Expert answer:LGBT clients are faced with helpful and unhelpful
Expert answer:Please fallow instruction. APA format with references no later than 5 years old. Read this article that I sent to you as an attachment below to complete the paper. For this assignment, you will review and reflect on the LGBT article. This article can be applied to healthcare providers in the multiple care settings. Discussion of the article is based on the course objectives and weekly content, which emphasize the core learning objectives for an evidence-based primary care curriculum. Throughout your nurse practitioner program, discussions are used to promote the development of clinical reasoning through the use of ongoing assessments and diagnostic skills, and to develop patient care plans that are grounded in the latest clinical guidelines and evidence-based practice. Discuss any “take-away” thoughts from the article. How do you plan to make a positive impact on the care of LGBT patients when you become a NP? What attitudes/behaviors/communication/understanding is important for the NP to have? What specific screenings / interventions will you incorporate into practice when providing care to a LGBT patient?
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Psychotherapy Research, May 2008; 18(3): 294 305
Helpful and unhelpful therapy experiences of LGBT clients
TANIA ISRAEL, RAYA GORCHEVA, THEODORE R. BURNES, & WILLIAM A. WALTHER
Gevirtz Graduate School of Education, University of California, Santa Barbara.
(Received 15 March 2007; revised 5 June 2007; accepted 6 June 2007)
Abstract
The purpose of this study was to identify a broad range of variables that characterize the helpful and unhelpful therapy
experiences of lesbian, gay, bisexual, and transgender (LGBT) individuals. Interviews were completed with a diverse sample
of 42 LGBT individuals who have been in therapy, and a content analysis was conducted. Results indicated that basic
counseling skills and relationships were key determinants of the quality of LGBT clients’ therapy experiences. Also
important to the helpfulness of the therapy experience were therapist variables such as professional background and
attitudes toward client sexual orientation/gender identity; client variables such as stage of identity development, health
status, and social support; and environmental factors such as confidentiality of the therapy setting.
Gay, lesbian, bisexual, and transgender (LGBT)
individuals experience specific stressors as a function
of being a sexual minority in a potentially hostile
social environment in which they face stigma, prejudice, and discrimination (Meyer, 2003; Russel &
Richards, 2003). Specifically, experience of social
stigma and discrimination (Mays & Cochran, 2001;
Meyer, 1995), deficit in social support (Lackner,
Joseph, Ostrow, & Eshelman, 1993), and experiences of heterosexism in the workplace (Waldo,
1999) contribute to increased rates of psychological
and physical health problems among LGB individuals. For example, LGB individuals are an at-risk
population for mental health problems such as
depression and anxiety, substance abuse, and suicidality (Cochran & Mays, 2000; D’Augelli & Hershberger, 1993; Kourany, 1987; Meyer, 2003;
Remafedi, French, Story, Resnick, & Blum, 1998;
Safren & Heimberg, 1999). Not surprisingly, such
experiences of chronic stress may also account for
the higher rates of mental health services utilization
by LGBT clients compared with their heterosexual
peers (Bieschke, McClanahan, Tozer, Grzegorek, &
Park, 2000).
Despite evidence of the pressing mental health
needs of LGBT individuals, mental health professionals do not necessarily respond to these clients in
therapeutic ways. There is ample evidence that some
therapists view homosexuality as a disorder, attribute
all presenting concerns to sexual orientation, lack
knowledge and awareness about the possible con-
sequences of coming out, use a heterosexual frame of
reference for a same-sex relationship, display heterosexual bias, and express demeaning beliefs about
homosexuality (Bartlett, King, & Phillips, 2001;
Bieschke et al., 2000; Garnets, Hancock, Cochran,
Goodchilds, & Peplau, 1991; Hayes & Gelso, 1993).
Although many LGBT individuals receive biased
therapy treatment, researchers have identified both
helpful and unhelpful practices with this client
population. The earliest of these studies asked
psychologists to describe harmful and beneficial
care for lesbian and gay male therapy clients,
including episodes in which they were involved as
the client or therapist and those in which they did
not directly participate (Garnets et al., 1991). This
study resulted in the identification of 17 biased,
inadequate, or inappropriate practices (e.g., assuming a client is heterosexual, urging a client to change
his or her sexual orientation, focusing on sexual
orientation when it is not relevant) and 14 exemplary
practices (e.g., helping clients overcome internalized
homophobia, recognizing the importance of alternative families, countering biased views of other
professionals). Subsequently, Liddle (1996) surveyed 392 lesbians and gay men about their encounters with these practices and demonstrated the
relationship of inappropriate practices to early termination and client perception that therapy was
unhelpful.
