexually transmitted diseases and teen pregnancy. The curriculum during this time focused on prevention and contraception, but no content was included on LGBTQ sexuality. In the 1990s, there was an effort to develop national guidelines for comprehensive sex education by the Sexuality Information and Education Council of the United States, a task force composed of educators and health professionals. However, these guidelines also lacked specific and clear directives on how to address the needs of LGBTQ students in schools.

Health care reform legislation in 2010 provided states with funding to draft comprehensive sex education in schools. One of the programs created from this initiative was the Personal Responsibility Education Program for young adults. Once again, however, this program
failed to offer educational content or policy language that was inclusive of LGBTQ students.

Given this reality, school counselors can take leadership roles in advocating to administrators and teachers on the importance of including educational information and materials about LGBTQ sexuality in the sex education curriculum. Counselors may need to ensure that the programs being used to teach sexuality are inclusive. Counselors can assist health educators by providing appropriate materials (see hrc.org/resources/a-call-to-action-lgbtq-youth-need-inclusive-sex-education for more information on LGBTQ-inclusive sex education). Counselors can also conduct psychoeducational workshops to dispel myths and misconceptions regarding LGBTQ students with all stakeholders, including students, school staff and parents.

 

A call to action

Clearly, the perpetuation of these myths indicates that something more needs to be done to better support LGBTQ students within school systems. School counselors, as outlined by ASCA, have an ethical obligation to support underserved and oppressed populations. Additionally, school counselor training programs emphasize the role of school counselors as agents of change within the school system and professional leaders who must act as allies and advocates for all students.

This role includes:

  • Being aware of the challenges that LGBTQ students face within the school system
  • Designing a developmental, comprehensive school counseling program to support the LGBTQ student population
  • Advocating for policies and practices that address inequities regarding academic, career and social/emotional domains for LGBTQ students 

Therefore, supporting LGBTQ students and promoting social justice initiatives should be done through large-scale, small-scale and individual interventions in an effort to create a positive school climate for everyone.

Readiness assessment

The first step is to conduct a needs and readiness assessment. This assessment should focus on gauging the school’s current climate related to LGBTQ students and the willingness of staff to make needed changes. Assessments should target students, faculty, staff and parents. Their openness toward acceptance and making changes, as well as the amount of education and training they have received related to LGBTQ populations, is important to assess.

Parents and school personnel may be reluctant to support LGBTQ youth in part because they do not feel prepared to respond to the unique needs of these students. School counselors will need to collaborate and discuss concerns with all stakeholders to comprehensively make appropriate systemic changes. These conversations also allow school counselors to gain awareness of current school policies and procedures related to the treatment of LGBTQ students.

Additionally, before changes can begin, school counselors should collect data that may be reflective of disparities and issues that LGBTQ students face within the school. Such data may include behavioral referrals, truancy rates and negative changes in grades and attitudes/behaviors. Behavioral referrals should be more specific and include incidents of verbal and physical harassment that LGBTQ students have endured as well as LGBTQ students who might be “acting out” in class in reaction to bullying or oppressive interactions.

LGBTQ students who are lacking support and involved with negative interactions often are truant, report somatic complaints and disengage from the learning process. It is therefore important that school counselors collect and examine data concerning absenteeism, visits to the school nurse, incidents of skipping class and dropping grades. This data should be saved and used as well during the measurement of formative and summative program success. This information will help inform what needs exist and how the school can best support LGBTQ students in dealing with their struggles.

It is important to note here that when collecting and analyzing data, counselors should look for patterns and then meet with students individually, regardless of their sexual or gender identity. At the time of this meeting, if the student discloses that their struggles are indeed related to their LGBTQ identity (for example, they are being bullied because of their gender expression), then counselors should move forward with interventions while making sure to protect the student’s confidentiality.

Intervention formulation

After school counselors have conducted a thorough assessment of their schools’ climate and needs, they can begin to formulate interventions and adjust policies to better support LGBTQ students. School counselors should include LGBTQ community members on their advisory boards to assist with inclusivity when promoting change and programming. Change and programming should include interventions at the schoolwide, small group and individual levels. 

