Homework Assignments and Handouts for LGBTQ+ Clients: A Mental Health and Counseling Handbook 0367542692, 9780367542696

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Homework Assignments and Handouts for LGBTQ+ Clients: A Mental Health and Counseling Handbook
 0367542692, 9780367542696

Table of contents :
Cover
Half Title
Title Page
Copyright Page
Dedication Page
Contents
Foreword
Introduction
SECTION I Homework, Handouts, and Activities for the Coming-Out Process across the Life Span
1. A Pet-Assisted Intervention during Coming-Out Experiences
2. Assisting Individuals in Coming Out in Later Life as Lesbian, Gay, or Bisexual
3. Transgender Teens and Gender-Identity Disclosure
4. Assisting Youth with Disclosing Their Sexual Orientation and/or Gender Identity Using an Ecomap
5. Must Be the Music: Musical Autobiography and Critical Lyric Analysis
6. Cinematherapy for LGBT Clients
7. How Does God See Me? A Reflective Exercise
SECTION II Homework, Handouts, and Activities for Managing Oppression and Building Resilience
8. Survival in an Unjust World: A Tool for Coping with Multiple Forms of Oppression
9. Managing the Intersections: A Narrative Approach to Guiding Queer People of Color in Navigating Multiple Oppressions
10. A Lovingkindness Meditation to Heal from Heterosexism, Transphobia, and Other Forms of Oppression
11. From Stress to Strength: A Group Intervention for Processing Minority Stress Experiences with Transgender and Gender-Nonconforming Individuals
12. Exploring Multiple Marginalized Identities in LGBT Clients of Color
13. Somos Latinx: Exploring Cultural Values of Sexually and Gender-Diverse Latinx Clients
14. Building Resilience with Clients Who Face Multiple Forms of Oppression
15. Building a Stronger Advocacy Role for Older LGBT+ Adults in Nursing Home Settings
16. A Toolkit for Collaborative Safety and Treatment Planning with Transgender Youth of Color
17. Healing from Heterosexism: An Empirically Based Exercise for Processing Heterosexist Experiences
18. At the Intersection of the Autism Spectrum and Sexual and Gender Diversity: Case Studies for Use with Clinicians and Clients
19. Clinical Work with LGBTQ Asylum Seekers
20. Value-Driven Exploration of Intersections between Sexual and Religious Identity
SECTION III Homework, Handouts, and Activities for Relationships
21. Exploring and Navigating Sexual Desire in Relationships
22. Intimate Partner Violence: Initial Interventions for LGBTQ Clients
23. Transgender Youth and Healthy Relational Skills
24. Two Stars and a Wish: Termination Activities for Groups with Sexual- and Gender-Identity Diverse Clients
25. The Quadrant Exercise of Relationship Exploration for Sexual- and Gender-Identity Diverse Clients
26. Negotiating Information and Communication Technologies with Sexual and Gender Minority Youth and Young Adults
27. BDSM Exploration and Communication within LGBT Relationships
SECTION IV Homework, Handouts, and Activities for LGBTQ Parenting and Family Therapy
28. Transgender-Affirmative Parenting: Practicing Pronouns
29. Family Mapping Exercises (FMEs) for Adults and Children in LGBTQ-Parented Families
30. Expanding Binary Thinking: A Reflective Activity for Parents and Caregivers of Transgender and Gender-Expansive Youth
31. Parents of Transgender Teens and the Initial Disclosure Process
32. Maintaining the Family Unit When an Adolescent Family Member Comes Out as a Sexual or Gender Minority
33. Empty-Chair Work for Coping with Heterosexist and/or Transphobic Family Rejection
34. Addressing Blended Family and Trauma Issues with Sexual and Gender Minority Parents
35. An Informative Intervention for Parents and Caregivers of Transgender and Gender-Nonbinary Children and Adolescents
36. Circles of Outness: Systemic Exploration of Disclosure Decisions in Mixed-Orientation Relationships
SECTION V Homework, Handouts, and Activities for Gender and Sex Identity Exploration
37. The Matrix for Sexuality and Gender: My Sexual and Gendered Self in the World of Sexual and Gender Diversity
38. Exploring Gender Identity with a Photo Diary
39. Creative Interventions for Traumatized Transgender and Gender-Nonconforming (TGNC) Youth
40. The Importance of Language: Creating Nonbinary Assessment Forms That Reflect a Full Range of Gender Identities
41. Mapping of Desires and Gender: Explorations at the Intersections
42. Asexuality: An Introduction for Questioning Clients
43. Inhabiting Our Bodies: Working with Gender Dysphoria in Transgender and Gender-Nonbinary Children and Adults through Body Maps
44. Using Expressive Art Therapy with LGBTQ Youth: A Picture Is Worth a Thousand Words
45. An Eight-Week Identity Exploration Group for Transgender and Gender-Nonconforming Individuals
46. Using Mindfulness to Enhance Identity Integration for LGBTQ clients
47. Managing Religious and Sexual Identity Intersections
48. Rose as a Name Is So Much Sweeter: Navigating the Name-Change Process with Transgender and Gender Nonbinary Clients
49. The Aging Transgender Client: Mapping the Acceptance of Experience
SECTION VI Homework, Handouts, and Activities for Substance Use Disorders
50. A Relapse-Prevention Intervention for LGBTQ Clients with Substance Use Disorders: The C3PO
51. Exploring the Concept of Honesty with Transgender Clients in Recovery from Addiction
52. Using Art Therapy to Address Body Dysphoria, Body Image, and Eating Concerns with Trans and Nonbinary Clients
53. The Inextricable Relationship between Marginalization and Addiction: Bridging the Gap through Charting
54. LGB Addiction Recovery and Community Membership
SECTION VII Homework, Handouts, and Activities for Career, Employment, and Education Issues
55. Job Search and Career Resources for LGBT People
56. Sexual-Identity Management in the Job-Search Process with Lesbian and Gay Clients
57. Strategies for Helping LGBTQ Clients Address Discrimination in the Workplace
58. Exploring Values in Career Exploration with Adolescent LGBTQ Clients
59. The College Search: Campus Climate Checklist
60. Exploring Career Decision-Making Self-Efficacy with Sexual and Gender Minority College Students
SECTION VIII Homework, Handouts, and Activities for Use in Outreach Programming and Training Workshops
61. Intersecting Identities: A Self-Reflective Activity for Outreach Programming and Workshops
62. Building Community on Campus: A Workshop on Sharing and Support for LGBTQ College Students
63. Outreach Ally-Training Activities
64. Reflections of Assumptions
65. The Papercut Activity: Understanding the Subtle and Ongoing Effects of Microaggressions
66. Examining Our Blind Spots: Considerations in Working with Lesbian, Gay, and Bisexual Clients with Disabilities
67. Outreach on a College Campus: Understanding the Campus Climate
68. Understanding Me, You, and LGBTQ: An Outreach Workshop for General Audiences and Allies
69. Living in Intersectional Spaces: Exploration of Social Identities in the LGBT Community
70. Creating Consciousness to Create Connection: Attending to Biases When Working with Queer Victim-Survivors of Sexual Violence
71. Addressing Anti-Trans Prejudice: Decoding the Gender Matrix
About the Editors and Contributors
Index

Citation preview

HOMEWORK ASSIGNMENTS

AND HANDOUTS

FOR LGBTQ+ CLIENTS

Featuring over 70 affirming interventions in the form of homework assignments, handouts, and activities, this comprehensive volume helps novice and experienced counselors support LGBTQ+ community members and their allies. Each chapter includes an objective, indications and contraindications, a case study, suggestions for follow-up, professional resources, and references. The book’s social justice perspective encourages counselors to hone their skills in creating change in their communities while helping their clients learn effective coping strategies in the face of stress, bullying, microaggressions, and other life challenges. The volume also contains a large section on training allies and promoting greater cohesion within LGBTQ+ communities. Counseling and mental health services for LGBTQ+ clients require between-session activities that are clinically focused, evidence based, and specifically designed for one or more LGBTQ+ sub-populations. This handbook gathers together the best of such LGBTQ+ clinically focused material. As such, it will appeal both to students learning affirmative LGBTQ+ psychotherapy/counseling and to experienced practitioners. Offering practical tools used by clinicians worldwide, the volume is particularly useful for courses in clinical and community counseling, social work, and psychology. Those new to working with LGBTQ+ clients will appreciate the book’s accessible foundation to guide interventions. Joy S. Whitman, PhD, is a licensed professional counselor (LPC) in Missouri and a licensed clinical professional counselor (LCPC) in Illinois. She is clinical professor at The Family Institute of Northwestern University in the master’s [email protected] program. A past president of ALGBTIC, Joy serves as a board member of The International Academy for LGBT+ Psychology and Related Fields. She maintains a private practice in Missouri. Cyndy J. Boyd, PhD, is a licensed psychologist, consultant, and psychotherapist in private practice in Philadelphia. She is Director of Training at Counseling and Psychological Services at the University of Pennsylvania. She has served on the APA Commission on Accreditation, the board of directors of ALGBTIC of the American Counseling Association, the supervision and training section of Division 17 of the American Psychological Association (APA), and the Association of Counseling Center Training Agencies.

“Overall this is a very strong guidebook for helping professionals who work with LGBTQ+ clients. The editors should be applauded for organizing each facet of this massive notebook into a cohesive book.” — Michael P. Chaney, Oakland University “This text stimulates clinicians to think of the many questions they should ask to ensure that their counseling sessions are LGBTQQ+ affirming. I believe the drive to ask and answer even more questions about queer and trans mental health therapy is this text’s ultimate contribution to the discipline and the profession. It provides resources that we might not have even realized that we need.” — Anneliese Singh, PhD, University of Georgia “The resources in this book represent a significant source of activities for LGBTQ+ clients regardless of their social location. Authors of the homework exercises have been very thoughtful in the design of their activities, clearly identifying when an activity would not be indicated. Many activities are devoted to transgender and nonbinary clients. If you work with LGBTQ+ clients, you need this in your library!” — lore m. dickey, PhD, North Country HealthCare “Joy Whitman and Cyndy Boyd share a queer treasure trove of innovative and practical exercises for use with LGBTQ+ clients. This must-have resource brings together top clinicians and scholars who share therapeutic best practices for affirming and supporting queer and trans clients across a variety of contexts and issues.” — David P. Rivera, PhD, Queens College, City University of New York “Homework Assignments and Handouts for LGBTQ+ Clients is a welcome addition to any mental health training program, or post-master’s advanced seminar in counseling members of the LGBTQ+ community. [It provides] intriguing exercises and interventions that can supplement empathic treatment planning for best practice with a focus on intersectionality in counseling. A solid, engaging addition to the literature.” — Catherine Roland, EdD, LPC, NCC, past president, American Counseling Association “Doctors Whitman and Boyd have woven together a revolutionary resource that is desperately needed by mental health professionals. This incredibly creative compilation of exercises not only applies effortlessly to allies and members of the LGBTQ+ communities but also cuts across issues related to lifespan milestones and the intersectionality of multiple identities. I know of no other resource in existence—buy it, use it in the class­ room, use it with your clients and, dare I say it, use it with yourself. Bravo!” — Colleen R. Logan, PhD, LPC-S, Southern Methodist University

