Tag Archives: LGBTQ Issues

LGBTQ Issues

Pride in practice: The journey towards LGBTQ+ counseling competence

By Jonah Friedman and Megan Brophy June 30, 2021

Lesbian, gay, bisexual, transgender and queer+ (LGBTQ+) people are marginalized, often at risk of discrimination due to sexual, gender and affectional minority orientations. While queer people experience heightened prejudice, research from the American Psychiatric Association has indicated a lack of suitable counseling for LGBTQ+ groups that would greatly benefit from increased services.

This need for appropriate queer counseling is amplified by the growing percentage of self-identifying LGBT people. The Washington Post recently published findings from a Gallup Poll revealing a 1.1% increase in LGBT adults from 2017 to 2020 and that 1 in 6 individuals ages 18-23 identify as LGBT. Given a growing queer population and the increased need for counseling, there is a clearly identifiable gap for qualified services.

Queer-competent counselors can help. Unfortunately, there is a lack of queer competence among many practitioners, perhaps because of the small number of available LGBTQ+ courses and training opportunities for counseling graduate students. Even when proactive and eager graduate students seek out dedicated coursework, internships and training experiences in queer settings, viable options are limited. The cycle of limited to nonexistent queer-accessible counseling resources is perpetuated without available training experiences. How can we become LGBTQ-competent counselors when so few opportunities exist for education and practice in this area?

The queer experience

We live in a society that gives preference to white, Christian, male, cisgender, and heterosexual people. To retain power, both intentionally and not, these dominant identities often oppress any divergence. Youth are commonly indoctrinated to believe that departure from societally deemed normative standards, such as same-sex attraction or nonbinary gender, is deviant or wrong. This belief system often intensifies with age and can lead to the discrimination and oppression of queer people throughout the life span. To remain safe in today’s heteronormative and cisnormative society, many queer individuals hide their identities. Doing so is often the only way for them to be treated equally to their straight, cisgender counterparts.

Researchers Laura S. Brown and David Pantalone showed that the nature of constant secrecy, dissonance and struggle to conform adversely affects mental health. The Substance Abuse and Mental Health Services Administration has found that sexual minorities who experience exclusions from society have higher rates of mental health disorders, major depressive episodes and substance abuse. The Trevor Project’s data even indicate that queer youth experience higher rates of suicidal ideation.

Additionally, Darrel Higa et al. from the University of Washington found that when LGBTQ+ people choose to share their identities with parents, guardians, schools and workplaces, they are often met with rejection and discrimination. This is seen through higher rates of homelessness and increased unemployment in comparison with heterosexual individuals. Despite LGBTQ+ people experiencing heightened mental health disparities, queer clients often find unsupportive counseling services. 

Counselor competence 

LGBTQ+ clients benefit from counselors and mental health agencies that provide acceptance and validation through queer counseling competence. The Society for Sexual, Affectional, Intersex and Gender Expansive Identities (formerly known as the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling), established a task force in 2012 that outlined queer-competent counseling behaviors. The competencies touch on queer human growth and development, social and cultural foundations, helping relationships and more. The same group released competencies for counseling transgender clients in 2009. These resources, while important for agencies to utilize, have not been updated in a decade and would benefit from the inclusion of newer relevant queer research.

Having queer-competent counselors in all mental health settings is crucial to fostering open discussion and disclosure of LGBTQ+ client identities. A survey by the Center for American Progress shows that a lack of trust exists within the LGBTQ+ community for health care systems. It is likely that counselors will need to continually gain the trust of queer clients due to their historically negative health care experiences and traumas. To achieve such trust, counselors should provide appropriate services to LGBTQ+ clients as directed by the queer counseling competencies and the American Counseling Association’s ethical obligations of beneficence and nonmaleficence.

Paper guidance on LGBTQ+ competence exists, but the field is obligated by these same values to provide more than the prevailing “self-teach” approach. When queer competence is effectively implemented, the resulting safe spaces, open dialogue and unconditional positive regard will encourage more LGBTQ+ clients to show up authentically. Findings from Edward Alessi et al. revealed that a queer affirmative approach to counseling resulted in a stronger therapeutic alliance and increased well-being for LGBTQ clients. There is a great need for graduate students and current practitioners to better learn queer counseling competencies.

Missing coursework

To gain LGBTQ+ competence, graduate students and practitioners must engage in coursework and continuing education on queer theory. Furthermore, they must partake in related training experiences. Many students and practitioners face obstacles to finding such offerings. The following details our experiences (Jonah Friedman and Megan Brophy) as we struggled to find appropriate training in this area.