More recent studies using analogue and qualitative
investigations have identified additional factors that
Correspondence: Tania Israel, CCSP, Gevirtz Graduate School of Education, University of California, Santa Barbara, Santa Barbara, CA
93106-9490. E-mail: tisrael@education.ucsb.edu
ISSN 1050-3307 print/ISSN 1468-4381 online # 2008 Society for Psychotherapy Research
DOI: 10.1080/10503300701506920
Therapy experiences of LGBT clients 295
affect clients’ perceptions of or experiences in therapy. Therapist use of bias-free language had a strong
effect on client intent to use treatment and comfort in
disclosing sexual orientation (Dorland & Fischer,
2001). In addition, therapist knowledge and sensitivity regarding sexual orientation and other aspects
of clients’ identities, therapist warmth and acceptance, therapist experience with LGB clients, and
client perception of therapist sexual orientation were
also factors that contributed to perceptions of helpfulness (Hunt, Matthews, Milsom, & Lammel, 2006;
Lebolt, 1999). Silencing, or not adequately exploring
clients’ experience with sexuality, was a commonly
identified unhelpful practice for gay men in therapy
(Mair & Izzard, 2001).
Although such extant research sheds some light on
the experiences of LGBT therapy clients, these
studies provide an incomplete picture of the phenomenon. The foundational research in this area
drew on therapist perspectives (e.g., Garnets et al.,
1991), and even in more recent research, the
perspectives of LGBT clients have been largely
absent (Bieschke, Paul, & Blasko, 2007). The few
studies reviewed previously that investigated LGB
client perspectives limited their focus to therapist
contributions, such as attitudes and behaviors, without inquiring about client and service-level variables.
Although therapists are a key component of therapy,
considering the systemic heterosexism in institutions
and society, it may be important to understand the
larger context in which services are provided.
Furthermore, qualitative investigations of helpful
and unhelpful therapy practices have focused on
limited samples, such as gay men (Lebolt, 1999;
Mair & Izzard, 2001) or lesbians with disabilities
(Hunt et al., 2006), limiting transferability of conclusions and comparison among subpopulations.
Noticeably absent from these and other studies are
bisexual and transgender clients, who are often
poorly represented in research on sexual minority
counseling (Carroll & Gilroy, 2002; Carroll, Gilroy,
& Ryan, 2002, Gainor, 2000; Israel & Mohr, 2004).
Without a thorough understanding of the full
range of factors contributing to LGBT clients’
therapy experiences, it will be difficult for mental
health professionals to optimally serve these populations. The aim of this study is to identify patterns
that characterize client descriptions of helpful and
unhelpful situations that they experienced in therapy. We intend to fill some of the gaps in the existing
literature by fully representing subpopulations of
LGBT individuals and by inquiring about client,
therapist, and service variables. Ideally, the results of
this study can provide guidance for therapists and
administrators, helping them to design and deliver
appropriate services for sexual minority clients. In
addition, the results can guide future research in this
area by identifying variables that have received little
attention in previous studies.
Method
Participants
A total of 42 LGBT individuals took part in the
study. Participants who were selected for interviews
on the basis of their sexual orientation were bisexual
women (n 6), bisexual men (n 6), lesbians (n
9), and gay men (n 12); three of these participants
indicated another identity label (e.g., ‘‘queer’’) in
addition to an LGB sexual orientation category. Six
transgender people (3 male-to-female and 3 femaleto-male) and three individuals who identified as
gender-queer (an identity label that allows transgender individuals to express a flexible, fluid, or unique
gender, gender expression, or gender transgression;
Fassinger & Arsenau, 2007; Nestle, Howell, &
Wilchins, 2002) were selected on the basis of their
gender identity. The participants self-reported their
ethnicity as European American/White (n 23),
African American/Black (n 6), Asian American/
Pacific Islander (n 5), Hispanic/Latino/a (n 3),
multiracial (n 4), and other (n 1). At the time of
the interview, the participants ranged in age from 20
to 56 years (M 36).
Participants had been in counseling an average of
4.55 times (range 1 12). All participants had been
in counseling as adults; in addition, 35.7% (n 15)
had been in counseling as adolescents (age range
13 17 years), and 21.4% (n 9) had been in
counseling before age 13. Participants had participated in individual (n 42), group (n 13), and
couples/family (n 8) counseling. Of the total sample, 66.7% described their overall experience in
counseling as positive, 9.5% as negative, and
23.8% as mixed.