HOMEWORK ASSIGNMENTS AND HANDOUTS FOR LGBTQ+ CLIENTS

A MENTAL HEALTH AND COUNSELING HANDBOOK EDITED BY

JOY S. WHITMAN AND CYNDY J. BOYD

First published 2021 by Routledge 52 Vanderbilt Avenue, New York, NY 10017 and by Routledge 2 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN Routledge is an imprint of the Taylor & Francis Group, an informa business © 2021 selection and editorial matter, Joy S. Whitman and Cyndy J. Boyd; individual chapters, the contributors Te right of Joy S. Whitman and Cyndy J. Boyd to be identifed as the authors of the editorial material, and of the authors for their individual chapters, has been asserted in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. Te purchase of this copyright material confers the right on the purchasing institution to photocopy pages which bear the photocopy icon and copyright line at the bottom of the page. No other part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without prior permission in writing from the publisher. Trademark notice: Product or corporate names may be trademarks or registered trademarks and are used only for identifcation and explanation without intent to infringe. Publisher’s Note Tis book has been prepared from camera-ready copy provided by Ciano Design. Library of Congress Cataloging-in-Publication Data Names: Boyd, Cynthia J., editor. | Whitman, Joy S., editor. Title: Homework assignments and handouts for LGBTQ+ clients : a mental health and counseling handbook / edited by Joy S. Whitman and Cyndy J. Boyd. Description: New York, NY : Routledge, 2021. | Includes bibliographical references and index. Identifers: LCCN 2020019452 (print) | LCCN 2020019453 (ebook) | ISBN 9780367542726 (hardback) | ISBN 9780367542696 (paperback) | ISBN 9781003088639 (ebook) Subjects: LCSH: Sexual minorities—Mental health—Problems, exercises, etc. | Sexual minorities—Counseiing of.—Problems, exercises, etc. | Psychotherapy—Problems, exercises, etc. | Counseling—Problems, exercises, etc. Classifcation: LCC RC451.4.G39 H6572 2021 (print) | LCC RC451.4.G39 (ebook) | DDC 616.890086/6—dc23 LC record available at https://lccn.loc.gov/2020019452 LC ebook record available at https://lccn.loc.gov/2020019453 ISBN: 978-0-367-54272-6 (hbk) ISBN: 978-0-367-54269-6 (pbk) ISBN: 978-1-003-08863-9 (ebk) Typeset in Minion Pro by Ciano Design

This book is dedicated to Bill Cohen and Patricia Chalem Kupelian. Bill, as the former publisher and editor-in-chief of Harrington Park Press, was the creative force behind this book and a champion of LGBTQ+ education and psychology. Without his gentle nudge, we would not have recreated the original book and landed on this current and more inclusive one. We miss his energy, wit, and belief in ensuring LGBTQ+ scholarship was at the forefront of social and behavioral sciences. Our deep gratitude as well to Patricia. Without her legal counsel and advocacy, this book would have never been published. When we reached a stopping point because of Bill’s unexpected passing, Patty’s generosity, creativity, and talent led the way. Patty, we do not know how to thank you enough for the hours you dedicated to this project and your dogged pursuit for what is right and fair. Thank you from the bottom of our hearts.

CO NTEN T S Foreword Anneliese Singh

xii

Introduction Joy Whitman and Cyndy Boyd

xiv

SECTION I Homework, Handouts, and Activities for the Coming-Out Process across the Life Span 1. A Pet-Assisted Intervention during Coming-Out Experiences Michael P. Chaney and Kathryn L. Pozniak

1 4

2. Assisting Individuals in Coming Out in Later Life as Lesbian, Gay, or Bisexual Vincent M. Marasco and Randall L. Astramovich

14

3. Transgender Teens and Gender-Identity Disclosure Laura R. Haddock

22

4. Assisting Youth with Disclosing Their Sexual Orientation and/or Gender Identity Using an Ecomap Richard A. Brandon-Friedman and M. Killian Kinney

30

5. Must Be the Music: Musical Autobiography and Critical Lyric Analysis Kiahni Nakai

40

6. Cinematherapy for LGBT Clients Jennifer Lancaster and Angelica Terepka

52

7. How Does God See Me? A Reflective Exercise Hannah B. Bayne and Anita A. Neuer Colburn

60

SECTION II Homework, Handouts, and Activities for Managing Oppression and Building Resilience

67

8. Survival in an Unjust World: A Tool for Coping with Multiple Forms of Oppression Jessica Chavez

70

9. Managing the Intersections: A Narrative Approach to Guiding Queer People of Color in Navigating Multiple Oppressions Jayleen Galarza

76

10. A Lovingkindness Meditation to Heal from Heterosexism, Transphobia, and Other Forms of Oppression Eve M. Adams, Tracie L. Hitter, and Virginia Longoria

82

11. From Stress to Strength: A Group Intervention for Processing Minority Stress Experiences with Transgender and Gender-Nonconforming Individuals Caroline Carter and Diane Sobel

90

12. Exploring Multiple Marginalized Identities in LGBT Clients of Color Vanessa Dabel

100

13. Somos Latinx: Exploring Cultural Values of Sexually and Gender-Diverse Latinx Clients Zully A. Rivera Ramos, Amanda Lawson-Ross, and Carlos Hernández

108

14. Building Resilience with Clients Who Face Multiple Forms of Oppression Kristin N. Bertsch

124

15. Building a Stronger Advocacy Role for Older LGBT+ Adults in Nursing Home Settings

Angela Schubert

132

16. A Toolkit for Collaborative Safety and Treatment Planning with Transgender Youth of Color

Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

140

17. Healing from Heterosexism: An Empirically Based Exercise for Processing Heterosexist Experiences

Kathleen M. Collins, Meredith R. Maroney, Tangela S. Roberts,

Brianna M. Wadler, and Heidi M. Levitt

150

18. At the Intersection of the Autism Spectrum and Sexual and Gender Diversity: Case Studies for Use with Clinicians and Clients

Eva Mendes and Meredith R. Maroney

158

19. Clinical Work with LGBTQ Asylum Seekers Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne

168

20. Value-Driven Exploration of Intersections between Sexual and Religious Identity Angelica Terepka and Jennifer Lancaster

176

SECTION III

Homework, Handouts, and Activities for Relationships

183

21. Exploring and Navigating Sexual Desire in Relationships Sara K. Bridges

186

22. Intimate Partner Violence: Initial Interventions for LGBTQ Clients Sabina de Vries

194

23. Transgender Youth and Healthy Relational Skills Luke R. Allen

206

24. Two Stars and a Wish: Termination Activities for Groups with Sexual- and Gender-Identity Diverse Clients

Theodore R. Burnes

212

25. The Quadrant Exercise of Relationship Exploration for Sexual- and Gender-Identity Diverse Clients

Theodore R. Burnes

218

26. Negotiating Information and Communication Technologies with Sexual and Gender Minority Youth and Young Adults

Nathaniel Amos

224

27. BDSM Exploration and Communication within LGBT Relationships Kandice H. van Beerschoten

234

SECTION IV

Homework, Handouts, and Activities for LGBTQ Parenting and Family Therapy

243

28. Transgender-Affirmative Parenting: Practicing Pronouns Jennifer M. Gess

246

29. Family Mapping Exercises (FMEs) for Adults and Children in LGBTQ-Parented Families

Fiona Tasker, Maeve Malley, and Pedro Alexandre Costa

254

30. Expanding Binary Thinking: A Reflective Activity for Parents and Caregivers of Transgender and Gender-Expansive Youth

Rebekah Byrd and Laura Boyd Farmer

264

31. Parents of Transgender Teens and the Initial Disclosure Process Laura R. Haddock and Hilary Meier

270

32. Maintaining the Family Unit When an Adolescent Family Member Comes Out as a Sexual or Gender Minority

Susannah C. Coaston, Patia Tabar, and Lori Barrett

280

33. Empty-Chair Work for Coping with Heterosexist and/or Transphobic Family Rejection

Cara Herbitter and Heidi M. Levitt

288

34. Addressing Blended Family and Trauma Issues with Sexual and Gender Minority Parents

Anthony Zazzarino, Veronica M. Kirkland, and Jenae Thompson

298

35. An Informative Intervention for Parents and Caregivers of Transgender and Gender-Nonbinary Children and Adolescents

Heather Kramer

306

36. Circles of Outness: Systemic Exploration of Disclosure Decisions in Mixed-Orientation Relationships

Mary R. Nedela, M. Evan Thomas, and Michelle M. Murray

314

SECTION V

Homework, Handouts, and Activities for Gender and Sex Identity Exploration

321

37. The Matrix for Sexuality and Gender: My Sexual and Gendered Self in the World of Sexual and Gender Diversity

K. Jod Taywaditep

326

38. Exploring Gender Identity with a Photo Diary M. Killian Kinney and Richard A. Brandon-Friedman

340

39. Creative Interventions for Traumatized Transgender and Gender-Nonconforming (TGNC) Youth

Alexandra M. Rivera and Crystal Morris

348

40. The Importance of Language: Creating Nonbinary Assessment Forms That Reflect a Full Range of Gender Identities Andrew Suth and Sorrel Rosin

354

41. Mapping of Desires and Gender: Explorations at the Intersections Shannon Solie

366

42. Asexuality: An Introduction for Questioning Clients Emily M. Lund, Bayley A. Johnson, Christina M. Sias, and Lauren M. Bouchard

376

43. Inhabiting Our Bodies: Working with Gender Dysphoria in Transgender and Gender-Nonbinary Children and Adults through Body Maps

Natasha Distiller

384

44. Using Expressive Art Therapy with LGBTQ Youth: A Picture Is Worth a Thousand Words

Jean Georgiou

392

45. An Eight-Week Identity Exploration Group for Transgender and Gender-Nonconforming Individuals

Julie M. Mullany

400

46. Using Mindfulness to Enhance Identity Integration for LGBTQ clients Marilia S. Marien

410

47. Managing Religious and Sexual Identity Intersections Matt Zimmerman

420

48. Rose as a Name Is So Much Sweeter: Navigating the Name-Change Process with Transgender and Gender Nonbinary Clients

Cadyn Cathers

426

49. The Aging Transgender Client: Mapping the Acceptance of Experience Dorian Kondas

436

SECTION VI

Homework, Handouts, and Activities for Substance Use Disorders

445

50. A Relapse-Prevention Intervention for LGBTQ Clients with Substance Use Disorders: The C3PO

Michael P. Chaney and Fiona D. Fonseca

448

51. Exploring the Concept of Honesty with Transgender Clients in Recovery from Addiction

Mia Ocean and George Stoupas

456

52. Using Art Therapy to Address Body Dysphoria, Body Image, and Eating Concerns with Trans and Nonbinary Clients

Jeannine Cicco Barker

464

53. The Inextricable Relationship between Marginalization and Addiction: Bridging the Gap through Charting

John J. S. Harrichand and Christian D. Chan

472

54. LGB Addiction Recovery and Community Membership George Stoupas and Mia Ocean SECTION VII Homework, Handouts, and Activities for Career, Employment, and Education Issues

482

489

55. Job Search and Career Resources for LGBT People Anita A. Neuer Colburn

492

56. Sexual-Identity Management in the Job-Search Process with Lesbian and Gay Clients Suzanne M. Dugger and Jason A. Owens

498

57. Strategies for Helping LGBTQ Clients Address Discrimination in the Workplace Randall L. Astramovich and Matthew J. Wright

508

58. Exploring Values in Career Exploration with Adolescent LGBTQ Clients Jane E. Rheineck and Tracy Peed

514

59. The College Search: Campus Climate Checklist Suzanne M. Dugger, Carina Lindsey, and Jason A. Owens

522

60. Exploring Career Decision-Making Self-Efficacy with Sexual and Gender Minority College Students Marilia Marien and Yuhong He

534

SECTION VIII Homework, Handouts, and Activities for Use in Outreach Programming and Training Workshops

543

61. Intersecting Identities: A Self-Reflective Activity for Outreach Programming and Workshops Laura Boyd Farmer and Christian D. Chan