Schoolwide interventions addressing bullying and diversity have been deemed most effective in promoting a more positive school environment for all students. These interventions should include procedures and programming specific to the LGBTQ population, such as staff training on LGBTQ issues, multicultural awareness and response procedures regarding victimization of LGBTQ students. Schoolwide strategies and policies to address LGBTQ-specific bullying and harassment must also be outlined.

Schools are also encouraged to provide educational workshops for parents that address issues related to sexual and gender identity, ways of talking at home about bullying (with both victims and perpetrators), and ways to discuss diversity and acceptance beyond the school setting. These conversations should include information that is pertinent and specific to LGBTQ students.

As a universal approach, teachers should be encouraged to incorporate LGBTQ-affirming curricula into their existing core areas of focus at the elementary, middle and high school levels as developmentally appropriate. School counselors also need to include examples of LGBTQ populations and the issues they face in classroom guidance lessons and when promoting positive behavior intervention and character education programs at their schools. Positive recognition of LGBTQ students, parents, staff and community members can also help to promote a more accepting environment overall. Additionally, it is beneficial to foster support from those involved in athletics and other extracurricular activities. This includes recruiting the active assistance and endorsement of coaches and athletes regarding LGBTQ students.

In addition to schoolwide interventions, schools can better support LGBTQ students by providing small group and individual services designed specifically for them. Safe zones/diversity rooms can be designated to serve as a resource for LGBTQ student needs or concerns. These spaces should be run by the school counselor or other trained staff and must respect the confidentiality of the students who use them. These spaces can serve as a safe, supportive environment for LGBTQ and other students to discuss issues they are facing. In addition, they can serve as resource rooms stocked with helpful books, flyers and other materials.

School counselors can also facilitate support groups specifically for LGBTQ students, allowing them to openly discuss their experiences, process their thoughts and feelings, and develop coping strategies. Group topics could include local and national resources available for LGBTQ individuals, LGBTQ role models, family relationships, intimate relationships, coming out, personal and professional issues that LGBTQ individuals encounter, and information about higher education institutions that are affirming of LGBTQ individuals.

Support groups for parents of LGBTQ students should also be offered. These groups would address ways for these parents to support their children. The groups would also provide a forum for parents to share their experiences and concerns with each other and with the school. In addition, many schools now offer a Gay-Straight Alliance (GSA), a student-led organization with a faculty adviser that typically meets to learn about issues that LGBTQ students are facing. GSA is meant to be a group that promotes acceptance, social justice and advocacy. 

School counselors also make themselves available to all students for individual counseling. In many cases, they may be the only mental health professional that students have easy access to for support. It is therefore imperative that school counselors demonstrate cultural competency and provide a safe, affirming environment that includes acceptance and respect for all students.

School counselors need to be aware that LGBTQ students may not present with problems related to their sexuality or gender identity. School counselors also need to consider other contextual factors such as family dynamics when counseling LGBTQ students. In addition to providing leadership toward systemic change, counselors need to have an understanding of issues that specifically affect LGBTQ students on an individual basis. This understanding is achieved through an ongoing process that includes communicating with the local LGBTQ community, participating in continuing education opportunities about LGBTQ students, reading the latest research related to this population and familiarizing themselves with the legal and ethical mandates surrounding LGBTQ students. Most important, school counselors must engage in ongoing self-examination of their own biases, stereotypes and blind spots concerning all students.

The role of school counselors in advocating for LGBTQ students in school is critical. It is school counselors’ professional and ethical responsibility to ensure a safe and harassment-free learning environment for all youth. Connecting with parents and educating them on the continuum of gender and sexual identity can also be an important part of the process. Given counselors’ expertise and skills in supporting diversity and communicating difficult topics, they can play a central role in helping staff, administrators and students create schools that empower LGBTQ youth.