Jonah entered a master’s in counselor education graduate program in August 2020. In an early academic advising session with faculty, he expressed interest in LGBTQ+ counseling. When seeking out classes in gay affirmative therapy and related theories, Jonah was informed there were no related course offerings at the college he attends. An institution that so strongly emphasizes its core tenet of multicultural competency had no classes specifically on LGBTQ+ counseling. While regretful, this is the case at a majority of universities offering master’s in counseling and related degrees. The resulting options were to forgo such classes or to transfer in pertinent elective credits from one of the few programs with queer counseling coursework. Eager to obtain such training, Jonah began the search to find other CACREP-accredited graduate programs offering courses in LGBTQ+ theoretical approaches.

In New Jersey, there are 12 CACREP-accredited universities offering graduate counseling degrees on a variety of tracks. A review of these programs and their course directories revealed only four clinical mental health programs regularly offering electives on sexual issues in counseling or gender issues. None of these courses was explicitly dedicated to the study of working with LGBTQ+ clients. The remaining programs did not list relevant electives or did not offer any form of an LGBTQ+ counseling course. This absence may be attributed to CACREP not requiring the integration of LGBTQ+ counseling education to earn accreditation for clinical mental health programs.

To take appropriate courses, Jonah applied to Southern Methodist University (SMU) in Dallas. The school has a counseling program that boasts an affirmative therapy with LGBT clients track. Jonah has since enrolled as a nonmatriculated student in two electives: “Affirmative Therapy with LGBTQ+ Individuals: Advocacy Across the Lifespan” and “Affirmative Therapy with Transgender and Gender Non-Conforming Clients.” Although the experiences have been enlightening, allowing for exploration of sexuality and gender through a deeper and more critical lens, it was a difficult and arduous process to obtain this theoretical training. The time, costs and effort of taking these classes at a second institution only adds to the hardships created by the lack of initial course offerings.

Additionally, Jonah was able to take courses online and remotely at SMU only because of COVID-19 guidelines. During regularly structured semesters, such courses are in person and unavailable to out-of-state students. Furthermore, Jonah enrolled in these courses proactively; students not seeking out queer counseling coursework will be minimally exposed to these crucial theories. When such courses are not offered or required, there is an inherent implication that queer theory is not important to CACREP or our practice as counselors.

Lacking clinical experiences

Even if LGBTQ+ courses are secured, counseling students must then engage in queer-relevant training experiences to build practice competency. This approach follows the logic of formative development within the counseling field: first learning the theories through coursework, followed by application during clinical experiences.

Megan Brophy’s experience finding an LGBTQ+ based internship as a graduate student proved challenging. Throughout the states of New Jersey, New York and Pennsylvania, Megan found only four sites offering exclusively LGBTQ+ oriented counseling. To secure competitive internships at such sites, students often begin applications and interviews up to six months prior to the start of a program. At one site in Philadelphia, the application window was open only for a single month. Many other sites accept only one to three interns annually. This highly selective approach for interns greatly increases the already difficult endeavor of finding a relevant training position. The limited funding and logistical roadblocks for hiring interns and licensed practitioners at these sites hinder counseling students from gaining the clinical experiences necessary to become queer-competent counselors. Students struggle to structure their degrees around obtaining these queer-focused internships while working to stay on track to graduate.

In her search for internships, Megan called a variety of LGBTQ+ community centers in New Jersey to assess the availability of internship opportunities. She discovered that among those offering services, most were limited to support groups facilitated by nonlicensed professionals. In part due to a lack of funding and resources, services were more related to social gatherings, legal referrals and Pride celebrations. Resultantly, queer youth have severely limited access to appropriate counseling services. Relatedly, graduate students attending CACREP-accredited programs cannot obtain internships that meet accreditation requirements for supervision without licensed clinicians at such sites.

Even when qualified services are available, they are often niche and unrepresentative of the greater queer community. One such counseling opportunity is offered through a residential living program available to queer, homeless adolescents in Ewing, New Jersey. While homelessness is critical to address, it is an extreme situation for LGBTQ+ youth to find themselves in. We must also consider queer youth not displaced who are still looking for mental health services.

Finally, we must consider how the lack of availability and accessibility to LGBTQ+ sites directly affect our clients. Traveling great distances to the nearest LGBTQ+ counseling center is a privilege that many do not have. We cannot expect or require our queer clients to travel so far to attain mental health services. Queer-identifying youth almost never have this option without the help of a supportive friend or family member. Beyond that, given school and homework obligations and involvement in extracurricular activities, they may not have the time to travel long distances for services.