546

62. Building Community on Campus: A Workshop on Sharing and Support for LGBTQ College Students Alaina Spiegel

552

63. Outreach Ally-Training Activities Brandy L. Smith

558

64. Reflections of Assumptions Jayleen Galarza and Matthew R. Shupp

566

65. The Papercut Activity: Understanding the Subtle and Ongoing Effects of Microaggressions Jeanne L. Stanley

574

66. Examining Our Blind Spots: Considerations in Working with Lesbian, Gay, and Bisexual Clients with Disabilities Michelle M. Murray

580

67. Outreach on a College Campus: Understanding the Campus Climate Batsirai Bvunzawabaya and Matthew LeRoy

588

68. Understanding Me, You, and LGBTQ: An Outreach Workshop for General Audiences and Allies

Alaina Spiegel

596

69. Living in Intersectional Spaces: Exploration of Social Identities in the LGBT Community

Matthew LeRoy and Batsirai Bvunzawabaya

604

70. Creating Consciousness to Create Connection: Attending to Biases When Working with Queer Victim-Survivors of Sexual Violence

Deborah O’Neill and Laura Kay Collins

610

71. Addressing Anti-Trans Prejudice: Decoding the Gender Matrix Soumya Madabhushi

624

About the Editors and Contributors

634

Index

656

FORE WO R D For so many reasons, it’s a true honor to write this foreword to Homework Assignments and Handouts for LGBTQ+ Clients: A Mental Health and Counseling Handbook. The first reason I am honored to write this fore­ word is that I remember vividly the first time I held the precursor to this text, The Therapist’s Notebook for Lesbian, Gay, and Bisexual Clients (2003), in my hands. I had just started my counseling psychology doctoral program at Georgia State University. I was so excited to begin my doctoral program because I was so looking forward to learning all about how to counsel LGBTQQ+ (lesbian, gay, bisexual, trans, queer, questioning, and more) persons. What I found instead, however, was a more general training curriculum that didn’t address how to work with queer and trans people in counseling, much less queer and trans folks who had intersectional identities of race or ethnicity, social class, gender, sexual orientation, nationality, disability, and more. I found often that as a very green counselor I was teaching myself how to take up coun­ seling interventions with queer and trans clients. Of course, I’d had a basic multicultural counseling course and an advanced one as well, but I felt desperate to find LGBTQQ+ training that brought to life some of the basic ideas we learned (e.g., heterosexism exists) about how we can support queer and trans clients who are healing from societal oppression. So, you can imagine that, amid the huge vacuum of training in my program on LGBTQQ+ issues at the time, laying my hands on The Therapist’s Notebook for Lesbian, Gay, and Bisexual Clients was a mentoring moment I will never forget. The second reason I am honored to write this fore­ word is that Cyndy Boyd and Joy Whitman became my mentors off the page through our shared member­ ship in the American Counseling Association (ACA). Yes, the gifts they gave me through their text were important, and having a guidebook that made queerand trans-affirming counseling real was quite astound­ ing at the time. However, the bonus I received from

their mentoring influence during my graduate studies— when I often felt isolated and alone as a queer coun­ selor—well, that was sacred space. Through their men­ toring, I was able to see how they both led in the Association for LGBT Issues in Counseling (ALGBTIC, a division of ACA), which also astounded me. Here were two powerful queer women who helped show me what advocating for women, people of color, and others within the margins of a mostly gay-white divi­ sion full of men “looked like.” As you work with this text, I know that you will be inspired by the group of activities that Joy and Cyndy have brought together for use with your queer and trans clients. At the same time, I hope you will find ways to engage in leader­ ship on behalf of the most marginalized communities within the LGBTQQ+ community. The third reason I am honored to write this fore­ word is that it offers an opportunity to celebrate the current affirming work with queer and trans clients. In the not-so-recent past, it was a fight to get profes­ sional counseling organizations to address queer and trans issues in counseling. We still have a long way to go in establishing a solid foundation of what queerand trans-affirming counseling really means when we are in sessions with LGBTQQ+ clients and when we are working for justice in queer and trans commu­ nities. It is also important to celebrate our successes, however, and this book is one of them. All eight sections of the book focus on queer- and trans-affirming counseling practice. Each section pro­ vides homework, handouts, and activities that solidly situate us as counselors in intersectional approaches to LGBTQQ+ counseling. Section I lays the founda­ tion for intersectionality by taking a life-span approach. You will find practical approaches that help you affirm and empower queer and trans clients, whether they are just coming to understand themselves later in life— or whether they were able to identify and honor their gender and sexual orientation identities earlier on as youth. In this life-span approach, you also will see how the contributors use creativity (e.g., pet-assisted

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

xii

interventions, ecomaps, music, and cinematherapy) to help counselors tap into the very emotional process that coming to understand one’s LGBTQQ+ identity in an unjust world entails. The chapters in Section II focus on building resil­ ience to anti-LGBTQQ+ oppression. I study queer and trans people of color’s resilience to discrimination, so it is very exciting to see that intersectionality is woven into this section, along with an advocacy focus (e.g., work with LGBTQQ+ asylum seekers, intersections of LGBTQQ+ identities and religion, LGBTQQ+ expe­ riences of autism). Section III continues this focus on intersectionality, with a special emphasis on LGBTQQ+ people who are developing relationships. How we as queer and trans communities decide to engage (or not to engage) in relationships is still an understudied topic, but this book provides a plethora of informa­ tion to assist counselors in helping their clients develop relational skills in adolescence, identifying ways to address intimate partner violence, and exploring the importance of BDSM for some LGBTQQ+ people. Section IV provides all the resources you wish had existed a long time ago to support your work with families. From the basics of pronouns and family map­ ping with LGBTQQ+ families to experiential chair work, this section is packed with interventions you can use right now to affirm and empower the families of queer and trans people. The chapters in Section V provide an opportunity to dive more deeply into identi­ ties of sex and gender. Again, a life-span and intersec­ tional perspective is built across these chapters, with the main goal of helping LGBTQQ+ clients explore their assigned sex and gender, as well as their identified sex and gender, with care, compassion, and tenderness. Many of these chapters use a longer intervention (e.g., eight-week identity exploration for trans and nonbi­ nary youth) or expressive arts to explore these impor­ tant identities in nonverbal ways. I am also excited to note that this section includes the nascent counseling research on the experiences of asexual people. Section VI addresses the realities of substance abuse disorders. This is such a very important topic, and the homework, handouts, and activities consider the very real oppression, and other complications, that queer and trans clients face when they seek recovery. This section offers chapters on relapse prevention,

disordered eating and body concerns, and the critical role of community building in recovery, to name just a few of the topics covered here. Section VII provides helpful resources on support­ ing queer and trans people who face job discrimina­ tion. It also offers information on finding college cam­ puses that are affirming. This section is particularly important because anti-LGBTQQ+ bias is often related not only to homelessness for LGBTQQ+ young peo­ ple but also to their career decisions. The text wraps up with Section VIII, which encourages you to take up outreach programming and training workshops in a variety of settings (e.g., school, college, commu­ nity). Like the other sections in this text, Section VIII emphasizes intersections of identity that are critically important for queer and trans clients. Ultimately, this text stimulates clinicians to think of the many questions they should ask to ensure that their counseling offices and sessions are LGBTQQ+ affirming. These questions include: • Who are the queer and trans people on the margins? • What intersectional identities must I understand to work most effectively and affirmatively with a par­ ticular queer or trans client? • How can I increase my own awareness of my privi­ lege and oppression identities and experiences as a mental health therapist? • How can I advocate further for the basic human rights of queer and trans clients from a wide vari­ ety of intersectional backgrounds? And, I believe, the drive to ask and answer even more questions about queer and trans mental health ther­ apy is this text’s ultimate contribution to the discipline and the profession. Yes, it provides resources that we might not have even realized that we need; but, beyond that, it compels, motivates, and excites us to expect even more of ourselves as providers of queer- and transaffirming therapy. Anneliese Singh, PhD, LPC University of Georgia Trans Resilience Project Georgia Safe Schools Coalition

Foreword xiii

IN T RO D U C T I O N In 2003 we published an edited book titled The Ther­ apist’s Notebook for Lesbian, Gay, and Bisexual Clients: Homework, Handouts, and Activities for Use in Psycho­ therapy. At the time, fewer LGBTQ+-specific resources were available for clinicians working with LGBT cli­ ents. Thus, many clinicians needed to translate prac­ tical interventions designed for people who identified as heterosexual and cisgender into affirming inter­ ventions for those who identified as LGBTQ+. At the time, the LGBTQ+ community had few rights or access to institutions and services such as marriage, adoption, parenting, military service, and health care. Much has changed since the turn of the century, and this book reflects the influences of the current sociopolitical context on the mental health and well­ ness of people with diverse sexual and gender identi­ ties. For example, more countries are recognizing mar­ riage equality, and there is a greater understanding and appreciation of the fluidity of sexual and gender identities. LGBTQ+ people throughout the world still experience many forms of violence and oppres­ sion, however, and the risk of violence to LGBTQ+ persons of color in the United States continues to be much higher than for those who identify as white. Additionally, current U.S. policies vacillate between granting and then removing rights for people who identify as transgender or non-cisgender. Therefore, clinicians need to continue helping their clients navi­ gate oppression, shape identity, and build resilience. The optimistic news is that research and experience show us that a validating support system can mitigate the negative mental health consequences of margin­ alization that is based on social identities. Another notable change in the last decade is that the terms that people use to describe their gender and sexual identities have multiplied exponentially. In fact, terminology is still expanding and constantly evolving. To reflect the diversity of the LGBTQ+ com­ munity and the wide variety of ways in which people are currently identifying, many different terms and

perspectives are used in this book. Given that identity exploration is a dynamic process, it is likely that many of the terms in this book will be less common in the near future as they are replaced by new descriptors and that some of the identity descriptions will feel more applicable to certain clients than to others. Dozens of mental health professionals have con­ tributed their expertise to this new collection of over seventy affirming interventions. By “affirming,” we mean an approach to therapy that embraces a positive view of LGBTQ+ identities and relationships and addresses the negative influences that discrimination and oppression based on sexual and gender identi­ ties have on the lives of LGBTQ+ clients. The book is organized into eight content areas: (1) coming out across the life span; (2) managing oppression and building resilience; (3) relationship concerns; (4) par­ enting and family therapy; (5) gender and sex identity exploration; (6) substance use disorders; (7) career, employment, and education issues; and (8) outreach programming and training workshops. Because there is overlap among the content areas, they can also inform one another, and clinicians can combine activ­ ities, handouts, and homework to tailor them to their clients’ specific concerns. Within the content areas, each chapter follows the same format. Each chapter begins with an objective, followed by a rationale for the activity solidly grounded in the research and in affir­ mative practices. Instructions clearly describe how to use the homework, handout, or activity; a brief vignette then provides an example of how the activity can be used. Each chapter closes with suggestions for followup, a brief section on contraindications, and a list of resources for clinicians and for clients. Each activity is formatted for easy copying and distribution. This emphasis on activities and homework assign­ ments provides a powerful tool for clinicians, as meta­ analyses of studies have shown that engagement in homework assignments does indeed produce a posi­ tive effect on therapy outcome (Beutler et al., 2004;