 

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Recommended resources from the authors

  • A Queer Endeavor (aqueerendeavor.org): This site provides educators, school staff, families and students with resources (videos, lesson plans, curriculum development best practices, textbook recommendations) to help support and create an inclusive school environment for sexual minority and gender-expansive students.
  • GLSEN Educator Resources (glsen.org/educate/resources): GLSEN is one of the nation’s largest advocacy groups focused on providing resources that promote the well-being of sexual minority and gender-expansive students in grades K-12. This site provides tools for schoolwide advocacy programming and lesson plans that are LGBTQ inclusive.
  • It’s Pronounced Metrosexual (itspronouncedmetrosexual.com): This site provides online resources (worksheets, videos, articles, books) about privilege and oppression overall, with an emphasis on educating society about topics related to sexual and gender identity. The site serves as a source of information for social justice advocates, researchers and clinicians.
  • American Psychological Association (APA) Safe and Supportive Schools Project (apa.org/pi/lgbt/programs/safe-supportive/default.aspx): APA’s Safe and Supportive Schools Project partners with five professional organizations, including the American Counseling Association and ASCA, to provide training and educational resources. The goal is to help school personnel, leaders of community organizations, parents and students to build positive, supportive and healthy environments that promote acceptance, allowing LGBTQ youth to thrive as their authentic selves.

 

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Roberto L. Abreu is an assistant professor of counseling psychology at Tennessee State University. His research agenda focuses on the well-being of LGBTQ people of color, with specific attention to parental, school and community acceptance of Latinx LGBTQ youth. Contact him at rabreu@tnstate.edu.

Adriana G. McEachern is a professor emerita, a visiting associate professor and the program director for counselor education in the Department of Leadership and Professional Studies at Florida International University. She is a national certified counselor, certified rehabilitation counselor and licensed mental health counselor in Florida.

Jennifer Geddes Hall is a clinical assistant professor at Clemson University and a licensed professional counselor. She has more than 15 years’ experience working with children and teenagers as a school counselor and clinical mental health counselor in various community settings.

Maureen C. Kenny is a professor of counseling at Florida International University and director of the university’s clinical mental health counseling program.

 

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

In search of an affirming faith

By Laurie Meyers July 25, 2018

One of Cyndi Matthews’ most vivid memories of growing up in a fundamentalist Christian church was watching the minister point at her brother’s best friend during a service and say, “You don’t belong here. Get out.” The reason? The boy was gay.

Matthews, a licensed professional counselor supervisor (LPC-S), says that incident was her first glimpse of a pattern of spiritual abuse directed at congregation members who identified as lesbian, gay, bisexual, transgender, queer or questioning (LGBTQ). The animosity that leaders of the church held for LGBTQ members did not fit Matthews’ conception of Christianity. This religious cognitive dissonance would lead her to leave the church and subsequently focus her research and counseling practice on spiritual abuse.

Matthews, a member of the American Counseling Association, sees many LGBTQ clients in her Garland, Texas, private practice who struggle to reconcile their religious beliefs and experiences with their affectional orientation or gender identity. Many of these clients grew up internalizing a message that it wasn’t just their identity or orientation and behaviors that were wrong, but that there was something “wrong” with them as people, she says.

The LGBTQ community has frequently encountered intolerance from religious institutions. Although there are religious traditions that are affirming and open to LGBTQ people, many are not, says Misty Ginicola, lead editor of the book Affirmative Counseling With LGBTQI+ People, published by ACA. Nonaffirming religious groups usually have markedly rigid beliefs — there is wrong and there is right, and nowhere in between, she says. These are the voices that call for anti-LGBTQ legislation under the guise of exercising their religious freedom. As a result, even LGBTQ individuals who do not identify as religious are affected by nonaffirming religious beliefs, points out Ginicola, a member of ACA.

This conflict has produced not just a broader culture clash, but in some religious traditions, a pernicious history of rejection and outright abuse of LGBTQ individuals. Many of Matthews’ LGBTQ clients have been subjected to a wide range of religiously sponsored or endorsed abusive techniques intended to “cure” them. One client — a gay male — was not allowed to cross his legs or wear pink. He was directed to pray anytime he had “gay” thoughts and to replace “gay behavior” with Scripture reading or increased proselytizing. Other of Matthews’ clients were sent to church-sponsored “reparative” retreats where they were prayed over or even subjected to “exorcisms.” Matthews, an assistant professor of counseling at the University of Louisiana Monroe, has also been told about particularly horrific techniques such as forced ice baths and electroconvulsive therapy.

The emotional and even physical abuse that some LGBTQ individuals from strict religious traditions experience is so traumatic that Matthews says all of the survivors she has encountered in her practice were actively suicidal or had been suicidal in the past. At the same time, because clients from strict religious traditions have internalized the idea that what they are told in their churches is God’s word, it is often difficult for them to label their experience as abuse, she says.