While the recent influx of online mental health services stemming from the COVID-19 pandemic has made counseling more widely available, online counseling within an unsupportive home environment may be harmful for LGBTQ+ clients. In such situations, queer clients may not be able to safely disclose information regarding their sexual or gender identity. This emphasizes the work that still needs to be done within the counseling field to create more queer-inclusive spaces with queer-competent counselors.

Understanding queer identity

As counselors, we have a duty to be multiculturally competent. The Multicultural and Social Justice Counseling Competencies, developed by the Association for Multicultural Counseling and Development, detail the layers leading to more inclusive counseling: counselor self-awareness, client worldview, the counseling relationship, and advocacy interventions.

While our field has made strides in the integration of diversity, there is more to be done in helping queer clients. To train and sustain queer-competent counselors, we must make a commitment to better understand the multifaceted aspects of queer culture, identity and relevant terminology. Beyond this, counselors can engage in continued research and relevant literature with the community, including resources provided by leading queer organizations (e.g., The Trevor Project, GLSEN). The understanding of queer identity and worldview is foundational in effectively working with LGBTQ+ clients and empathizing with their unique experiences.

Active advocacy

Rainbow Black/Shutterstock.com

ACA has established a nondiscrimination policy banning all forms of harassment, including protections for transgender, gender nonconforming and LGBTQ+ individuals. We as a profession must move past this passive protection and evolve as active advocates. Practitioners can act with and on behalf of their queer clients on the micro-, meso- and macrolevels of advocacy.

On the microlevel, counselors may work with queer clients to continually affirm their identities. On the mesolevel, advocacy might take the form of working alongside local school systems to organize LGBTQ+ support groups or arranging professional development for staff. On the macrolevel, practitioners can become involved with legislation that is supportive of LGBTQ+ individuals and communities. All three levels of advocacy are required to make a difference in our current climate.

Graduate course offerings

Gov. Phil Murphy of New Jersey recently signed into law LGBTQ+ inclusive curriculum legislation, following the states of California, Colorado, Illinois and Oregon. Out of 50 states, only five have recognized the importance of a queer-inclusive approach to education. Across New Jersey, boards of education have begun to integrate the accurate representation of queer individuals and history into curricula.

So many of the accredited institutions of higher education in the same state have yet to adopt similar coursework. These schools, which are training the counselors of the future, need to offer more classes on queer theory. In doing so, all graduate counseling students will be exposed to basic LGBTQ+ terminology and culture. This integration of queer curriculum will take queer counseling skills past the point of specialization.

LGBTQ+ oriented sites

While it would be ideal to open queer-focused counseling sites across every state, a more realistic plan would be for existing agencies to introduce LGBTQ+ services. For example, High Focus Centers in New Jersey, known for their outpatient substance abuse programs, recently added an LGBTQ+ track addressing substance abuse, queer wellness, self-esteem, empowerment and relational skills. Other sites can commit to adding queer tracks within their programs to allow for more internship opportunities and training in queer-competent counseling. In turn, sites will become more welcoming to queer clients.

A better future

By gaining basic queer counseling competence, advocating for all LGBTQ+ people, enhancing counseling curriculum to be queer-inclusive, and integrating queer support services at all agencies, our field can significantly improve the counseling provided to LGBTQ+ people. We must all become queer-competent counselors and the agents of change in our increasingly progressive field.

 

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Related reading: See Counseling Today‘s June cover story, “Listening to voices of color in the LGBTQ+ community

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Jonah Friedman is a Master of Arts in clinical mental health counseling candidate at the College of New Jersey. He completed his undergraduate studies at Tulane University, where he first discovered his passion for helping others and the value of counseling. Inspired by his current work with the Trevor Project, Jonah hopes to eventually work as a practitioner utilizing an LGBTQ+ affirmative approach. Contact him at friedj11@tcnj.edu.

Megan Brophy (she/her/hers) is a recent graduate from the College of New Jersey. Her work is guided by a passion for social justice and advocacy for marginalized communities. Contact her at brophym1@tcnj.edu.

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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.

Listening to voices of color in the LGBTQ+ community

By Laurie Meyers May 26, 2021

It has been 52 years since the Stonewall uprising — a multiday protest that began when police raided the Stonewall Inn, a gay bar located in Greenwich Village in New York City, in the early hours of June 28, 1969, and began arresting patrons and employees. The bar was a haven for the LGBTQ+ community, and the raid — purportedly for liquor license violations — was one more in a pattern of police harassment of queer and transgender establishments. 

