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.

Resources for self- and other-care in difficult times

Many of us have been impacted by the election results.  Whether you are feeling shock, fear, anger, sadness, confusion, disbelief, or excitement, joy, satisfaction or hope, you are likely not alone.

If you have been struggling, some of these resources might be helpful (thanks to Jennifer Villatte for sharing this list).  I prefaced each with a quote that spoke to me.  I also noticed the urge to provide a more in depth review of each, but eventually decided to practice self-care by calling it good.  I hope you find something you might be seeking.

Resources for Self-Care in the Face of Social Injustice and Marginalization

“When we hold space for other people, we open our hearts, offer unconditional support, and let go of judgement and control.”
What It Really Means to Hold Space for Someone, by Heather Plett
http://upliftconnect.com/hold-space/

“Have you showered in the past day? If not, take a shower right now.”
4 Self-Care Resources for Days When the World is Terrible, by Miriam Zoila Perez
https://www.colorlines.com/articles/4-self-care-resources-days-when-world-terrible

“Oppression is far more effective when the oppressed are also mentally drained and physically ill, so our physical and mental wellness is, in itself, a personal counter-attack on oppression.”
3 Ways to Prioritize Self-Care While Resisting Dehumanization: Because #BlackWellnessMatters, by Akilah S. Richards
http://everydayfeminism.com/2015/07/self-care-resisting-dehumanization/

“There are things you can do for yourself right now to get prepared for the next four (to eight) years.”
What to Do If You’re Trans and Live in America Now, by Jessica Lachenal
http://www.themarysue.com/trans-in-america-2016/

“Anger used as a catalyst for social transformation can go a long way.”
Transforming Anger into Building Solidarity, by Beth Berila
http://www.contemplativepracticesforantioppressionpedagogy.com/blog/transforming-anger-into-building-solidarity-by-beth-berila-phd

“Sometimes saying no is a radical act of self-care that’s as vital to our struggles as the marches, teach-ins, and walk-outs in which we participate.”
5 Self-Care Tips for Activists – ‘Cause Being Woke Shouldn’t Mean Your Spirit’s Broke, by Kim Tran
http://everydayfeminism.com/2016/04/self-care-for-woke-folks/

“The antidote for exhaustion isn’t rest.  It is wholeheartedness.”
What’s Missing When We Talk About Self-Care, by Carmenleah Ascencio
https://www.youtube.com/watch?v=4eX5Wjm4FrE

Resources for Engaging in Difficult Conversations and Being an Ally

“I’m more interested in helping them change their oppressive behavior than publicly shaming them for it.”
Calling In: A Quick Guide on When and How, by Sian Ferguson
http://everydayfeminism.com/2015/01/guide-to-calling-in/

“Comfort IN, dump OUT.”
How not to say the wrong thing – The “Ring Theory” of Comfort, by Susan Silk & Barry Goldman
http://articles.latimes.com/2013/apr/07/opinion/la-oe-0407-silk-ring-theory-20130407

13. Recognize That Yes, You’re Going to Do it Wrong and 14. Apologize Without Caveats”
30 Ways to Be a Better Ally, by Jamie Utt
http://everydayfeminism.com/2014/01/30-ways-to-be-a-better-ally-in-2014/

“We Center The Voice and Leadership of the Survivor and Oppressed Communities.”
Being An Ally/Building Solidarity, by Southerners On New Ground (S.O.N.G.)
http://southernersonnewground.org/wp-content/uploads/2012/12/SONG-Being-An-Ally-Building-Solidarity.pdf

“Create and Share Art, Support People with Disabilities”
26 Ways to Be in the Struggle Beyond the Streets, by Anderson, Barett, Dixon, Garrido, Kane, Nancherla, Narichania, Narasimham, Rabiyah and Richart
https://issuu.com/nlc.sf.2014/docs/beyondthestreets_final

To those who feel afraid or hurt after the election

For many of us, these are frightening and uncertain times. We at Portland Psychotherapy want to make a declaration of support to the millions of people around the nation and here in Portland that have been targeted, oppressed, attacked, or silenced and to those who feel fearful of what may come.  Portland Psychotherapy does not endorse discrimination in any form and is invested in ensuring the safety of all members of our community.

If you feel marginalized, oppressed, angered, hurt, afraid, ashamed, or stigmatized, we want you to know you are welcome here.  You are all part of the community we love and serve. This is a safe place for you to speak and to be heard. We value you.

