Tailoring Therapy for Gender and Sexual Minority Clients

Clients with minority identities related to their sexual orientation or gender seek therapy for a variety of concerns, and many therapists use the evidence-based approaches they are most comfortable with to respond to the presenting symptoms. The impact of possessing a stigmatized identity, encountering discrimination, or witnessing political debates regarding one’s belonging in society lead to vulnerabilities and challenges that set these clients apart. Some of the most researched difficulties experienced by gender and sexual minorities that traditional treatment packages may not respond to are internalized stigma, rejection sensitivity, and shame.

When Our Worst Thoughts are About Ourselves

Internalized stigma (i.e., internalized homophobia, biphobia, or transphobia) refers to those attitudes or stereotypes about a minority group present in our culture that might be internalized and believed by an individual. These sorts of thoughts can be painful, from assertions that attraction to the same sex is a result of sexual abuse as a child (a theory that might be repeatedly asserted by family or religious leaders), to ideas about what the future holds (“I’ll never be respected in my field”, “Real relationships don’t exist for people like me”, or “My parents will never love me again”).

Tips for addressing internalized homophobia:

Don’t argue with the fears – a client can get caught in a cycle of attempting to convince ourselves of which fears are true or not. Mindfulness techniques can help the therapist and client to observe when those thoughts arise, how they affect the client, and to notice those moments when the client might decide to engage with the world differently.
Defusion exercises can be helpful – fusion refers to the way that our thoughts, in that echo chamber between our ears, can seem completely true. Those same thoughts might feel lighter in the course of a day when a client is able to notice how the believability rises and falls, or old habits of responding to those thoughts.

Armor Up: Avoiding Rejection and Intimacy

Growing up, many GSM individuals have experienced rejection – and not just rejection, but rejection from parents, siblings, and those who knew them and had appeared to love them most! Learning to be less guarded emotionally, to engage vulnerably and authentically in relationships after such experiences of rejection, is one of the most difficult tasks for GSM clients to overcome, in my clinical experience – particularly if one’s parents do not allow for reestablishing a relationship after adjusting to a child coming out.

Tips for building client capacity for vulnerability and intimacy:

Drawing attention to the relationship in the room – for many clients, it is easy to discount a therapist’s warmth as part of their job, or service in response to payment. Slow down, be mindful, and guide a client to notice the feel in the room with therapist.
A warm relationship including disclosure – while associated with better therapeutic relationships for all clients, a relationship that emphasizes the client’s genuine care for the client and authentic responses to events in the client’s life are particularly important.
Encouraging risks outside of therapy – tracking and sharing experiences of behaving in a more vulnerable or authentic way, particularly when the risk of rejection feels possible, can both build confidence and reduce fear of being fully seen by others.

When You Can’t Seem to Love Yourself

Shame is a complicated emotion, and tends to involve barriers to notice or let in warmth from others, a harsh and judgmental attitude toward yourself, and a feeling of isolating difference from other people. According to some experts, like Paul Gilbert, this is an emotion with evolutionary roots tied to being a social animal. We want to feel safe in our group, as it’s a dangerous world to go alone. Shame also may have different origins for GSM people. One recent study of cisgender men’s experiences found that while heterosexual men have a variety of people, places, and situations that come up when reporting early shame memories, gay men overwhelmingly report experiences of feeling shamed by their fathers. In this study, caregiver shame was more associated with depressive symptoms.

Use compassion training skills to address shame:

Compassion for others – at times the most accessible way to notice how a lack of safety or of shaming environments affects a GSM client is to encourage exploring how those around them are affected. Caring for others warms the heart to care for ourselves.
Compassion from others – as described above, guardedness to the emotional responses of others can become habit for many GSM people. In CFT, practicing guided visualization exercises that involve receiving warmth from a loving, ideal figure is sometimes required as a precursor to feeling safe receiving it from the therapist or others in the client’s life.
Compassion toward ourselves – in the face of bias, relationship challenges, or navigating politically charged environments, GSM clients benefit from the reminder to slow down and notice those parts in need of care. To work effectively, one must be able to both generate and receive compassion, so this is often the most difficult step for clients (or clinicians).

If you are a therapist wanting to learn more about responding to these common processes in psychotherapy, you can read more about these approaches here, or attend an upcoming workshop on this topic at Portland Psychotherapy.

Matthew D. Skinta, Ph.D., ABPP, is a board-certified clinical psychologist and a trainer of acceptance & commitment therapy and functional analytic psychotherapy. He directs Palo Alto University’s Sexual & Gender Identities Clinic, and is passionate about increasing the application of evidence-based care to work with GSM clients.

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