Many in the LGBTQ+ community credit Marsha P. Johnson, a Black transgender woman and frequent patron, with throwing the first brick that sparked the uprising. However, in interviews in the 1970s, Johnson said she didn’t arrive until the clash was underway. Other stories had Sylvia Rivera, a Black and Latina transgender woman, throwing the first Molotov cocktail. Rivera later said she was in the crowd throwing coins before the cocktails began flying. LGBTQ+ historian Charles Kaiser believes that Stormé DeLarverie, a Black biracial lesbian and drag king, sparked the resistance by throwing the first punch. 

People may not agree on how the uprising began, but one thing is clear: Trans and queer women of color were at the forefront of the gay liberation movement that emerged from Stonewall. Johnson and Rivera also helped found the group STAR (Street Transvestite Action Revolutionaries), which offered housing to homeless and transgender youth. 

Their contributions to the LGBTQ+ communities are starting to be recognized. The East River State Park in Brooklyn was renamed Marsha P. Johnson State Park, and in 2019, New York City announced plans to build monuments to honor Johnson and Rivera. They will be the first permanent monuments of transgender women in the state of New York. The monuments are also part of the city’s effort to address the gender gap in public art. 

But the gap stretches beyond gender. Over time, the contributions of Johnson, Rivera, DeLarverie and many other queer and trans people from Black, Indigenous and people of color (BIPOC) communities have been overshadowed by white narratives and priorities. In the eyes of many, the face of the LGBTQ+ community is still too often exclusively that of white, gay, cisgender men. 

Often, nonwhite queer and trans people do not feel included — or necessarily even safe — within the larger LGBTQ+ community. As in other spaces in a system built on white supremacy, racism is all too prevalent. People who are part of communities across the BIPOC spectrum also face increased oppression and unique challenges because of the intersection of their cultural and LGBTQ+ identities. Although the term BIPOC is meant to be inclusive, sometimes it can be used as a catchall term that — intentionally or not — erases individual communities. What follows are professional insights from seven Black, Latinx, Indigenous and Asian counselors on how racism and oppression affect clients who identify as both ethnic/racial minorities and LGBTQ+.

Creating safe, inclusive spaces

Historically, white people have been the ones to decide where or how people of color fit into their world, observes Adrienne Erby, an assistant professor of counselor education at Ohio University. Her research focuses on intersectionality and racial, cultural and LGBTQ+ issues.

In a wider society that consistently looks to white, cisgender men to lead, LGBTQ+ communities can replicate that same dynamic, Erby says. White, gay, cisgender men may not lead all aspects of the LGBTQ+ movement, but they  have become the face — and the voice — of it, she notes.

“Who gets to have a voice? Who sets the agenda for activism?” Erby asks. Navigating racism and genderism — particularly among Black transgender women — increases the risk of experiencing violence or being killed, she explains. Constantly questioning one’s safety creates different priorities — such as sheer survival, notes Erby, an American Counseling Association member. For BIPOC queer, trans and nonbinary individuals, the interaction of racism and genderism affects even the most basic things, such as the ability to find and keep employment, health care and safe housing.

Trans activists note that the addition of transphobia on top of racism compounds the problems with employment and housing. Transgender women often have no place to go when they need shelter or are in danger because most homeless and domestic violence shelters do not accept trans individuals. 

Disrupted education is also a major issue for LGBTQ+ individuals who are BIPOC. Trans and nonbinary adolescents — particularly those of color — frequently drop out of school to escape race- and gender-based bullying by peers and even teachers, in addition to being pushed out of school through disciplinary measures that disproportionately affect BIPOC students, Erby says. 

Counselors can be crucial advocates by challenging policy and procedure and function as “safe adults” for these students, she emphasizes. At the same time, Erby cautions counselors to resist the desire to “reframe” legitimate issues such as racism, heterosexism, genderism and transprejudice. Rather than helping, these approaches serve as barriers to open communication, especially among queer, trans and nonbinary people of color. BIPOC are more likely to respond to honesty and authenticity, she says. 

“In our homes, most of us have learned to read very quickly if a person is someone [we] can talk to,” Erby says. “Instead of expecting people to come out to us, we need to show that we can be invited in.” Inviting someone in — putting the power with the student or client to share what they choose — is essential to building trust, she stresses.

Counselors are often trained to assess through questions that are information driven rather than narrative driven. “We ask for the information that we need to have, which is not a bad thing — it’s essential — but we also need to be asking broader questions,” Erby says. So, instead of just confirming that a client is living with their family, for example, counselors should invite clients to tell them more about their families, she advises. 