Even LGBTQ individuals who break away from their religious traditions so they can fully embrace their affectional or gender orientation have a hard time discounting what they were taught. If someone who identifies as LGBTQ has been told from a young age that they are inherently wrong and immoral, it creates an inner message that lingers, says Ginicola, an LPC in West Haven, Connecticut, whose practice specialties include LGBTQ issues.

Brady Sullivan, a provisionally licensed professional counselor specializing in LGBTQ issues, has worked with clients who believed God hated them. “Every time they engage in sexual or romantic behavior or participate in pride activities, they feel an overwhelming sense of guilt,” he says.

Examining beliefs

Matthews says that, despite their experiences with spiritual abuse, some of her LGBTQ clients still want to find a way to reconnect with religion or at least retain a sense of personal spirituality. Others no longer want anything to do with religion; they come to counseling to untwine the message of being sinful or wrong from their sense of self and sexuality or gender identity.

The therapeutic relationship that is the core of counseling is especially crucial with clients attempting to navigate a conflict between their religious upbringing or current beliefs and their identity as LGBTQ, Matthews says. When people have been taught to seek comfort and strength from a religious tradition that then ends up rejecting them, it feels like a violation of trust, she says. Unfortunately, that sense of rejection can be further compounded when people in the LGBTQ community seek therapy from a practitioner who turns out to be nonaffirming. Matthews always asks clients if they have previously been in counseling and, if so, what that experience was like. This information helps her to address the therapeutic trauma that some LGBTQ clients have experienced.

Matthews screens for spiritual abuse as part of her intake process. She asks clients about their religious background and beliefs and if their experiences are something they would like to address as part of the counseling process. She says that LGBTQ clients from strict or fundamentalist religious backgrounds are highly likely to have experienced spiritual abuse, so the question usually isn’t “if” they will need to work through their experiences, but “when.”

These clients don’t always disclose or even perceive a history of spiritual abuse. However, counselors can look for a number of red flags, Matthews says. These include clients who:

  • Talk about how they are the cause of their own suffering and need to attend church more and to be more faithful and forgiving to alleviate their suffering.
  • Display magical thinking attached to “good” and “bad” behavior; they commonly believe that accidents, illnesses and other tragedies are the result of their “sinful” behavior.
  • Have a difficult time setting boundaries and saying no because of underlying guilt and shame.
  • Feel powerless to take action or make decisions because they fear repercussions from family members, church members, church leaders or their personal deity.

It is critical that counselors understand their role as helping professionals dedicated to providing a safe and affirming space for all clients, including those who are LGBTQ, says Ginicola, a professor of counseling and school psychology and coordinator of the clinical mental health counseling program at Southern Connecticut State University. Simply sitting with clients, supporting them in their pain and validating their experiences helps the healing process begin, she says.

Once clients are ready to talk about their conflicted views and feelings related to their sexual or gender identity and their experiences with religion, Matthews helps them explore the harmful beliefs they have been holding on to and works to dispel them. She is careful not to disparage clients’ faith traditions but does encourage them to question whether the condemnation they have been confronted with is actually the voice of God.

Lorrie Byrd Slater, a licensed professional counselor-mental health services provider in Chattanooga, Tennessee, who counsels many survivors of spiritual abuse, uses her knowledge of Christianity to help clients examine their beliefs. She urges clients whose religious communities have condemned or disparaged them to consider what the Scriptures say about the nature of Jesus Christ. She then asks them if their experiences are in line with Christ’s teachings. Slater, an ACA member, also reminds clients that their particular church is just one church out of many; other places of worship hold very different — and affirming — views of LGBTQ individuals.

Ginicola says cognitive behavior therapy is particularly helpful when confronting clients’ internalized beliefs that being LGBTQ is wrong or sinful. She asks clients to consider how those beliefs began and who taught them that they are inherently wrong. Ginicola exposes clients to religious viewpoints that are affirming to LGBTQ individuals through documentaries and bibliotherapy or putting them in touch with affirming pastoral help. She also encourages clients to explore a question for themselves: If God is love, as they have been taught by their faith communities, how could he hate them?