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xiv

Kazantzis, Deane, & Ronan, 2000). The use of activi­ ties outside sessions is so powerful because it broadens the scope of the work by encouraging the client to be less dependent on the therapist and by providing them with more opportunities to work toward their goals (Nelson, Castonguay, & Barwick, 2007). It has been used as an intervention successfully by clinicians since the first days of psychoanalysis, as Freud (1924) believed that patients should extend their work in therapy to everyday situations. Cognitive therapy approaches are most strongly associated with using homework as a central compo­ nent of the process (Ellis, 1962), but practitioners from many schools of thought find homework assignments to be valuable and relevant to their work. In fact, a sur­ vey of 827 psychologists from a variety of theoretical orientations, including 24 percent who identify as psy­ chodynamic, showed that homework is a widespread feature of therapy (Kazantzis, Lampropoulos, & Deane, 2005). The term homework may be defined and integrated differently depending on the background of the practitioner, and it can include things like the application of insights, journaling, or information gathering (Kazantzis & L’Abate, 2005). Readers will find many different forms of activities and homework presented in this book that can be tailored to a variety of different approaches and client populations. There are some factors that make the integration of homework more successful. L’Abate (1997) noted, for instance, that it must be practiced on a regular basis. Another important point is that the most powerful source of motivation is intrinsic to the client and driven by the client’s clear understanding of the benefits of engaging in the activity (Kazantzis & L’Abate, 2005). The rationales provided by the authors in this book in many ways can assist the clinician in conveying the potential benefits of the highlighted intervention. Since all clients have both gender and sexual iden­ tities as well as many other social identities, we have chosen to organize the sections of the book according to overarching themes rather than to separate chap­ ters according to specific targeted identities. Although some chapters do emphasize the needs of clients with certain identities, it is our intention that most chapters are applicable and generalizable to a multitude of

LGBTQ+ clients. We have aspired to be as inclusive of diversity as possible, and so chapters include explicit discussions about working with clients from different backgrounds and intersecting identities. Each chapter also discusses ethical guidelines and the need for culturally competent care. A social justice perspective is also evident throughout, because of our belief that clinicians should support the LGBTQ+ com­ munity by showing through example that they, them­ selves, attempt to create meaningful change in the communities within which LGBTQ+ individuals live, work, and learn. Therefore, while this book’s activities are designed to bolster coping strategies in individual clients, many activities also serve to identify and fortify their available supports and resources. We are very pleased to feature a large number of activities on pro­ viding training to enhance ally communities as well as to promote greater cohesion in LGBTQ+ communities. We have worked to make this book accessible to all clinicians no matter their training and experience. For more seasoned clinicians, the chapters and activ­ ities may offer innovative ways to approach their cli­ ents’ complex issues. For those just beginning to work with LGBTQ+ clients, the content provides a solid foundation to guide interventions and perspectives. The diverse topics apply to a variety of age groups, modalities, and settings, while also addressing many of the typical clinical issues relevant to LGBTQ+ clients. In addition, the activities in this book can be used by professionals who train others to counsel LGBTQ+ clients. The case studies included through­ out this book will be particularly useful in training. We are humbled by the contributors’ creativity, as well as their commitment to working with LGBTQ+ clients. We hope the book finds a permanent place on your bookshelf and in your classrooms and supports your work with LGBTQ+ clients. We also want to thank the graduate assistants who helped us with the book. Danica M. Rodriguez, Samantha Ruda, Emma Davidson, and Lyn Parsons were invaluable to our work, and we just wanted to say thanks. Joy Whitman Cyndy Boyd

Introduction

xv

References Beutler, L. E., Malik, M., Alimohamed, S., Harwood, T. M., Talebi, H., & Noble, S. (2004). Therapist variables. In M. J. Lambert (ed.), Bergin and Garfield’s handbook of psycho­ therapy and behavior change, 5th edition, 227–306. New York: John Wiley & Sons. Ellis, A. (1962). Reason and emotion in psychotherapy. Secaucus, NJ: Lyle Stuart. Freud, S. (1924). Inhibitions, symptoms and anxiety. In R. M. Hutchins (ed.), Great books of the Western world, 718–734. Chicago: Encyclopedia Britannica. Johnson, D., Sikorski, J., Savage, T. A., & Woitaszewski, S. A. (2014). Parents of youth who identify as transgender: An exploratory study. School Psychology Forum, 8 (1), 56. Kazantzis, N., Deane, F. P., & Ronan, K. R. (2000). Homework assignments in cognitive and behavioral therapy: A meta-analysis. Clinical Psychology: Science and Practice, 7, 189–202. Kazantzis, N., & L’Abate, L. (2005). Theoretical foundations. In N. Kazantzis, F. P. Deane., K. R. Ronan., & L. L’Abate (eds.), Using homework assignments in cognitive behavior therapy, 9–33. New York: Routledge.

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Introduction

Kazantzis, N., Lampropoulos, G. L., & Deane, F. P. (2005). A national survey of practicing psychologists’ use and atti­ tudes towards homework in psychotherapy. Journal of Consulting and Clinical Psychology, 73, 742–748. L’Abate, L. (1997). The paradox of change: Better them than us! In R. S. Sauber (ed.), Managed mental health care: Major diagnostic and treatment approaches, 40–66. Bristol, PA: Brunner/Mazel. Mustanski, B., & Liu, R. (2013). A longitudinal study of pre­ dictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Archives of Sexual Behavior, 42 (3), 437–448. Nelson, D. L., Castonguay, L. G., & Barwick, F. (2007). Direc­ tions for the integration of homework in practice. In N. Kazantzis & L. ĽAbate (eds.), Handbook of homework assignments in psychotherapy, 425–444. Boston: Springer. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low cost strategies for positive adjustment. Family Relations, 64 (3), 420–430. doi:10.1111/fare.12124.

SECTION I

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR THE

COMING-OUT PROCESS

ACROSS THE LIFE SPAN

We begin the book with a section on coming out, which is often a starting point in our work with LGBTQ+ clients. Feeling affirmed and safe in the com­ ing-out process is critical to the cognitive, emotional, and relational well-being of LGBTQ+ individuals (Ryan, Legate, & Weinstein, 2015). There are many ways to engage our clients in conversations about how, when, to whom, and if to come out, and the contribu­ tors in this section offer creative ideas and interven­ tions. They propose using pets, music, ecomaps, letter writing, and cinema to address the often complex decision and process of disclosing sexual and gender identities. They also emphasize the influence of the clients’ sociocultural contexts, facilitating greater understanding of the forms of oppression faced by cli­ ents with multiple marginalized identities. Addition­ ally, the chapters focus on clients at different devel­ opmental stages, speaking to the unique nuances of the coming-out process from adolescence through later life. Chapter 1, “A Pet-Assisted Intervention during Coming-Out Experiences,” by Michael P. Chaney and Kathryn L. Pozniak, offers a unique suggestion to use pets as confederate loved ones to practice coming out. Pet-assisted treatment is an accepted form of treatment and has been used with clients to success­ fully manage stress and anxiety (Bao & Schreer, 2016), to enhance mental health (Bao & Schreer, 2016), and to increase trust (Woolf & Brown, 2013). Chaney and Pozniak propose that practicing disclosures with a trusted pet companion can increase clients’ confidence and minimize the feelings of isolation and disconnec­ tion they sometimes experience when coming out. The next three chapters address coming out at various stages of development across the life span. Chapter 2, by Vincent M. Marasco and Randall L. Astramovich, “Assisting Individuals in Coming Out in Later Life as Lesbian, Gay, or Bisexual,” focuses on coming out at midlife or later adulthood and high­ lights the additional challenges that clients face at these ages. They propose the use of a cost-benefit anal­ ysis based on cognitive-behavioral therapy. The activ­ ity walks the client through the common life experi­ ences and themes experienced by those in midlife and later adulthood. The authors note, for instance, that compared to adolescent or young adult LGBTQ+ 2

clients, many older clients may have to negotiate sig­ nificant changes in long-term romantic relationships after coming out. Following this chapter are two that highlight the process for youth. Chapter 3, “Transgender Teens and Gender-Identity Disclosure,” addresses coming out as transgender in adolescence. Laura R. Haddock aptly discusses the potential loss of safety and emotional security these teens may face when coming out to their caregivers; she also underscores the resilience of teens who identify as transgender. Haddock points out that the alarming reality for trans individuals of color, who are six times more likely to experience hate violence than the white trans community (NCAVP, 2014), makes having a thoughtful strategy particularly essential for this community. Haddock shows counselors how to use letter writing to explore adolescent clients’ transgender identities. The focus is on self-awareness and self-affirmation followed by movement toward action. The second chapter on youth uses an ecomap to help adolescents disclose their sexual and/or gen­ der identities. Richard A. Brandon-Friedman and M. Killian Kinney, in “Assisting Youth with Disclosing Their Sexual Orientation and/or Gender Identity Using an Ecomap” (Chapter 4), demonstrate that the process of diagramming youth’s social environments facilitates the identification of the people to whom they want to come out and the potential relational support and loss in doing so. They explain that the emphasis on privileging clients’ own perspective of their world is especially empowering for youth. Using this strategy, clients are guided to explore the interplay between their web of relationships and their sociocultural context to make coming-out decisions that feel congruent with their lived experiences. The next two chapters of this section use two dif­ ferent forms of expressive arts to facilitate coming out for LGBTQ+ clients. “Must Be the Music: Musical Autobiography and Critical Lyric Analysis,” by Kiahni Nakai (Chapter 5), guides clients through the use of a musical autobiography assessment and a critical lyric analysis activity, helping them nonverbally express their needs and experiences and manage nonaccep­ tance and vulnerability. In addition, music has been shown to lower anxiety and improve immune func­ tioning (Novotney, 2013), thereby providing much­

needed support for many people during the com­ ing-out process. This approach is a powerful option for clients who use music as a mechanism to cope with oppression. Jennifer Lancaster and Angelica Terepka’s chapter, “Cinematherapy for LGBT Clients” (Chapter 6), offers a similar avenue of expression through the use of film. Many LGBTQ+ individuals are searching for visible role models in the coming-out process, and especially for those who hold multiple minority identities, role models may be hard to find. Using media represen­ tative of LGBTQ+ people and pairing these media with a film analysis worksheet, the authors aim to help clinicians validate and normalize clients’ identities, thereby easing the coming-out process. Both chapters provide clinicians with opportunities to use art and culture to situate LGBTQ+ clients’ experiences and augment the exploration of their identities. Finally, in the last chapter (Chapter 7), “How Does God See Me? A Reflective Exercise,” Hannah B. Bayne and Anita A. Neuer Colburn present an activity to deepen the self-exploration and the understanding of the effect of oppression and coming out when reli­ gious values conflict with one’s sexual identity. This is a common issue for LGBTQ+ clients and one often in need of discussion in treatment to ease the process of coming out.

References Bao, K., & Schreer, G. (2016). Pets and happiness: Examining the association between pet ownership and wellbeing. Anthrozoös, 29 (2), 283–296. doi:10.1080/08927936.2016 .1152721. National Coalition of Anti-Violence Programs (NCAVP) (2014). Lesbian, gay, bisexual, transgender, queer, and HIV-af­ fected hate violence in 2013. http://avp.org/wp-content/ uploads/2017/04/2013_ncavp_hvreport_final.pdf. Novotney, A. (2013, November). Music as medicine. Monitor on Psychology, 44 (10). www.apa.org/monitor/2013/11/ music.aspx. Ryan, W. S., Legate, N., & Weinstein, N. (2015). Coming out as lesbian, gay, or bisexual: The lasting impact of initial disclosure experiences. Self and Identity, 14 (5), 549 – 569. doi:10.1080/15298868.2015.1029516. Woolf, A., & Brown, A. (2013). Man’s best friend: The thera­ peutic impact of emotional relationships with animals. In C. Mohiyeddini (ed.), Emotional relationships: Types, challenges, and physical/mental health impacts, 161 – 178. Hauppauge, NY: Nova Science Publishers.