Erby recommends that counselors get a sense of who clients are not just in the moment, but in their lives outside of counseling. Who are their family members? Where did they grow up? What is their relationship to a faith community? “It’s important that we talk about the things that shaped [clients], like family, school, race, faith, spiritual belief and how [they] identify,” she says.

“We [also] have to broach the issues of race, culture and gender from the start and throughout our relationship,” she asserts. “I always make sure to mention race, gender, affectional and spiritual identity. These are things that people may not bring up themselves.”

Pushing past a white-centric narrative

Tameeka Hunter, an assistant professor of counselor education and supervision at the University of Arkansas, believes one of the most consequential elements in understanding and centering the diverse stories of the LGBTQ+ population is to stop using white experiences as a benchmark. For example, coming out of the closet is a white, patriarchal construct, she explains. Western (white) culture is an individualistic one that places more emphasis on individual desires and independence than on collectivist or relational cultures. However, as Hunter points out, most of the cultures across the BIPOC spectrum are relational, so the community is a core part of the person’s identity.

“Coming out is not possible for everyone,” says Hunter, an ACA member whose research focuses on marginalized populations, including LGBTQ+ and disability populations. “It may not be safe to do so. ‘Coming out’ may cause significant losses.”

For example, Black culture is a relational culture that honors its elders, and the community’s support is an essential tool in surviving racism, Hunter says. Coming out may jeopardize the person’s place in the community and threaten their source of social and financial support and safety, she notes. 

Part of being an LGBTQ+ affirming counselor requires examining one’s own biases about issues such as gender, affectional identity and race, and understanding the complexity of being at an intersection, says Hunter, who is a diversity speaker and researcher. 

In addition to making sure their intake forms are inclusive, including categories for racial, affectional and gender identity and pronouns, counselors need to let clients know that they’re open to talking about religion and spirituality, because as Hunter points out, that can be a central part of many Black people’s lives. And if an LGBTQ+ client’s family believes that being a sexual minority is sinful, it could create serious identity issues for them. Letting clients know that they can safely talk about religion/spirituality in session “creates a space for them to tell you, ‘I’m in conflict with my family’ or ‘I might believe that my sexuality is a sin or an abomination,’” she explains.

In situations in which clients are struggling with being gay and fear that their family will reject them, counselors should assess the client’s support system, Hunter says. Is there anyone they can talk to in the family? If not, counselors can help clients expand the way they think about support. For example, LGBTQ+ people frequently have “found” families — nonbiological kinships that provide a supportive environment. Hunter helps clients find supportive networks by asking them about places or people who bring them a sense of peace or joy. They can also choose to whom they want to disclose their LGBTQ+ identity. That may mean being open with some family members but not with others, she adds. 

“People of color who are also LGBTQ+ have a tendency to find community with those who share [their] sexual identity, racial identity or another marginalized identity,” she says. “That’s a way to hold on to … culture. Part of finding community is holding on to the validity of our experiences.”

People with multiple marginalized identities are constantly forced into presenting little bite-sized pieces of themselves. Being among like-minded people is a way of finding relief from the strain of holding back so much of one’s self, she says.

But Hunter also cautions that it’s all too easy for counselors to indulge in what she calls “disparity porn” — stereotypical narratives such as being Black makes someone more prone to substance abuse or that Black families are typically less accepting of LGBTQ+ family members or are more homophobic. “While it is important to acknowledge health and other systemic disparities so that we can educate future counselors and support clients contending with those concerns, many times we disproportionately attend to those disparities,” she says. “Disparities and systemic oppression are important topics, but there needs to be balance in how often these topics are covered.” 

Hunter recommends that counselors also focus on positive affirming concepts such as resilience. “We can celebrate those who are thriving in the community by illuminating their stories,” she says.

Hunter concludes by emphasizing our shared humanity: “I strongly believe that our liberation is bound together — all marginalization from systemic suppression is bound together — even if we do not share the same marginalized identity.” In other words, she thinks that when the most stigmatized among us — such as Black transgender women — are free, then we all, as a society, will be free.

Unfracturing identity

When people engage with the LGBTQ+ community, there is often an initial feeling on the part of those who have been marginalized that this part of their identity has finally been validated, and they feel safe, says Misty Ginicola, a licensed professional counselor (LPC) who specializes in counseling LGBTQ+ individuals. Often, however, those who are Black, Latinx, Asian, Indigenous or other people of color “soon learn that [they] are not completely safe,” she says.

Colonization and the oppressive system it established is everywhere, Ginicola notes, so racism and misogyny are also entrenched in the LGBTQ+ community. “It hurts worse when it comes from a space where you think you are safe,” she observes.