Practicing GRACE

Both Ginicola and Sullivan have found the GRACE model originally developed by counselor R. Lewis Bozard and pastor Cody J. Sanders — particularly helpful for guiding LGBTQ clients through the resolution of their conflicted religious views. Sullivan, who is practicing part time in addition to earning his doctorate in counselor education at the University of Missouri–Saint Louis, emphasizes that the model is just a guide, not a step-by-step process. For most clients, he uses only a few of the “stages.” The process involves:

  • Goals: Sullivan, an ACA member, talks to clients about their religious background, asking questions such as what faith tradition they grew up in (Christian, Muslim, Jewish, other) and whether they identify with a particular denomination or sect. He also asks how they feel about what they have experienced, both good and bad.

Ultimately, he wants to find out what clients are hoping to achieve by addressing the conflicts they feel between religious belief and who they are as a person. Sullivan asks: “If you woke up tomorrow and all these issues went away, what would that look like?”

As Sullivan guides clients through their background and goals, he stays alert for reactions, particularly any signs of trauma. If a client seems too upset in a particular session, he will back off and switch to another topic.

  • Renewal of hope: This stage involves uncovering shame and abuse and working through it, Sullivan says. For instance, some nonaffirming religious leaders individually confront LGBTQ congregants with questions about their affectional orientation or gender identity. These confrontations often take on the tone of an interrogation, culminating with  a reminder that “God hates those people.”

Sullivan tells clients that although a particular pastor might think that God hates LGBTQ people, many other religious leaders and faith communities do not hold that belief. If clients are amenable, Sullivan offers to help them make contact with an affirmative pastor to talk about religious views that do not condemn those who are LGBTQ.

  • Action: This stage represents decision time. Sullivan and the client have talked about the religious conflict for a while, and together they’ve processed the client’s trauma and grief. What does the client want to do now?

Sullivan says his role is to explain clients’ options to them and help them identify what they need to do to move forward. Some clients choose to remain planted in their current religious tradition, unready to move on from a community in which their spiritual roots were cultivated, even if that means continuing to wrestle with painful beliefs and practices. Other clients want to stay under the larger umbrella of their current religious faith but choose to find another church home or denomination that is more affirming of LGBTQ people. Still others decide to make a more drastic change, such as converting to a different faith system entirely. And, finally, Sullivan says, many clients decide that they no longer want anything to do with religion at all.

  • Connection: For some clients, processing their past experiences and finding a new place to worship isn’t enough, Sullivan says. Instead, they need to examine their personal relationship with God or whatever higher power they relate to. Ultimately, this involves clients identifying what God or that higher power believes about them and how that affects their view of their religion as a whole.

For instance, Sullivan might probe by asking clients what they believe God’s reaction is when they engage in sexual activity with someone of the same sex. He says that most clients are only able to develop the view that although they are sinning, God loves them anyway.

Sullivan does not like to end the GRACE process with this belief still intact. However, he says the pervasive sense of shame that many LGBTQ clients feel often makes it difficult for them to let go of the notion that living a life that embraces their true affectional or gender identity is sinful behavior. “It’s a struggle to get people to realize that God has made them this way and to accept that they are not sinners,” he says.

  • Empowerment: Sullivan acknowledges that he doesn’t see this stage achieved very often. It takes place only after clients have taken some kind of step such as attending a different church, joining a church-affiliated small group gathering or Bible study, or connecting with a church-sponsored social event, he says. Counselors have an obligation to help clients process these experiences, particularly if they are negative.

“The goal of the empowerment phase is to keep the client traveling down the path toward connection of spiritual and sexual identities, even if they have a negative experience,” Sullivan explains. “This is important because self-confidence and comfort with sexual identity are increased as a result of exploring the intersection between spiritual and sexual identities.”

In reality, Sullivan says, most clients who go through the GRACE model still struggle to reconcile their religion beliefs with being LGBTQ, but they are more at peace with the conflict.

Looking for aff irmative alternatives

One way that counselors can support LGBTQ clients who want to maintain their religious affiliation but feel conflicted is to help them find an affirming congregation, Sullivan says. However, he stresses that counselors must do their due diligence. It isn’t enough to read that the church is part of an affirming denomination or to see that it includes a rainbow flag on its website.