Procedures
Participants were initially recruited by mailing fliers
and packets of demographic forms to LGBT-oriented community agencies, organizations, events,
businesses, and conferences throughout the United
States. Additional Internet-based recruitment targeted underrepresented groups within the LGBT
community (e.g., transgender individuals) by means
of message boards and e-mail lists. As a result of
these recruitment methods, 127 demographic forms
were completed and returned. Participants were
excluded from selection for interviews if they were
heterosexual and not transgender at the time of the
study (n 2), had not been in therapy in the 6
months before the study (n 25), or did not respond
296
T. Israel et al.
to attempts to be contacted (n 6). Of the remaining
94 potential participants, 42 were selected for interviews to adequately represent diversity and balance
in terms of sexual orientation, ethnicity, geographic
region, gender, and gender identity. The research
team was composed of one faculty member and
three doctoral students in counseling psychology
with expertise in LGBT issues. This team included
members who were gay, bisexual, queer, and heterosexual; female and male; and European American,
European, and biracial Asian American. The team
ranged in age from 23 to 38 years. The faculty
member had prior experience conducting qualitative
studies, and all research team members received
training in qualitative research either before or
during the course of the study.
The semistructured interviews were conducted
over a 6-month period by the research team members. Interviews lasted an average of 32 min (range
13 60 min). Each participant was asked to recall one
situation in therapy that was particularly helpful and
one situation that was particularly unhelpful. For
each situation, participants then were asked a
standard series of questions related to client characteristics (e.g., ‘‘How did you feel about your sexual
orientation when you started counseling?’’), counselor characteristics (e.g., ‘‘Can you describe the
therapist in terms of professional training?’’), counseling process (e.g., ‘‘Was the presenting concern
mostly what you dealt with, or were there other
issues you addressed in therapy?’’), counseling
services (e.g., ‘‘What were your interactions with
the agency like?’’), and contextual aspects of the
counseling experiences (e.g., ‘‘What was your life
like outside therapy?’’).1
Research assistants transcribed the interviews, and
each transcript was audited by the research team
member who conducted the interview. The data
analysis was based on ethnographic content analysis
(Altheide, 1987), which enabled the researchers to
adapt categories based on emerging data as well as
identify patterns across a consistent coding system.
The research team developed an initial coding
schema by identifying topics based on the interview
questions and identified additional topic areas that
reflected new information from participant interview
material. For each topic, the team developed categories and a code sheet to reflect the content of
participant responses (e.g., modes of previous counseling: individual therapy, group therapy, and couples or family therapy). All research team members
who coded a transcript listened to the corresponding
interview beforehand. Each interview transcript was
coded individually by at least three members of the
research team, and the team argued to consensus
when discrepancies in coding arose. Some topics
(e.g., interventions the therapist used) did not lend
themselves to simple response options and required
additional qualitative analysis. For these categories,
the interview transcript material was identified by
the research team for each participant. The research
team reviewed the interview material across all
participants that pertained to a particular category
and identified all participant responses for that topic
area. The team then developed a code sheet with
these response options for that category and coded,
reviewed, and developed consensus in the same way
as for earlier categories. This process was repeated
for each of these new categories.
Results
Unless otherwise noted, results are based on percentage of the total number of participants or, for topics
that were applicable to only a subset of the participants (e.g., the category ‘‘feelings about gender
identity’’ was applied only to transgender participants), are percentages of the number of participants
for whom the topic was applicable. Because participant responses fell into more than one category for
certain topics, percentages may add up to more than
100. Percentile values presented in parentheses are
listed in the order of helpful first and unhelpful
second, unless otherwise noted.
Description of Clients
Although the clients were the same individuals in the
helpful and unhelpful situations, their therapy and
life circumstances (e.g., relationship status, employment, presenting concerns) were not necessarily
similar across situations. For example, the situation
occurred in the participant’s first time in therapy for
one third of the unhelpful situations but in only one
sixth of the helpful situations. The helpful situations
occurred from 1977 to 2004, although more than
half of the situations occurred in 2002 or later. The
unhelpful situations occurred from 1968 to 2005,
although more than half of the unhelpful situations
occurred in 2000 or later.