3

1 A PET-ASSISTED INTERVENTION DURING COMING-OUT EXPERIENCES Michael P. Chaney and Kathryn L. Pozniak Suggested Uses: Activity, homework Objective

The purpose of this activity or homework assignment is to assist counselors with clients who are contem­ plating coming out by creating a safe and affirming context in which to do so. By involving a personal pet in the coming-out process, clients may experience an increase in confidence and a decrease in mental stress, providing them with a positive and supportive envi­ ronment in which to practice coming out to others. This exercise could be adapted to meet the needs of transgender clients in the coming-out process as well. Rationale for Use

Disclosure of sexual orientation, or coming out, is the process of acknowledging same-sex physical and/or affectional attractions and identifying to oneself or others as lesbian, gay, bisexual, queer, questioning, or some other nonheterosexual identity (LGBQQ+, Chaney, Filmore, & Goodrich, 2011). Coming out is an individual decision that has the potential to bolster one’s identity (Sand, 2015). Further, positive comingout experiences can lead to the development of an affirmatory sexual identity, greater self-esteem, and improved psychosocial well-being (Carnelley, Hepper, Hicks, & Turner, 2011). However, disclosure of nonheterosexual sexual/affectional orientations also can be a major struggle for many LGBQQ+ individuals owing to fear of perceived or actual negative repercus­ sions (Carnelley et al., 2011). Thus, affirming interven­ tions that maximize the potential for positive com­ ing-out experiences and minimize the risk of negative consequences are needed.

As societal attitudes toward LGBQQ+ individuals have become more accepting, individuals are coming out at younger ages. Just several years ago, Rothman, Sullivan, Keyes, and Boehmer (2012) reported that the average age at which individuals came out to parents was twenty-five, and participants were more likely to come out to mothers before fathers. More recent stud­ ies reported the average age of disclosure occurs as young as mid- to late teens (sixteen to eighteen years old) (Charbonnier & Graziani, 2016; Dunlap, 2016). Because these individuals are coming out at such young ages, it has been suggested, they may come out with less emotional maturity and minimal coping skills to assist them as they negotiate the disclosure process. Coming out is considered a stressor consisting of two stages (Riley, 2010). In the first phase, LGBQQ+ persons recognize and acknowledge a nonheterosexual identity within themselves. The second phase is char­ acterized by disclosing the nonheterosexual identity to others. The process of revealing sexual orientation to others can be extremely stressful, especially when disclosing to family members. A study that explored the coming-out experiences of four hundred LGB young adults (eighteen to twenty-six years old) revealed that when they came out, they believed they had lim­ ited coping skills, which ultimately influenced their perceived sense of control (Charbonnier & Graziani, 2016). Participants reported that the lack of control magnified the intensity of their stress when coming out. Therefore, counselors would serve their clients well to use affirming interventions that increase psy­ chological safety, emotional support, and perceived control and decrease the distress associated with com­ ing out. Involving a beloved pet in therapy to assist

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

4

with the coming-out process could give clients a sense of control, thus enhancing self-efficacy and empow­ erment as they navigate the disclosure process (Berget, Ekeberg, & Braastad, 2008). When working with clients who are considering whether to come out, affirming helping professionals should weigh the benefits and consequences of com­ ing out for those clients (Hill, 2009). Though there are numerous benefits associated with coming out, such as living authentically and personal empower­ ment, depending on clients’ contextual factors, dis­ closure of sexual orientation to others may not be the right decision at that particular time. Should a client decide not to come out, counselors should inform clients about potential risks associated with concealing one’s sexual identity. For example, concealment of sexual orientation is related to cognitive impairment and negatively influences a person’s ability to develop and maintain close interpersonal relationships (Ryan, Legate, & Weinstein, 2015). Schope (2004) reported that gay men who had not disclosed their sexual orien­ tations experienced greater fear of negative appraisal from others than peers who had disclosed. Moreover, hiding sexual orientation can lead to increased anxiety, damaged self-esteem, substance use, and other health risk behaviors (D’Amico & Julien, 2012; Rothman et al., 2012). The bottom line is this: counselors must not force LGBQQ+ clients to come out unless a client has coping skills to deal with some of the intense feel­ ings and reactions related to the coming-out process (Chaney et al., 2011). Affirming counseling for clients in the beginning stages of coming out should involve strategies to instill hope, promote positivity, and bolster a client’s sup­ port system (Budge, 2014). Furthermore, a critical component of affirming counseling is assisting clients in examining the meaning of their physical and/or affectional attractions for their sexual identities and, on the basis of conclusions reached, making decisions about disclosure (Hill, 2009). Throughout the coun­ seling process, affirming clinicians should help clients develop interpersonal skills as a way to connect with supportive others, which can counteract feelings of loneliness and alienation. Involving a trusted pet in the therapeutic process with LGBQQ+ clients who are in the process of com­

ing out could minimize feelings of loneliness and iso­ lation that many individuals experience. Studies have shown that during the coming-out process, self-esteem and overall satisfaction with life decrease, and feelings of loneliness increase (Halpin & Allen, 2004). One reason that some LGBQQ+ people feel disconnected and isolated when coming out is because of their dis­ engagement from heterosexual support networks as they seek support from and connection to other nonheterosexuals. Consequently, being out increases the potential to lose important social connections in a person’s life (Sand, 2015). For other LGBQQ+ people, rejection and other negative reactions upon disclosure exacerbate feelings of loneliness and alienation. Stud­ ies have shown that negative reactions from friends and family significantly influence levels of depression and self-esteem in negative ways (Ryan et al., 2015). Additionally, negative parental reactions to disclosure contribute to health problems and substance use dis­ orders among nonheterosexuals (D’Amico & Julien, 2012). Of utmost concern is that LGBQQ+ people who have experienced parental rejection upon coming out reported increased suicide attempts (Ryan, Huebner, Diaz, & Sanchez, 2009). On the other hand, LGBQQ+ individuals are more likely to come out to parents whom they perceive to be encouraging of autonomy while their children are growing up (Carnelley et al., 2011). For LGBQQ+ individuals who are in the pro­ cess of coming out, perceived parental acceptance can influence the decision to disclose to family mem­ bers. To that point, using a pet in therapy with clients struggling with coming out could serve as a source of unconditional acceptance and much-needed support. When working with LGBQQ+ clients who are deciding whether to come out, counselors must take into consideration cultural aspects of a client’s identity that could influence the disclosure process. Rosario, Schrimshaw, and Hunter (2004) proposed that cultural factors such as family, gender roles, religious and spiritual values, and oppression make the coming-out process more complicated. These ideas are consistent with studies that found LGBQQ+ people of color (e.g., African American, Asian and Pacific Islander, Latinx, etc.) are less likely to disclose sexual orientation to parents compared to white LGBQQ+ individuals (Grov, Bimbi, Nanin, & Parsons, 2006; Rosario et al., 2004).

A Pet-Assisted Intervention during Coming-Out Experiences

5

A more recent study illustrated the intersectionality of sexual orientation, race, and gender. Aranda and colleagues (2015) found that although African Amer­ ican lesbians were more likely to report depression than their white peers, Latina lesbians were not only least likely to come out to their family members, but also more likely than African American and white lesbians to struggle with depression. In sum, the coming-out process is difficult enough, and multiple oppressed and intersecting identities make the process that much more challenging. There­ fore, affirming counselors should have in their thera­ peutic toolbox effective strategies that make coming out less stressful for LGBQQ+ clients. One affirming intervention is to explore the influence of oppression in a client’s life and to validate feelings of anger and grief associated with oppression (Hill, 2009). In addi­ tion, depending on a client’s needs, affirming counsel­ ors will integrate diverse counseling strategies to facili­ tate the coming-out process. Counselors are reminded that they have an ethical obligation to be multicul­ turally competent and to acquire counseling knowl­ edge and skills to be effective with diverse client popu­ lations (ACA, 2014, C.2.a). Moreover, the counseling interventions and methods selected by counselors must be theory-based or have an empirical rationale (ACA, 2014, C.7.a). Although traditional methods of talk therapy can effectively be used to assist clients as they navigate the coming-out process, some LGBQQ+ cli­ ents may be more responsive to creative and innovative interventions that also have a scientific basis. For example, Aronoff and Gilboa (2015) examined the role music played in the lives of gay men as they were coming out. Many of the men revealed that not only did music serve as a companion (i.e., a source of support), but music also helped them practice dis­ closing their sexual orientations to others through the lyrics of particular songs. Men in the study went on to comment that music provided the support that they were not receiving from family and friends during the coming-out process. Other forms of art have been recommended to facilitate the coming-out process. Pelton-Sweet and Sherry (2008) suggested using art therapy to promote psychological safety for clients who are negotiating the process of coming out. Interestingly,

6

Chaney & Pozniak

one exercise they recommended was for a client to select an animal figurine and to craft a safe environ­ ment for the animal using art supplies. The chosen animal figurine metaphorically represents a facet of the client (e.g., sexual identity) that is to be kept safe in the created space. Like these creative arts– related counseling strategies, using pets in the counseling ses­ sions to facilitate positive coming-out experiences for clients is simply another innovative intervention that counselors might choose when dealing with this issue. The mission of creating an atmosphere of hope for clients, providing a safe space to explore and validate emotions while also affirming individuals’ unique coming-out processes, can be achieved through the involvement of a pet in the counseling relationship. A common theme within the professional litera­ ture pertaining to helping LGBQQ+ clients navigate disclosure of sexual orientation is practice. Saltzburg (2007) urged counselors to work with clients in behav­ ioral rehearsals of coming out to assist them in pro­ gressing in their sexual identity development. Coun­ selors need to meet their clients where they are in their identity development. In other words, when working with clients who are coming out, counselors must consider the timing and sequence of planned interventions. Russell and Hawkey (2017) recom­ mended that counseling related to coming out begin with imagined disclosures, then progress to enacted disclosures at the client’s pace, so that the process is not overwhelming and the client has the coping skills to handle the intense feelings and reactions that might arise. Therefore, integrating a trusted and loved pet into behavioral rehearsals could decrease anxiety related to coming out. Furthermore, clients who may not be comfortable about disclosing to friends or fam­ ily may be more comfortable practicing coming out to a nonjudgmental being such as a pet. The follow­ ing section explores pet-assisted therapy as an effective intervention to assist LGBQQ+ clients during the coming-out process. A unique bond exists between humans and ani­ mals, one that can aid individuals in their search for meaning and companionship in everyday life. Animals have been employed as a way to increase mental and physical well-being in humans since the 1860s, when