The Staff of Portland Psychotherapy

New resource: a dictionary of terms commonly used in transgender and gender nonconforming communities

New resource: a dictionary of terms commonly used in transgender and gender nonconforming communities

APA has a new set of guidelines for psychologists working with transgender and gender nonconforming people (TGNC). In an appendix to those guidelines, APA included a very useful index defining many of the terms used within the TGNC community. Terminology of this sort is rapidly evolving and it can be difficult to stay abreast of it all. The index APA included in its guidelines is a helpful resource as psychologists strive towards treating others in a respectful and culturally competent way. For example, the term “transgender” has rapidly become part of American lexicon, especially since Caitlyn Jenner told her story in Vanity Fair magazine earlier this summer. However, although I’m familiar with the term, I’ve never heard the term “cisgender” used in the popular media. The APA terminology index defines “cisgender” as “An adjective used to describe a person whose gender identity and gender expression align with sex assigned at birth; a person who is not TGNC.” Only using a term to describe one experience/group implies that those in that group are “not the norm”; you’re either transgender or you’re “normal.” By knowing and using terms like cisgender to describe people whose experience isn’t that of those in the TGNC community, we make a small but important statement affirming the equality of all experiences of gender identity. If you’re interested in updating your knowledge of terms commonly used in the TGNC community, go to the appendix of the APA document.

Jenna LeJeune, Ph.D

Author: Jenna LeJeune, Ph.D

Jenna is a clinical psychologist who specializes in working with people who struggle with relationship and intimacy difficulties and with those who have a trauma history. Her research focuses on developing compassion-based interventions targeting stigma, shame, and chronic self-criticism.

APA’s new guidelines for psychological practice with transgender and gender nonconforming people: A brief summary

APA’s new guidelines for psychological practice with transgender and gender nonconforming people: A brief summary

There is great news coming out of APA this week. (Finally, some good news coming out of APA!) The APA Council of Representatives has finally approved a set of guidelines for psychologists working with transgender and gender nonconforming people (TGNC).  You can read the entire 55 page document here and it is certainly on my “to read” list as well. However, given how important this is and given the fact that my “to read” list is dauntingly long at this point, I wanted to make sure I was familiar with at least the main guidelines until I can have time to read the entire document. And so, I created this cheat sheet of the 16 guidelines outlined in the document.  So if your “to read” list is like mine, here is a summary of the APA guidelines on working with TGNC people.

APA Guidelines for Psychological Practice with Transgender and

Gender Nonconforming People

Guideline 1. Psychologists understand that gender is a non-binary construct that allows for a range of gender identities and that a person’s gender identity may not align with sex assigned at birth.

Guideline 2. Psychologists understand that gender identity and sexual orientation are distinct but interrelated constructs.

Guideline 3. Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people.

Guideline 4. Psychologists are aware of how their attitudes about and knowledge of gender identity and gender expression may affect the quality of care they provide to TGNC people and their families.

Guideline 5. Psychologists recognize how stigma, prejudice, discrimination, and violence affect the health and well-being of TGNC people.

Guideline 6. Psychologists strive to recognize  the influence  of  institutional  barriers  on  the  lives of TGNC people  and  to assist in  developing TGNC-affirmative  environments.

Guideline 7. Psychologists understand the need to promote social change that reduces the negative effects of stigma on the health and well-being of TGNC people.

Guideline 8. Psychologists working with gender questioning and TGNC youth understand the different developmental needs of children and adolescents and that not all youth will persist in a TGNC identity into adulthood.

Guideline 9. Psychologists strive to understand both the particular challenges that TGNC elders experience and the resilience they can develop.

Guideline 10. Psychologists strive to understand how mental health concerns may or may not be related to a TGNC person’s gender identity and the psychological effects of minority stress.

Guideline 11. Psychologists recognize that TGNC people are more likely to experience positive life outcomes when they receive social support or trans-affirmative care.

Guideline 12. Psychologists strive to understand the effects that changes in gender identity and gender expression have on the romantic and sexual relationships of TGNC people.

Guideline 13. Psychologists seek to understand how parenting and family formation among TGNC people take a variety of forms.

Guideline 14. Psychologists recognize the potential benefits of an interdisciplinary approach when providing care to TGNC people and strive to work collaboratively with other providers.

Guideline 15. Psychologists respect the welfare and rights of TGNC participants in research and strive to represent results accurately and avoid misuse or misrepresentation of findings.

Guideline 16. Psychologists seek to prepare trainees in psychology to work competently with TGNC people.

American Psychological Association. (2015). Guidelines for Psychological Practice with Transgender and Gender Nonconforming People. Retrieved from http://www.apa.org/practice/guidelines/transgender.pdf.

UPCOMING TRAINING EVENTS


Acceptance & Commitment Therapy – An Experiential & Practical Introduction

Jason Luoma, PhD and Jenna LeJeune, PhD
November 13th and 14th, 2021 from 8:30am-4:30pm
at Hilton Garden Inn Portland Airport
This two-day in-person workshop provides a thorough overview of the theory, principles, and techniques of Acceptance and Commitment Therapy. It is intended for those who are relatively new to ACT and for those who have done some reading on their own about ACT but who may not have had the opportunity to participate in more experiential learning, observe models, or receive feedback while using the ACT model. Read More.


Ethical & Legal Considerations in Psychedelic Integration Therapy

Brian Pilecki, PhD and Jason Luoma, PhD
November 19th, 2021 from 9am-11am

There is an increasing demand from clients seeking therapeutic support in their personal use of psychedelics. However, many clinicians interested in psychedelic preparation and integration are unsure as to how to provide these services as psychedelics mostly remain illegal. In this workshop, we will outline legal and ethical frameworks relevant to providing therapy to clients around their personal use of psychedelics, as well as describe how harm reduction approaches are suitable for this developing clinical area. Read More.