Mirroring may be a developmental psychology concept applied primarily to children, but Ginicola, a professor in the clinical mental health counseling program at Southern Connecticut University, thinks that adults instinctively do it too. “We look for people who mirror and validate [us],” she says. “For those of us who have different marginalized identities, we never get a true mirror. … No matter what — I think I can speak personally from this angle — there won’t be a community where you have all of your marginalized identities [mirrored].” 

It’s not just that no one community can encompass every aspect of a person; it’s that when it comes to marginalized identities, there will always be environments that are not only unwelcoming but also hostile, explains Ginicola, an ACA member and co-editor of the ACA-published book Affirmative Counseling With LGBTQI+ People. For safety — and many other reasons — it may be necessary to suppress parts of one’s identity, which may cause a person’s identity to fracture, she says.

To remain whole, the person must cultivate a home and community within themselves, Ginicola notes. Her goal is for clients to be able to say, “If I don’t feel welcome somewhere, I’m not going to go there. I won’t fracture to fit in anymore.” But getting to a point where the client can say that requires examining all of their identities, Ginicola says. 

She helps clients explore the boxes they are trying to fit into by asking them, “What is it that you think people expect you to be? Do you want to be that?” For example, Ginicola has a client who is queer and grew up in a rigid evangelical family. Because the client still has inner critical voices connected to his strict religious upbringing, she works with the client to explore where those voices come from and whether those voices reflect his value system or someone else’s. Counselors have to look at all of those areas that have shaped the client’s identity, even if it makes them uncomfortable, she says. 

“Colonizing beliefs and the value system that we have in place as a culture is a lose-lose for most people — even for people who do seemingly fit,” she says. “We all walk around fractured in some way, whether it’s about your physical experience [or] mental health diagnosis. We’ve been taught to pull those things inward in order to fit in.” 

“I think the other thing we have to tackle as individuals and as a society is binary thinking,” Ginicola adds. “Everything [is] black and white, good and bad. Our society has not prepared us to have complex emotions.” 

Navigating intersections 

An element of cultural misappropriation exists among the white LGBTQ+ community, says Christian Chan, an assistant professor in the counseling and educational development department at the University of North Carolina-Greensboro. One sentiment he often hears from clients who have at least one marginalized identity is that “I’m absolved from being microaggressive. I’m absolved from acknowledging that these other forces are at play. I can’t be racist.” But people with marginalized identities can still act in racially aggressive ways, he says.

In some ways, white LGBTQ+ individuals are established as the “norm and ideal,”  notes Chan, an ACA member whose research focuses on intersectionality, social justice and the LGBTQ+ population. Their white privilege helps mitigate some of the oppression they face, despite being queer or trans. 

Chan also points out that those from BIPOC communities often grow up in collectivist cultures. In Black, Latinx, Indigenous, Asian and other communities of color, there is a sense of kinship and sharing that helps them bear the weight of hatred and injustice, which is always present but has been particularly visible over the past year, he says. But if identifying as LGBTQ+ makes a person unwelcome in their culture or family and their race/culture is not widely accepted in the queer and trans community, where do they turn? What happens when they are disowned not only from their family but also from their culture? Chan says the sense of isolation that can occur from being physically in a community but not feeling a part of it can be profound. “It’s a dance of hypervisibility and invisibility,” he says. 

Race also intersects with genderism and heterosexist norms, Chan points out. Queer men have internalized many of the stereotypes of masculinity prevalent in straight culture. They not only view being “too feminine” as taboo, but also often have an ideal of hypermasculinity, he says.

Stereotyping and fetishization of BIPOC bodies are widespread in clubs and on dating apps, Chan continues. For example, on heterosexual dating apps, Asian men are often perceived as less masculine because of prevailing stereotypes in queer culture, he says. In contrast, Black gay men are fetishized because they are often perceived as hypermasculine. Blatant racist comments are also common on dating apps, he adds.

It is important for counselors not only to acknowledge that a client’s LGBTQ+ and BIPOC identities are connected but also to understand how the client navigates these overlapping forms of oppression, Chan stresses. He advises counselors against assuming that the reason a client is in their office is related to their racial, affectional or gender identity. But he also urges counselors to let clients know that they are in a safe space where they can talk about all of their experiences because internalized oppression is negatively linked to mental and physical well-being. Chan notes that affirming intersections can actually buffer negative encounters and reduce distress. Counselors can help clients see that there is strength in navigating their intersections because it can build resilience and even be lifesaving, he says.