Florence Nightingale highlighted the importance of using animals to assist individuals in gaining a sense of purpose, increase nurturing capabilities, and decrease feelings of isolation and loneliness (Woolf & Brown, 2013). Helping professionals have been using animals for therapeutic purposes for years; literature on the topic began in the early 1960s, when the scientific value of the bond was explored for the first time (Menna et al., 2012). Animals can provide great comfort in the home life of many, and these benefits can be expanded into the counseling domain. Research has demonstrated the potential of animal-assisted interventions in both psychological and physiological contexts, as animals provide benefits to both mental and physical health. The use of pets in therapy has been found to lower mental stress, increase confidence, and decrease worry and pain. Headey and colleagues (2002) found a health savings of over $3 billion over a ten-year period related to a decrease in doctor visits in Germany and Australia among individuals who owned pets as com­ pared to their counterparts who did not. Several connections have been made between the overall happiness and well-being of individuals and their relationships with pets. Bao and Schreer (2016) found evidence to support the theory that individuals who have pets have better mental health, increased happiness, and lower rates of depression. Pet owners were more satisfied with their lives than the individ­ uals who did not own pets; they also experienced an increase in physical health, including lower blood pressure and an increased survival rate following a heart attack (Bao & Schreer, 2016). These results are consistent with the work of Woolf and Brown (2013), who found pet owners to report increased life satis­ faction, reduction of psychological stress, and signif­ icant increase in trust. In addition, they found that the presence of a pet can aid in building self-confidence and provide structure, while also allowing for increased connection and acceptance. Pets can offer people sup­ port by providing a nonjudgmental relationship in which trust is established. By involving pets in coun­ seling sessions, counselors may be able to explore pre­ senting issues, including coming-out issues, more thoroughly while also improving a client’s communi­

cation and social skills (Chitic, Rusu, & Szamoskozi, 2012; Fung & Leung, 2014). Research has demonstrated that pets can increase feelings of confidence in children (Gee, Church, & Altobelli, 2010; Gee, Gould, Swanson, & Wagner, 2012). In these studies, children were more successful at com­ pleting tasks with the supportive presence of a dog than they were without the animal. Further, children who struggled with reading have been shown to improve their abilities in the presence of therapy dogs as a result of feeling more confident in their abilities (Kirnan, Siminerio, & Wong, 2016). Though these studies relate to confidence building associated with basic skills in children, the same principles could be applied to LGBQQ+ clients of all ages who are dealing with the coming-out process. The mental and physical benefits associated with involving pets in counseling could help provide an atmosphere that minimizes distress associated with disclosure of sexual orientation. Furthermore, pets in counseling can serve as a surrogate friend or family member for coming-out role-playing and behavioral rehearsals. The use of a pet in therapy sessions may aid in producing a safe space in which clients can prac­ tice coming out in an unconditionally accepting envi­ ronment. Moreover, inviting a pet into a session may minimize the anxiety, isolation, fear of rejection, and shame associated with coming out, yet maximize the potential for a positive disclosure. Research has shown that a positive coming-out experience is related to the development of a positive identity, improved selfesteem, and better psychological adjustment (Carnelley et al., 2011). Although the American Counseling Association’s (ACA) and American Psychological Association’s ethical codes do not specifically address the use of ani­ mals in counseling practice, ethical implications must be considered. It is mandatory that counselors adhere to guiding ethical principles when working with ani­ mals in counseling and seek supervision when neces­ sary. The ACA (2014) ethical principles to be consid­ ered include autonomy, nonmaleficence, beneficence, justice, fidelity, and veracity, each of which needs to be observed for both the animal and the client. An eth­ ical counselor must assess a client’s level of comfort

A Pet-Assisted Intervention during Coming-Out Experiences

7

in working with an animal during a session and give a client the opportunity to decline. In addition, the animal needs to feel comfortable taking part in the activity, and it should not be forced to interact. Nonmaleficence means doing no harm to the client or the animal and may include informing the client of the risks involved in working with a pet, such as nat­ ural defense mechanisms, animals using their mouths to play, and allergies, while also considering that the animal may face risks interacting with the clients. Beneficence dictates that the counselor work for the good of both the client and the animal involved in the activity; their participation should be benefi­ cial for both client and animal. The final three ethical principles of justice, fidelity, and veracity protect the client and animal from poor intentions, providing a solid framework for ethical interactions. Both the client and pet should be treated equally and fairly, providing them with the opportunity to discontinue the treatment and decide on their level of interaction and participation. Fidelity ensures that the counselor honors commitments, which allows the client to feel comfortable and protected by the clinician. Finally, veracity pertains to truthfulness, which is essential for an effective client-counselor relation­ ship, as well as a strong human-animal bond. Ethical counseling practice provides a solid structure for successful relationships with clients, ensuring the welfare of both clients and animals. When the human-animal relationship is used ethically, it can be a beneficial intervention in a therapeutic setting. Instructions

There are a couple of ways that a pet may be integrated into the counseling process to assist a client who is contemplating coming out. The first set of instructions pertains to involving a pet as an in-session disclosure activity; the second set describes how to adapt the insession exercise to a coming-out homework assign­ ment. As an in-session activity, the first step is to make sure the client consents to the activity and that the intervention has been selected specifically for the bene­ fit of the client. This activity should be used only if cli­ ents have decided that they are ready to explore coming out. There should be no pressure from the counselor.

8

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Next, help the client relax by engaging in deep breathing exercises or muscle relaxation techniques. After the client is relaxed, direct the client to face the pet. Encourage the client to imagine a future comingout situation or simply have the client remain in the here and now. When the client is ready, have the client verbalize the disclosure of sexual orientation to the pet. Support the client’s disclosure and encourage the client to engage in a dialogue with the pet about the client’s sexual orientation. Initially, some clients may feel embarrassed or silly for coming out to a pet, and these feelings should be explored and validated as normal. After the client has disclosed, the counselor should focus on the client’s verbal and nonverbal behavior during the activity and may ask questions about the client’s thoughts and feelings before, during, and after the disclosure. See the handout on page 12 for suggested questions the client should answer. The counselor should focus on the success of the client’s disclosure and offer support and encourage­ ment throughout the process. If a client is preparing to come out to significant people in their life, this activ­ ity can be repeated until the client has developed a sense of efficacy in putting together a potential comingout script. This activity can also be adapted to an out-of­ session homework assignment by providing the client with the aforementioned steps. The client can prac­ tice disclosing to the pet in the privacy and comfort of the client’s home. The client should be instructed to journal responses to the list of questions on the hand­ out. In the next session, client and counselor can pro­ cess the journal and plan for next steps. Brief Vignette

Jo seeks counseling to get support and guidance related to coming out to her family. Jo, who is thirty-seven years old, identifies as an African American cisgender lesbian. Because of her family’s strong religious back­ ground, Jo has been experiencing apprehension and anxiety about coming out to her parents. Although Jo has come out to one close friend, the fear of rejec­ tion that she has been experiencing related to dis­ closing to her parents has immobilized her. She comes to therapy motivated to get “unstuck” regarding coming

out to her parents. After a few sessions of rapport building, goal setting, and information gathering, it becomes apparent that a major source of emotional support for Jo is her German shepherd rescue dog, Callie. With this information, the counselor presents Jo with the option to bring Callie to the next session to engage in a simulated coming-out role-play. With­ out hesitation, Jo agrees. After the counselor provides Jo with explicit instructions and obtains her consent, in the next session Jo practices coming out, using Callie as a surrogate family member. Following the simulated coming out, the counselor explores with Jo her thoughts and feelings during the exercise. Callie is brought in for one more session, in which Jo is again able to practice coming out. Throughout the process, Jo’s counselor provides support, validation, and con­ structive feedback. When Jo eventually comes out to her parents, they are not as supportive as she had hoped, but because of the rehearsals with her counselor and Callie, and because she knew what the potential reactions could be, she feels prepared to cope with the experience in a healthy way, and she seeks support through a local support group. Jo continues to main­ tain a relationship with her parents, and they are begin­ ning to show support and acceptance in small ways. Suggestions for Follow-up

Therapists should follow up with the client across ses­ sions, as meanings found in the activity or homework assignment may be realized at a later time, after selfreflection. Counselor and client should contemplate how meaning gathered through the activity may trans­ late into relationships with friends and family and also how the activity relates to plans for future disclo­ sure. Further, counselor and client may work toward a plan of action for disclosure to safe, supportive oth­ ers. Additionally, if the client found the incorporation of the pet in the session to be valuable and effective, further sessions allowing for the inclusion of the pet may be discussed. Contraindications for Use

The decision to involve a client’s pet in a counseling session to facilitate the coming-out experience belongs to the client. As always, affirming counselors must

meet the clients where they are in their coming-out journey. Therefore, counselors should never encour­ age a client to come out if coming out would lead to high-risk situations (e.g., being kicked out of the house, interpersonal violence, etc.). An additional con­ sideration pertains to the demeanor of the pet. If the counselor is integrating a pet into a session, the ani­ mal should be socialized well. Moreover, potential animal allergies or fears of anyone who may come in contact with the animal must being taken into con­ sideration. Last, though coming out to a beloved pet can be therapeutic and offer the opportunity for behav­ ioral rehearsals, coming out to significant people in a client’s life can be much more intense, and the client should have a clear understanding of the differences. Professional Readings and Resources Association for LGBT Issues in Counseling. LGBT resources. www.algbtic.org/l-g-b-t-resources.html. DeBord, K. A., Fischer, A. R., Bieschke, K. J., & Perez, R. M. (2017). Handbook of sexual orientation and gender diversity in counseling and psychotherapy. Washington, DC: Amer­ ican Psychological Association. Fine, A. H. (2010). Handbook on animal-assisted therapy: Foun­ dations and guidelines for animal-assisted interventions, 3rd edition. San Diego: Academic Press. Fine, A. H., & Eisen, C. J. (2008). Afternoons with puppy: Inspi­ rations from a therapist and his animals. West Lafayette, IN: Purdue University Press. Olmert, M. D. (2010). Made for each other: The biology of the human-animal bond. Cambridge, MA: Da Capo Press. Parents and Friends of Lesbians and Gays (PFLAG). www. pflag.org.

Resources for Clients Boykin, K. (2012). For colored boys who have considered suicide when the rainbow is still not enough: Coming of age, coming out, and coming home. New York: Magnus Books. Downs, A. (2012). The velvet rage: Overcoming the pain of grow­ ing up gay in a straight man’s world, 2nd edition. Boston: Da Capo Press. Human Rights Campaign. (2014). Coming out resource guides. https://www.hrc.org/resources/coming-out-resource­ guides. Olmert, M. D. (2010). Made for each other: The biology of the human-animal bond. Cambridge, MA: Da Capo Press. Stevens, T. (2002). How to be a happy lesbian: A coming out guide. Asheville, NC: Amazing Dreams Publishing. Trevor Helpline. 1-866-4-U-Trevor (488-7386). www.thetrevor project.org.

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References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. https://www.counseling .org/resources/aca-code-of-ethics.pdf. Aranda, F., Matthews, A. K., Hughes, T. L., Muramatsu, N., Wilsnack, S. C., Johnson, T. P., & Riley, B. B. (2015). Com­ ing out in color: Racial/ethnic differences in the relation­ ship between level of sexual identity disclosure and depression among lesbians. Cultural Diversity and Ethnic Minority Psychology, 21 (2), 247–257. doi:10.1037/a003 7644. Aronoff, U., & Gilboa, A. (2015). Music and the closet: The roles music plays for gay men in the “coming out” process. Psychology of Music, 43 (3), 423–437. doi:10.1177/03057 3561351943. Bao, K., & Schreer, G. (2016). Pets and happiness: Examining the association between pet ownership and wellbeing. Anthrozoös, 29 (2), 283–296. doi:10.1080/08927936.2016. 1152721. Berget, B., Ekeberg, Ø., & Braastad, B. O. (2008). Animalassisted therapy with farm animals for persons with psy­ chiatric disorders: Effects on self-efficacy, coping ability and quality of life, a randomized controlled trial. Clinical Practice and Epidemiology in Mental Health, 4 (1), 9. doi: 10.1186/1745-0179-4-9. Budge, S. L. (2014). Navigating the balance between positivity and minority stress for LGBTQ clients who are coming out. Psychology of Sexual Orientation and Gender Diversity, 1 (4), 350–352. Carnelley, K. B., Hepper, E. G., Hicks, C., & Turner, W. (2011). Perceived parental reactions to coming out, attachment, and romantic relationship views. Attachment and Human Development, 13 (3), 217–236. doi:10.1080/14616734.201 1.563828. Chaney, M. P., Filmore, J. M., & Goodrich, K. M. (2011, May). No more sitting on the sidelines. Counseling Today, 53 (11), 34–37. http://ct.counseling.org/2011/05/no-more-sitting-on­ the-sidelines/. Charbonnier, E., & Graziani, P. (2016). The stress associated with the coming out process in the young adult popula­ tion. Journal of Gay and Lesbian Mental Health, 20 (4), 319–328. doi:10.1080/19359705.2016.1182957. Chitic, V., Rusu, A. S., & Szamoskozi, S. (2012). The effects of animal assisted therapy on communication and social skills: A meta-analysis. Transylvanian Journal of Psychology, 13 (1), 1–17. D’Amico, E., & Julien, D. (2012). Disclosure of sexual orienta­ tion and gay, lesbian, and bisexual youths’ adjustment: Associations with past and current parental acceptance and rejection. Journal of GLBT Family Studies, 8, 215–242. doi:10.1080/1550428X.2012.677232.