To ensure that he isn’t sending clients into a religious environment that appears affirming but actually isn’t, Sullivan makes a point of calling churches directly. He tells whoever answers the phone that he is a gay man and wants to know the church’s stance on the LGBTQ community. If the person tells him that he is welcome to attend the church and that the church will pray for him and support him in efforts to leave the gay lifestyle, Sullivan thanks them for their honesty but says the church is not for him. Although “welcoming” to LGBTQ people on the surface, churches that hold those types of beliefs do not make it on to Sullivan’s “recommended” list for clients.

Matthews notes that some faith traditions pose a specific and significant challenge to LGBTQ individuals who want to maintain a religious connection. Churches such as the Jehovah’s Witnesses and the Church of Jesus Christ of Latter-day Saints (the Mormon church) embrace particularism — the belief that their particular religious tradition is the only authentic path to God. These paths rest on tenets that are significantly different from what mainstream Christians believe.

For those raised in a church that embraces particularism (and is not affirming of LGBTQ individuals), pursuing their faith by switching denominations is akin to losing their religion entirely, Matthews says. When someone has been told all their life that there is only one path to becoming a Christian and gaining salvation, envisioning another form of faith and worship is almost inconceivable, she explains.

LGBTQ individuals struggling to align their personal and religious identities may look to their families for support. Unfortunately, families are sometimes part of the problem, Matthews says. Many families find it difficult to reconcile their religious beliefs with the reality of their child identifying as LGBTQ.

Matthews has worked with couples from strict religious backgrounds grappling with how to support a child who, according to what the parents hear in church, is living a sinful lifestyle. She provides these parents with psychoeducation by recommending books, giving them information about PFLAG (an advocacy and support organization for the friends, families and allies of those who identify as LGBTQ) and answering their questions, such as whether being LGBTQ is a choice. Matthews might also ask the couple to look for what the Bible actually says about being gay rather than relying solely on what their religious leaders say.

Counselors must also consider that particularly for LGBTQ people of color (POC) or those of low socioeconomic status (SES), leaving their religion behind may also mean losing their community, Ginicola says. “If you are a POC or have low SES, religion is not just a place you go sometimes; it could be a lifeline,” she says.

Losing a whole community can be devastating for anyone, but particularly for someone who has multiple marginalized identities, Ginicola continues. She gives the hypothetical example of a gay black man who, by coming out, loses his church. But when he turns to the LGBTQ community, he may encounter sporadic instances of racism. As a result, he ends up feeling like he is not fully accepted — and, thus, can never feel totally comfortable — anywhere.

Counselors need to let those with marginalized multiple identities know that counseling is one place where they can be fully themselves, Ginicola says. Counseling can encompass all of who these clients are — black, Christian, gay — without judging. Many people seem to think that they can identify either as LGBTQ or religious, but not both, Ginicola notes. She believes the idea that these two identities can’t coexist is harmful because faith — believing in something greater than ourselves, even if it isn’t a deity — is an integral part of life.

Given their negative experiences, some LGBTQ people lose all desire to return to organized religion. Regardless, spirituality can remain a significant part of who they are as people, says Slater, an assistant professor of counseling and associate dean of students at Richmont Graduate University. Spirituality is not the same as religion. In fact, an individual’s spirituality may not even encompass God. Spirituality is simply something that is bigger than us and that provides people with a sense of purpose, Slater says. For some people, that sense of spirituality and meaning can derive from nature, philosophy, personal ideology, science or even the belief in human rights for all, she explains.

Even when LGBTQ clients ultimately decide that they no longer identify with their past religious faith, Matthews tells them that it is possible to hold on to certain positive aspects and values of their religious upbringing that still resonate with them, such as practicing generosity and gratitude and loving others. Or, if these individuals previously enjoyed reading the Bible as literature, she might suggest that they explore other religious or spiritual texts outside of their faith tradition. If the ritual of prayer once provided clients with a sense of peace, she might encourage them to replace that experience with something nonreligious, such as a meditation practice.