De-Mystifying Self-As-Context in ACT: Practical Strategies for Clients

Brian Pilecki, PhD and Kati Lear, PhD
December 3rd, 2021 from 12pm-1:30pm

This workshop will outline how self-as-context can be used to conceptualize commonly discussed topics in therapy such as self-esteem, confidence, identity, and inner conflict. Participants will learn how to flexibly practice practical self-as-context interventions that can be used with clients, as well as have a chance to practice newly learned skills through structured role-play exercises in breakout groups. Read More.


Values in Therapy: An Intro to Working with Values from an ACT Perspective

Jenna LeJeune, PhD
January 21, 2022 from 12pm-2:00pm

This workshop will provide a theoretical and conceptual overview of values from a contextual behavioral science perspective. We will cover the “what”, “why”, “when”, and “how” of values within ACT. While we will also provide an overview of various values exercises and measures that can be used with clients, the emphasis in this workshop will be on providing a foundational framework that will help clinicians approach values work from a functional perspective rather than a primarily technique-focused approach. Read More.



Culturally Responsive Therapy: How to Apply Anti-Racist Values in Session

Christy Tadros, LPCC and RaQuel Neal, LCSW
February 4th, 2022 from 1:30pm-4:45pm
and February 5th from 9:00am-12:00pm

This 2 day 6-hour training will help therapists develop their ability to support clients from a different racial background than them, with a particular focus on Black, Indigenous and People of Color. Through a multicultural social justice framework, it will integrate research and clinical experience to teach a therapeutic model for rapport building, assessment, and treatment. This model is not a rigid therapeutic modality, but provides a contextual lens to build a strong, culturally grounded therapeutic relationship. It is a flexible model and can align with many therapeutic modalities, including a contextual behavioral approach to therapy. Read More.


Truffle Hunting: Bringing Values to Life in the Therapy Room

Jenna LeJeune, PhD
February 25, 2022 from 12pm-2:00pm

This brief workshop is designed to help clinicians deepen their values work with clients by shifting the focus from the content of values conversations to the quality of those conversation. By listening for and deepening the qualities of effective values conversations participants will get a taste for how more experiential and relationally-based values work can supercharge therapy. Participants will have opportunities to both observe demonstrations and practice in small groups with the benefit of feedback. Read More.


Values Prototyping: Using Action to Help Clients Explore Their Values

Jenna LeJeune, PhD
March 18, 2022 from 12pm-2:00pm

This workshop will focus on one specific experiential tool called “values prototyping” that helps clients learn more about their values through engaging in intentional valuing. As participants will hopefully already have a solid foundation of some of the core concepts of the values process in ACT, this workshop will dive right in on how to use values prototyping to help clients learn more about what they would choose to value in their life. You will have the chance to practice developing a values prototype in small groups with the benefit of feedback, so that by the end of the workshop you will be able to use this tool in your work with clients. Read More.


The Invitation to Change Approach: Helping Families Affected by Addiction

Jeff Foote, PhD and Cordelia Kraus, LPC, CADC 1, certified CRAFT clinician
May 13th and 14th, 2022 from 9:00am-5:00pm
at University of Portland, Terrace Room
This two-day in-person workshop will provide skills training for professionals focused on the process of working with clients who have a loved one struggling with substance use issues. The Invitation to Change Approach draws on CRAFT (Community Reinforcement and Family Training), MI (Motivational Interviewing), and ACT (Acceptance and Commitment Therapy) to provide a compassionate and collaborative way of working with the families and concerned significant others of people who struggle with substance use. Read More.


Therapy and Research in Psychedelic Science (TRIPS) Seminar Series

Second Friday of each month from 12:00 PM – 1:00 PM (PT)

TRIPS is an online seminar series that hosts speakers discussing science-informed presentations and discussions about psychedelics to educate healthcare professionals. This series was created to guide healthcare providers and students preparing to be professionals towards the most relevant, pragmatic, and essential information about psychedelic-assisted therapy, changing legal statuses, and harm reduction approaches in order to better serve clients and communities. This seminar series is a fundraiser for our clinical trial of MDMA-assisted psychotherapy for social anxiety disorder that Portland Psychotherapy investigators are preparing for and starting in the Fall of 2021. All proceeds after presenter remuneration will go to fund this clinical trial. Read more.

November 12th, 2021Psychedelic Research: Implications for Palliative Care and End-of-Life Existential Distress with Anthony Bossis, Ph.D.

December 10th, 2021Implementing Culturally-Attuned & Anti-Racist Psychedelic Therapy: Impact over Intention with Jamilah R. George, M.Div., M.S.

January 14th, 2022Psilocybin-Assisted Therapy of Major Depressive Disorder using Acceptance and Commitment Therapy as a Therapeutic Frame with Jordan Sloshower, MD, MSc

February 11th, 2022 – Drug-Drug Interactions Between Psychiatric Medications and MDMA or Psilocybin with Aryan Sarparast, MD