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Dunlap, A. (2016). Changes in coming out milestones across five age cohorts. Journal of Gay and Lesbian Social Services, 28 (1), 20–38. doi:10.1080/10538720.2016.1124351. Fung, S., & Leung, A. S. (2014). Pilot study investigating the role of therapy dogs in facilitating social interaction among children with autism. Journal of Contemporary Psycho­ therapy, 44 (4), 253–262. https://doi.org/10.1007/s10879 -014-9274-z. Gee, N. R., Church, M. T., & Altobelli, C. L. (2010). Preschool­ ers make fewer errors on an object categorization task in the presence of a dog. Anthrozoös, 23 (3), 223–230. https://doi.org/10.2752/175303710x12750451258896. Gee, N. R., Gould, J. K., Swanson, C. C., & Wagner, A. K. (2012). Preschoolers categorize animate objects better in the presence of a dog. Anthrozoös, 25 (2), 187–198. https://doi.org/10.2752/175303712X13316289505387. Grov, C., Bimbi, D. S., Nanin, J. E., & Parsons, J. T. (2006). Race, ethnicity, gender, and generational factors associated with the coming-out process among gay, lesbian, and bisexual individuals. Journal of Sex Research, 43 (2), 115–121. Halpin, S. A., & Allen, M. W. (2004). Changes in psychosocial well-being during stages of gay identity development. Journal of Homosexuality, 47 (2), 109–129. Headey, B., Grabka, M., Kelley, J., Reddy, P., & Tseng, Y. P. (2002). Pet ownership is good for your health and saves public expenditure too: Australian and German longitudinal evi­ dence. Australian Social Monitor, 5 (4), 93–99. Hill, N. L. (2009). Affirmative practice and alternative sexual orientations: Helping clients navigate the coming out pro­ cess. Clinical Social Work Journal, 37 (4), 346–356. doi: 10.1007/s10615-009-0240-2. Kirnan, J., Siminerio, S., & Wong, Z. (2016). The impact of a therapy dog program on children’s reading skills and atti­ tudes toward reading. Early Childhood Education Journal, 44 (6), 637–651. https://doi.org/10.1007/s10643-015-07 47-9. Menna, L. F., Fontanella, M., Santaniello, A., Ammendola, E., Travaglino, M., Mugnai, F., & Fioretti, A. (2012). Evalua­ tion of social relationships in elderly by animal-assisted activity. International Psychogeriatrics, 24 (6), 1019–1020. Pelton-Sweet, L. M., & Sherry, A. (2008). Coming out through art: A review of art therapy with LGBT clients. Art Therapy: Journal of the American Art Therapy Association, 25 (4), 170–176. Riley, B. H. (2010). GLB adolescents’ “coming out.” Journal of Child and Adolescent Psychiatric Nursing, 23, 3–10. Rosario, M., Schrimshaw, E. W., & Hunter, J. (2004). Ethnic/ racial differences in the coming-out process of lesbian, gay, and bisexual youths: A comparison of sexual identity devel­ opment over time. Cultural Diversity and Ethnic Minority Psychology, 10 (3), 215–228. doi:10.1037/1099-9809.10.3. 215.

Rothman, E. F., Sullivan, M., Keyes, S., & Boehmer, U. (2012). Parents’ supportive reactions to sexual orientation dis­ closure associated with better health: Results from a population-based survey of LGB adults in Massachusetts. Journal of Homosexuality, 59, 186–200. doi:10.1080/0091 8369.2012.648878. Russell, G. M., & Hawkey, C. G. (2017). Context, stigma, and therapeutic practice. In K. A. DeBord, A. R. Fischer, K. J. Bieschke, & R. M. Perez (eds.), Handbook of sexual orienta­ tion and gender diversity in counseling and psychotherapy, 75–104. Washington, DC: American Psychological Association. Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Fam­ ily rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics 123, 346–352. Ryan, C., Russell, S. T., Huebner, D., & Diaz, R. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23 (4), 205–213.

Ryan, W. S., Legate, N., & Weinstein, N. (2015). Coming out as lesbian, gay, or bisexual: The lasting impact of initial dis­ closure experiences. Self and Identity, 14 (5), 549–569. doi:10.1080/15298868.2015.1029516. Saltzburg, S. (2007). Narrative therapy pathways for re-author­ ing with parents of adolescents coming-out as lesbian, gay, and bisexual. Contemporary Family Therapy, 29, 57–69. Sand, S. (2015). Coming out, being out: Reconciling loss and hatred in becoming whole. Psychoanalysis, Culture, and Society, 20 (3), 250–266. Schope, R. D. (2004). Practitioners need to ask: Culturally com­ petent practice requires knowing where the gay male client is in the coming out process. Smith College Studies in Social Work, 74 (2), 257–270. doi:10.1080/003773104095 17715. Woolf, A., & Brown, A. (2013). Man’s best friend: The thera­ peutic impact of emotional relationships with animals. In C. Mohiyeddini (ed.), Emotional relationships: Types, challenges, and physical/mental health impacts, 161–178. Hauppauge, NY: Nova Science Publishers.

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H A NDO UT

1. What feelings did you experience before, during, and after you disclosed?

2. If (pet’s name) was (name of a friend of family member), how do you think they would have reacted to your coming out?

3. If (pet’s name) could respond to you, what do you think they would say?

4. How accepted did you feel by (pet’s name) after your disclosure, and if you were to come out to people in your life, what kind of support would you need from them?

5. What would you do the same or differently if you were coming out to (name of a friend of family member)?

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Michael P. Chaney and Kathryn L. Pozniak

2 ASSISTING INDIVIDUALS IN COMING OUT IN LATER LIFE AS LESBIAN, GAY, OR BISEXUAL Vincent M. Marasco and Randall L. Astramovich Suggested Use: Homework Objective

This homework activity will help clients who are com­ ing out as lesbian, gay, or bisexual (LGB) during middle and later adulthood reflect on advantages and disad­ vantages of coming out to partners, children, extended family, friends, and coworkers. Rationale for Use

The coming-out process for LGB people during middle and later adulthood often involves developmental experiences similar to those involved in coming out during adolescence and early adulthood. Although the sequencing and timing may vary depending on indi­ vidual development, coming out generally involves milestones that include the recognition of same-sex attraction; identity confusion and experimentation in same-sex sexual relations; self-identification as lesbian, gay, or bisexual; and coming out to others (Calzo, Antonucci, Mays, & Cochran, 2011; Floyd & Bakeman, 2006). However, people coming out in middle and later adulthood often experience these milestones after identifying as a heterosexual for many years, and possibly being involved in opposite-sex romantic relationships before recognizing and accepting their same-sex attraction. As a result, they may experience significant changes in established relationships with partners, children, extended family, friends, and co­ workers (Johnston & Jenkins, 2004). Research also suggests that LGB people coming out in middle and later adulthood may experience ageism from within the LGB community, which may limit access to sup­ port and acceptance as an LGB person (Kimmel,

Rose, Orel, & Greene, 2006). Other struggles often experienced by individuals coming out in middle and later adulthood include grief over not having experi­ enced a typical adolescence, engaging in unhealthy behaviors as a mechanism for coping with homopho­ bia, coping with religious belief systems that margin­ alize LGB people (Johnston & Jenkins, 2004), and career development concerns (Chung, Chang, & Rose, 2015). Consequently, the coming-out process may lead to increased risk for depression and decreased self-esteem (Ryan, Legate, & Weinstein, 2015). Research on coming out later in life is limited; however, studies with younger LGB populations sug­ gest that coming out may have psychological advan­ tages, including decreasing depression and improving self-esteem (Kosciw, Palmer, & Kull, 2015). In addi­ tion, older clients coming out as LGB may experience increased authenticity and intimacy in their relation­ ships (Johnston & Jenkins, 2004). Identity intersec­ tionality undoubtedly affects the coming-out process, and older clients, especially those from multiply oppressed populations, may have heightened struggles, particularly related to family issues (Goodrich & Ginicola, 2017). Because of the significant relationship changes, disruptions, and renegotiations that may occur as a result of coming out in middle and later adulthood, this homework activity will help clients assess the advantages and disadvantages of coming out to various individuals in their social systems, including partners, children, extended family, friends, and coworkers. Intersectionality and intersectional approaches have been used within feminist theory and scholar­ ship, as well as sociology (Davis, 2008; Valentine,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

14

2007). The foundational tenets of intersectionality are that each individual holds various identities that inter­ sect (Jones, Misra, & McCurley, 2013). Common examples of intersecting identities are race, class, and gender. However, a number of others exist and vary from person to person. Other examples include reli­ gious identity, physical or mental disability, and sexual identity or orientation. The influence of age and sex­ ual orientation has been found to be important. King and Richardson (2017) discussed mental health dis­ tress for older LGB persons, which includes substance use, depression, and an increased risk of suicide. Because of the intersecting nature of these identities, they must be examined together. When assisting clients in the coming-out process, it is important to address intersecting identities and how each identity affects the individual, their interactions with the self, and interactions within their interpersonal relationships. The American Counseling Association’s (2014) ACA Code of Ethics compels counselors to respect cli­ ent rights (B.1) and to consider multicultural factors when counseling clients from diverse backgrounds (B.1.a). Counselors working with adults coming out during middle and later adulthood should refrain from pressuring clients to come out and should honor the client’s readiness for the coming-out process. In addition, counselors should carefully consider the cul­ tural implications of coming out for clients from diverse ethnic and religious backgrounds. Furthermore, counselors are compelled to receive training and super­ vision in LGB-affirmative counseling interventions. Affirmative counseling with LGB clients emphasizes client empowerment and advocacy to help clients recognize and proactively respond to the negative effects of heterosexism in their lives (Finnerty, Kocet, Lutes, & Yates, 2017). This homework activity pro­ motes LGB-affirmative counseling practices by empow­ ering older clients in the coming-out process to explore advantages and disadvantages to coming out to spe­ cific individuals in their lives and to develop strate­ gies for addressing heterosexism, marginalization, and discrimination as they come out to others. Instructions