Wearing blinders

Counselors who identify as religious know that imposing their values on clients is unethical, and most counseling professionals work hard to bracket their beliefs. Laura Boyd Farmer, an assistant professor of counselor education at Virginia Tech, has published numerous research studies on LGBTQ issues. She recently completed a research study that has not yet been published but that was presented at the 2017 ACA Conference & Expo in San Francisco. The study consisted of a survey that asked 455 mental health and school counselors how they thought their religious beliefs affected their work with LGBTQ clients.

Some respondents said that because their religious traditions were based on acceptance and the idea that Jesus loves everyone, their beliefs had a positive effect, helping them to provide LGBTQ-affirmative counseling. Other participants said their work was in line with their religious tradition, which calls on believers not to judge. Some counselors said that they disagreed with the LGBTQ “lifestyle” but chose not to judge. Others disclosed that their religious beliefs pose a conflict with which they struggle — striving to practice ethically despite their nonacceptance of LGBTQ individuals. Some respondents said that they agreed with the statement “love the sinner, hate the sin” and that this belief did not negatively affect their counseling of LGBTQ clients.

When counselors refuse to counsel LGBTQ clients because their religious beliefs tell them that doing so is wrong, that represents an obvious violation of the ACA Code of Ethics. But where things get tricky is with counselors who take a low-profile nonaffirming stance, says Farmer, an LPC who provides pro bono counseling for LGBTQ individuals in the Roanoke, Virginia, area. These are the counselors who say that they don’t agree with the “lifestyle” but wouldn’t refuse to counsel LGBTQ clients. These practitioners may think that no matter what their beliefs are, they can still maintain unconditional positive regard for their clients, but they might be operating with a big blind spot, Farmer contends.

To illustrate her point, she describes a recent casual conversation she had with a practicing counselor. This person talked about working with gay clients despite believing that being LGBTQ is a sin. The counselor said that they just tried not to judge. Farmer, an ACA member, asked how the practitioner was able to do that. Their response: “To be honest, it doesn’t come up.”

In providing counseling yet not fully accepting LGBTQ clients, this counselor was attempting to manage conflicts with their personal religious beliefs by avoiding pertinent topics. For example, Farmer says the practitioner was working with a gay youth struggling with depression, yet the challenges of identifying as LGBTQ “never came up.” Farmer says this makes her wonder how many other professional counselors are walking around wearing blinders.

Counselors like the one in Farmer’s story are not fully owning — or understanding — their bias, Ginicola says. A bias isn’t just, “I hate these people,” she explains. It’s also that working with someone who is LGBTQ doesn’t feel “right” and the counselor isn’t comfortable with it. By not confronting the discomfort, counselors are much more likely to miss signs (even if unintentionally), miscommunicate and project their worldview on the client rather than identifying the real issues, Ginicola asserts.

Disaffirming counselors resent that ACA’s ethics code requires them not just to set aside their personal beliefs to work with LGBTQ clients but to actually be advocates for them, Ginicola says. These counselors don’t view the experiences of LGBTQ clients as valid, she adds, and it is impossible to work effectively with clients unless you intrinsically embrace their value.

 

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Additional resources

To learn more about the importance of exploring aspects of religion and spirituality in clients’ lives, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • Critical Incidents in Integrating Spirituality Into Counseling, edited by Tracey E. Robert and Virginia A. Kelly
  • Integrating Spirituality and Religion Into Counseling: A Guide to Competent Practice, second edition, edited by Craig S. Cashwell and J. Scott Young
  • Understanding People in Context: The Ecological Perspective in Counseling, edited by Ellen P. Cook

Journal of Counseling & Development (counseling.org/publications/counseling-journals)

  • “Psychological Safety and Appreciation of Differences in Counselor Training Programs: Examining Religion, Spirituality and Political Beliefs” by Amanda L. Giordano, Cynthia M. Bevly, Sarah Tucker and Elizabeth A. Prosek
  • “The Ways Paradigm: A Transtheoretical Model for Integrating Spirituality Into Counseling” by Joseph A. Stewart-Sicking, Paul J. Deal and Jesse Fox

Competencies (counseling.org/knowledge-center/competencies)

  • Competencies for Addressing Spiritual and Religious Issues in Counseling

ACA divisions

  • Association for Spiritual, Ethical and Religious Values in Counseling (aservic.org) and Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling (algbtic.org)

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editorct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.