Level of outness. Most LGB clients openly identified as LGB at the time of both the helpful (66.7%)
and unhelpful (54.5%) situations. In the helpful
situations, most transgender clients (66.7%) were
similarly openly transgender; however, in the unhelpful situations, only 11.1% were at a stage of
expressing their gender identity to others.
Presenting concern. The most common presenting
concerns across situations were relationships (23.8%,
19%), depression/suicidality (19%, 23.8%), career
Therapy experiences of LGBT clients 297
(21.4%, 11.9%), sexual orientation/gender identity
(16.7%, 16.7%), anxiety/stress (14.3%, 9.5%), and
family (7.1%, 14.3%). Less common issues that
differed across helpful and unhelpful situations were
medical health (7.1%, 2.4%) and mandated therapy
(2.4%, 7.1%). Other presenting concerns that were
similar for helpful and unhelpful situations were
adjustment, substance abuse, personal growth, body
image, chronic mental health issues, anger, and selfesteem. There was a striking difference between LGB
and transgender clients in terms of presenting concerns: Transgender participants were more likely to
seek therapy for gender identity than LGB clients were
to seek therapy for sexual orientation (Figure I).
Relationships. Approximately half of the participants in both the helpful and unhelpful situations
were either in a relationship or ending a relationship
when the situation took place. For those participants
who were in a relationship, dating, or having nonrelational sex, the partner was typically of the same
sex, but the partner was of the other sex in about
15% of the situations. For those participants who
commented on the quality of their relationship, there
was a trend indicating that relationship quality was
stronger in the helpful compared with unhelpful
situations. Specifically, individuals in the helpful
situations described their relationship as a source
of support more often (26.2% vs. 11.9%) and as
source of stress less often (16.7% vs. 33.3%) than
those in the unhelpful situations.
Unhelpful
Helpful
50
45
40
35
Percent
30
25
20
15
10
5
0
LGB
Transgender
Figure I. Lesbian, gay, bisexual (LGB), and transgender clients
with presenting concerns related to sexual orientation or gender
identity.
Employment status. Participants in the helpful
situations were more likely to be employed (45.2%
vs. 26.2%) and somewhat less likely to be in school
(31% vs. 45.2%) compared with those in the
unhelpful situations. A minority of participants also
reported being unemployed or on disability or in
transition regarding school and employment during
both the helpful and unhelpful situations.
Families. Participants’ relationships with their
families were fairly evenly distributed across family
as a source of support, family as a source of stress, no
or limited contact with family, and no information
reported about family. Furthermore, these distributions were fairly similar across the helpful and
unhelpful situations. In addition to describing their
relationships with their families of origin, less than
10% of participants reported having children at the
time of the helpful or unhelpful situations.
Social support. Participants most commonly described their social support as strong or stable in
both the helpful (28.6%) and unhelpful (21.4%)
situations. However, they tended to be more dissatisfied with social support in the unhelpful
(26.2%) compared with the helpful (14.3%) situations. A small minority of participants reported
developing social support, loss of social support,
and conflict with social support in the helpful and
unhelpful situations.
Additional client characteristics. Some participants
described other aspects of their lives outside of
therapy. Three distinctive patterns emerged from
this category. In the helpful compared with unhelpful situations, participants were less likely to report
experiencing a mental health issue that was impacting their global functioning (14.3% vs. 33.3%), more
likely to have a chronic physical health problem or a
disability (23.8% vs. 14.3%), and considerably more
likely to be involved in the LGBT community in
terms of activism and volunteer work (16.7% vs.
2.4%). Although data were not consistently gathered
regarding other dimensions of the clients’ life experiences, some participants provided information
about additional factors that were impacting their
functioning at the time of the situation. Such factors
included social or sexual involvement to an LGBT
community (e.g., going to bars or bathhouses),
religious involvement or activities, drug use, recreational or athletic activities, creative activities (e.g.,
theatre, poetry, drag), legal issues, and negative
experiences related to being LGBT (e.g., discrimination or harassment).
298
T. Israel et al.
Description of Therapists
For 23.8% of participants, the helpful and unhelpful
situations occurred with the same therapist. Thus,
some therapist demographic information is included
in the accounts of both the helpful and unhelpful
situations. Furthermore, information about therapists was gathered from the clients and thus reflects
client perspectives and knowledge regarding the
therapists.
Therapist demographics. Therapists were typically
European American and in their 30s, 40s, and 50s,
and there were no dramatic differences between
helpful and unhelpful situations in terms of therapist
ethn …
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