Becoming an accomplice

“One of my favorite sex educators, Ericka Hart, will frequently note that queerness does not absolve racism,” says Alandria Mustafa, an LPC at Sula Counseling in Goose Creek, South Carolina. “White LGBTQ+ folks perform Blackness, especially Black femininity, through a variety of mannerisms and the use of AAVE [African American Vernacular English] and slang terms that were born and bred in the Black queer community, while also invalidating and gaslighting queer and trans Black people, who are attempting to name and seek acknowledgment for harm done within the community.” 

“White LGBTQ+ people tend to believe that because they are also queer, they have a comparable oppressive experience to queer and trans Black people,” continues Mustafa (pronouns they/them/their). “This couldn’t be further from the truth, but attempts to explain and explore how this is false assumption are usually complicated by white fragility.” 

Mustafa stresses that white LGBTQ+ people need to listen to queer and trans Black people when they say that anti-Black attitudes are harming them, and they need to do the work of unlearning anti-Blackness. “Queer and trans Black people would best benefit from mutual aid and true accomplices, not just allies. Accomplices are willing to leverage resources and power in pursuit of true equity and accountability,” they add.

When working with clients who have been rejected by their communities of origin because they identify as members of the LGBTQ+ community, Mustafa encourages them to acknowledge the lack of acceptance as an internalization of white supremacy in individual Black communities. 

“The idea that we are disposable is a direct result of being disposed of over many, many years,” Mustafa explains. “This conversation usually supports the externalization of transphobia and queerphobia, so we can recognize that rejection is a product of generational and ancestral trauma.”

Mustafa also encourages clients to challenge their definition of family and the belief that families must be biological. “Queer and trans BIPOC have always been intentional and thoughtful around creating family dynamics amongst one another as a means to keep each other safe and provide support,” they say. “So, I typically invite the development of chosen family and social support systems as safe familial dynamics that can always be created and nurtured outside of those we share a genetic makeup with.”

Racism within the LGBTQ+ community also leads to extreme marginalization of transgender (particularly Black transgender women) and nonbinary people, who are at the greatest risk of violence and murder, Mustafa says. 

“It’s important to acknowledge that this [marginalization] is due to transphobia and anti-Blackness, both of which are a result of white supremacist rhetoric and the harmful nature of the gender binary,” Mustafa emphasizes. They point out that “trans and nonbinary folks are also less likely to engage in support services — whether this be mental/emotional health services or physical and reproductive health services — and are least likely to access a variety of community programs.” The reason for not accessing these services does not stem from a lack of desire or willingness, Mustafa says. It comes from “a variety of systemic barriers that make it incredibly challenging to access care that is safe.”

Mustafa suggests the following ways that counselors can support transgender and nonbinary people:

  • Offer some pro bono or sliding scale services to ensure that transgender and nonbinary people have access to mental health care. 
  • Do not charge for documentation that is required for transgender people to pursue affirming medical care. 
  • Vet providers who claim to provide gender-affirming medical care before referring clients to them. “We are responsible to our clients, and even more so to our clients who are trans, to ensure that the referrals we use are practicing affirming care and are not likely to cause harm to our clients,” Mustafa stresses.
  • Include gender-neutral language on websites, intake documents and signage in the office (on bathroom doors, for example).
  • Continue to learn and self-critique one’s perceptions about gender and sexual identity. Mustafa adds that counselors should challenge how they perceive gender in their personal lives as well. Counselors cannot say that they believe in affirming gender diversity and gender expansiveness in the therapeutic space and then present with rigidity and a lack of flexibility in the personal space, they say.
  • Advocate for clients. “The personal is political,” Mustafa says. “Trans folks of color are highly politicized, solely based on their intersecting identities.” It is virtually impossible to properly and wholeheartedly serve a population at the intersection of a variety of marginalized identities while also claiming neutrality about legislation and policies that cause harm, they point out. Mustafa stresses that counselors cannot stand by while working with a population of people who cannot access proper medical care because of anti-trans legislation and policies or who are murdered and discarded for simply existing.

Being LGBTQ+ and Latinx

One of Roberto L. Abreu’s principal areas of research is with the parents and families of Latinx queer and trans people. What he has found in his research challenges the belief and stereotype that Latinx families are not accepting of their LGBTQ+ family members. The families whose stories he highlights in his research are interpreting Latinx cultural norms in ways that are affirming of their LGBTQ+ children.

“Like in other collectivist cultures, there is a strong emphasis on community and family among Latinx people,” says Abreu, an assistant professor of counseling psychology and director of the Collective Healing and Empowering Voices through Research and Engagement (¡Chévere!) lab at the University of Florida. “Family is central to everything. The idea is that it doesn’t matter what happens; family comes before anything else,” he says. 

Gender norms are also important in Latinx culture, Abreu notes. Specifically, mothers or those in motherly roles are seen as the keepers of the culture. The mothers he spoke to often reported that one of the reasons they accept their LGBTQ+ child is because it’s their duty as a mother, which includes being self-sacrificing and putting the well-being of their children above all. 

Abreu points out that even Latino male gender norms, which are often described in terms of rigid views of masculinity, has layers. Part of Latino male gender norms involves keeping one’s word, being emotionally in touch with one’s family and setting a good example for the family unit — all characteristics associated with caballerismo (the idea of a man as the family provider who respects and cares for his family). For example, some of the fathers Abreu has spoken to describe working on their own feelings and emotions regarding their LGBTQ+ child and coming to a place of acceptance to ensure that their other children and family members also accept the LGBTQ+ child. 

“Latinx culture also places a heavy emphasis on the idea that everyone should be afforded dignity,” Abreu says. He has found that parents of LGBTQ+ children often interpret this as their child’s right to love whomever they wish.

Abreu also studies issues faced by Latinx transgender people and says access to health care is a challenge for this population. “The barriers go beyond simply getting to the doctor’s office. Not having forms in their native language and [experiencing] negative interactions with office staff are just two examples of the types of discrimination and hostile environments that Latinx transgender people face before they even see the doctor,” Abreu says. 

“Health care providers also frequently attribute everything to the patient’s identity as transgender,” Abreu notes. For example, a person might come in with a cold and be asked intrusive questions about being transgender. “Medical staff also tend to hyperfocus on parts of the trans women’s identities, such as making assumptions about what they do for a living,” he says.  

When Abreu asked study members what services they most needed, they named trans-specific health care sources, financial resources, spaces for transgender homeless people, addiction care, and help for the undocumented such as legal and documentation expertise. Abreu also believes there should be a center that offers education for family members to understand what being LGBTQ+ means. And all of these resources need to be offered in Spanish, he adds.

Acknowledging and advocating for BIPOC LGBTQ+ clients

“It is imperative to understand not only LGBTQ+ experiences, but [also] how that intersects with race/ethnicity,” says Tamekia Bell, an assistant professor at Governors State University in Illinois. “We are not monolithic individuals; we have multiple identities. However, sometimes we struggle or ignore the multiple identities that people have.” 

“I do believe some people of color may feel shut out by the larger LGBTQ+ community,” Bell continues. “BIPOC LGBTQ+ individuals need the community to not only speak out against hatred around LGBTQ+ issues, but [also] systemic racism and dismantling white supremacy. Again, the focus needs to center on all members of the community, not just the privileged ones.”

Bell, an ACA member whose research interests include multicultural competency surrounding individuals with disabilities and LGBTQ+ individuals, cautions counselors that not all individuals who identify as LGBTQ+ have the same experiences. “It is important for counselors to have our clients guide us in that discussion and not assume [that] because they identified as BIPOC and LGBTQ+, they will have struggles with who they are,” she says.

Society as a whole sends constant and consistent messages to BIPOC LGBTQ+ individuals that they are not valuable, notes Bell, chair of the Society for Sexual, Affectional, Intersex and Gender Expansive Identities’ Queer & Trans People of Color Committee. It is society that needs to change, she stresses, yet BIPOC LGBTQ+ individuals are expected to adjust to the society they live in. “This is where our work outside the therapeutic spaces is so crucial,” she emphasizes. “We can provide tools, resources and support for our clients, but ultimately, they go back into the world that tells them they are unworthy. In order to truly help our clients, we have to work to dismantle the systems that make our clients feel undervalued and unworthy.”

Bell advises counselors to seek out resources and readings to help them learn how to provide ethical and culturally competent care to BIPOC LGBTQ+ individuals. By doing their own work, counselors avoid placing the burden on BIPOC LGBTQ+ counselors, clients and community members. “The work is not always easy, and I sometimes find myself saying or doing the wrong thing,” Bell admits. “In those instances, I acknowledge my ignorance, apologize for my transgression and commit myself to continuing to do better in the future.” 

When working with LGBTQ+ individuals, Bell acknowledges her privileges and asks that they call her out if she says or does something offensive or inappropriate. “Because I know and understand my worldview is different, I am more intentional,” she says. “I do not mind the work because I want to live in a world, and have future generations live in a world, where they are honored and valued for who they are and being their authentic selves.”

Daniel Samray/Shutterstock.com

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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.

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 (https://imis.counseling.org/store/catalog.aspx#category=lgbtq)

  • “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

 

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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.