To assist a client in coming out to family, friends, and coworkers, instruct the client to complete a cost-benefit

analysis (CBA). A CBA is a method of assessing and examining potential benefits and disadvantages of alternative choices (David, Ngulube, & Dube, 2013) and has been incorporated into cognitive-behavioral therapy. Within the realm of counseling, a CBA can help a client visualize and better comprehend alterna­ tive decisions and potential outcomes of their choices. A client can complete a CBA to evaluate the var­ ious potential outcomes of coming out. In doing so, a client will evaluate the potential benefits of coming out, the potential disadvantages of coming out, the potential benefits of not coming out, and the potential disadvantages of not coming out. The possible outcomes of a CBA can cover a range of areas. In part, the counselor’s responsibility is to encourage the client to consider as many potential outcomes as possible. The example CBA will provide the counselor with prompts for the client to consider when completing it. Additionally, a CBA can be tai­ lored to be specific or general to meet the needs of the client. For example, the CBA can address coming out to one specific person or a group of individuals, and it can be modified at various points within the coun­ seling relationship in order to assess comfort and read­ iness. Completing the CBA multiple times through­ out counseling can help generate salient themes, assess changing outcomes, and evaluate with the client points of safety within each of the different areas of the CBA. When the client and counselor have decided to complete a CBA, they should consider various points and aspects of the coming-out process. The counselor and the client can brainstorm considerations and questions whose answers might affect the decision to come out. Such questions can include: Are there safety concerns related to the coming-out process? Will there be financial repercussions to coming out? Would coming out impair job security or benefits (if the cli­ ent is coming out within the work setting)? How would coming out affect the family system in the long term? Does the client wish to pursue a same-sex rela­ tionship after coming out? Are there spiritual or reli­ gious concerns? Considerations include meeting clients where they are, recognizing the intersection­ ality of identities, and readiness to come out. These questions and considerations are intended to be broad and to examine the coming-out process more Assisting Individuals in Coming Out in Later Life

15

holistically, and to assist the client in thinking about more than the emotional aspects of coming out. Concerns specific to each client will be addressed by completing the CBA. Brief Vignette

Alex is a fifty-three-year-old black cisgender male who presents in session with anxiety, fear, and shame. He has been married for twenty-seven years to a woman and has two children, ages twenty and twenty-three. He is involved in his local faith-based organization with his family. Alex’s anxiety, fear, and shame have had negative effects on his marriage, including increased fighting, lack of sexual intercourse, and decreased communication with his wife. Additionally, he has been scaling back his role within his faith-based orga­ nization with his wife and children. After a few weeks of meeting with his counselor, Alex discloses that he has been aware of his same-sex attractions “since I can remember”; Alex does not initially self-identify as gay or bisexual. Upon further inquiry and discussion, Alex discloses that he has limited experience in samesex relationships; he engaged in exploratory sexual behaviors when he was younger and occasionally engages in same-sex fantasy while masturbating. Over a span of roughly four months in counseling, Alex has accepted his same-sex attractions and desires as part of his sexual interests, and he has decided to explore disclosing and discussing his same-sex attrac­ tions with his wife. He maintains his sexual and roman­ tic attraction to his wife. As the counseling relation ship continues, Alex comes to recognize that sameand opposite-sex attractions fit within the bisexual identity, and he is comfortable assuming that identity. As Alex has moved through his own acceptance of his same-sex desires and attractions, he continues to experience anxiety and fear about coming out about having same-sex desires. He reports anxiety about coming out to his wife, fear of her rejection, and shame about potentially ruining his marriage and family. He also reports fear of being shamed for his desires. The use of a CBA will help Alex consider the potential costs and benefits of disclosing to his wife. The coun­ selor explains to Alex the purpose and aspects of the CBA that will allow Alex to explore the costs and benefits that are most applicable to him, his family, and 16

Marasco & Astramovich

his current sexual identity development. The coun­ selor explains that Alex is to consider all the potential benefits and disadvantages of coming out. Further, Alex is to take into consideration the various inter­ secting roles and identities he embodies, such as his involvement in a faith-based organization, his racial and ethnic identity, and his current relationships. Alex is struggling to accept or assume a nonhet­ erosexual identity. He and the counselor can explore resistance and disparities between his identities. Although Alex does not conceptualize the relationship between his current sexual identity and his past expe­ riences, he and the counselor can discuss and explore how behaviors and identity often interact with each other but are not synonymous. That is, although Alex has had same-sex attractions and experiences, he is not required to identify with a certain sexual identity on the sole basis of his sexual behaviors or attractions. Exploring the relationship between behaviors and iden­ tity is an important part of this counseling relation­ ship, and it allows Alex to self-identify without pres­ sure to assume an ill-fitting identity. Alex is then able to assume an identity that is appropriate and fitting for him. Suggestions for Follow-up

Completing a CBA can be done over the period of one to two weeks, or however long a client needs. Upon completion, meet with the client and review the CBA. Explore the various potential outcomes, their effect on the client’s choice to come out, and process with them any emotions they may have experienced while completing the CBA and those they are currently experiencing about coming out. Through exploring and processing, the client can decide, on the basis of the completed CBA, which route to take. The role of the counselor at this point is to offer support for their decisions and assistance with skills development and coping strategies. Examples of follow-up questions are: How are your interactions with others influenced by completing and reviewing your CBA? What do you hope will change as a result of having completed the CBA? The counselor can help the client reflect on how their different and intersecting identities affected its completion. The counselor can also assist in providing

alternative perspectives or help the client include more advantages or disadvantages for each category. Contraindications for Use

This activity is designed for clients who have selfidentified and self-accepted an LGB identity and who are interested in beginning the coming-out process with others in their lives. Therefore, clients who con­ tinue to struggle with same-sex attractions or who experience heightened emotions related to an LGB identity may not benefit from this activity until they have a more established sense of their sexual identity and a readiness to share this with others. Professional Readings and Resources Floyd, F. J., & Bakeman, R. (2006). Coming-out across the life course: Implications of age and historical context. Archives of Sexual Behavior, 35, 287–296. doi:10.1007/s10508-006­ 9022-x. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . & Hammer, T. R. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Coun­ seling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. Journal of LGBT Issues in Counseling, 7, 2–43. doi:10. 1080/15538605.2013.755444. Johnston, L. B., & Jenkins, D. (2004). Coming out in midadulthood: Building a new identity. Journal of Gay & Lesbian Social Services, 16, 19–42. doi:10.1300/J041v 16n02_02. Kimmel, D., Rose, T., & David, S. (eds.). (2006). Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives. New York: Columbia University Press.

Resources for Clients Berzon, B. (2004). Permanent partners: Building gay and les­ bian relationships that last. New York: Penguin Group. Gay Life after 40. www.gaylifeafter40.com. Pride Foundation. www.pridefoundation.org. Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders. www.sageusa.org. Signorile, M. (1995) Outing yourself: How to come out as les­ bian or gay to your family, friends, and coworkers. New York: Random House.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. Calzo, J. P., Antonucci, T. C., Mays, V. M., & Cochran, S. D. (2011). Retrospective recall of sexual orientation identity development among gay, lesbian, and bisexual adults.

Developmental Psychology, 47, 1658–1673. doi:10.1037/ a0025508. Chung, Y. B., Chang, T. K., & Rose, C. S. (2015). Managing and coping with sexual identity at work. Psychologist, 28, 212–215. David, R., Ngulube, P., & Dube, A. (2013). A cost-benefit anal­ ysis of document management strategies used at a finan­ cial institution in Zimbabwe: A case study. SA Journal of Information Management, 15 (2). Davis, K. (2008). Intersectionality as buzzword: A sociology of science perspective on what makes a feminist theory successful. Feminist Theory, 9, 67–85. doi:10.1177/1464 70008086364. Finnerty, P., Kocet, M. M., Lutes, J., & Yates, C. (2017). Affir­ mative, strengths-based counseling with LGBTQI+ people. In M. M. Ginicola, C. Smith, & J. M. Filmore (eds.), Affirmative counseling with LGBTQI+ people, 109–125. Alexandria, VA: American Counseling Association. Floyd, F. J., & Bakeman, R. (2006). Coming-out across the life course: Implications of age and historical context. Archives of Sexual Behavior, 35, 287–296. doi:10.1007/s10508-006­ 9022-x. Goodrich, K. M., & Ginicola, M. M. (2017). Identity develop­ ment, coming out, and family adjustment. In M. M. Ginicola, C. Smith, & J. M. Filmore (eds.), Affirmative counseling with LGBTQI+ people, 61–73. Alexandria, VA: American Counseling Association. Johnston, L. B., & Jenkins, D. (2004). Coming out in midadulthood: Building a new identity. Journal of Gay & Lesbian Social Services, 16, 19–42. doi:10.1300/J041v 16n02_02. Jones, K. C., Misra, J., & McCurley, K. (2013). Intersectionality in sociology. Sociologists for Women in Society. https:// socwomen.org/wp-content/uploads/2018/03/swsfact sheet_intersectionality.pdf. Kimmel, D., Rose, T., & David, S. (eds.). (2006). Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives. New York: Columbia University Press. Kimmel, D., Rose, T., Orel, N., & Greene, B. (2006). Historical context for research on lesbian, gay, bisexual, and transgender aging. In D. Kimmel, T. Rose, & S. David (eds.), Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives, 1–19. New York: Columbia Uni­ versity Press. King, S. D., & Richardson, V. E. (2017). Mental health for older adults. Annual Review of Gerontology and Geriatrics, 37 (1), 59–75. doi:10.1891/0198-8794.37.59. Kosciw, J., Palmer, N., & Kull, R. (2015). Reflecting resiliency: Openness about sexual orientation and/or gender iden­ tity and its relationship to well-being and educational outcomes for LGBT students. American Journal of Com­ munity Psychology, 55, 167–178. doi:10.1007/s10464-014­ 9642-6.

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Ryan, W. S., Legate, N., & Weinstein, N. (2015). Coming out as lesbian, gay, or bisexual: The lasting impact of initial disclosure experiences. Self and Identity, 14, 549–569. doi:10.1080/15298868.2015.1029516.

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Valentine, G. (2007). Theorizing and researching intersec­ tionality: A challenge for feminist geography. Professional Geographer, 59, 10–21. doi:10.1111/j.1467-9272.2007. 00587.x.

COMMEN TS O N THE HAN D O UT To be most effective and beneficial for a client completing a CBA, it is important to identify to whom the CBA is directed. Answering the question “Whom am I considering coming out to?” will help guide the client in completing the homework. Additionally, the counselor should discuss with clients how their different identities and roles can influence the Benefits and Disadvantages categories. Below is an example of what Alex’s completed CBA may look like as he contemplates coming out to his wife. It includes different identities that are intertwined with his identity as a husband.

BENEFITS Coming Out

DISADVANTAGES

• Being open with my wife and self

• That she will judge me for my attractions and desires

• Not being ashamed of who I am anymore • Increased communication and honesty and authenticity • Potentially less stress, anxiety, fighting • Potentially more intimacy between us

Coming Out

• That she’ll leave me • That she’ll tell the children or others before I do, which could affect my relationship with them or my faith-based organization

• Living authentically

• Dealing with questions about my sexual orientation or people challenging my relationship with my wife

• Will be accepted by her and will be supported

• What does it mean to be a bisexual black man?

• Feeling better

• Demonstrating trust within a relationship with my wife for our kids

BENEFITS

Not Coming Out

DISADVANTAGES

Not Coming Out

• I can’t be judged for what she doesn’t know about me

• I remain anxious, fearful, ashamed

• No one questions my relationship or challenges my sexual orientation

• How does or will this affect our children? What am I teaching them about relationships?

• Relationship remains intact and we continue our marriage

• I continue to fight with my wife

• Potential divorce because of hiding who I am • Continued lack of emotional and physical intimacy • Continued decreased involvement in my faith-based organization owing to anxiety and stress • Lying to my wife and family about who I am

Vincent M. Marasco and Randall L. Astramovich

19

HA NDO U T

COST-BENEFIT ANALYSIS

BENEFITS

Coming Out

DISADVANTAGES

Coming Out

BENEFITS

Not Coming Out

DISADVANTAGES

Not Coming Out

20

Vincent M. Marasco and Randall L. Astramovich

3 TRANSGENDER TEENS AND GENDER-IDENTITY DISCLOSURE Laura R. Haddock

Suggested Uses: Activity, homework Objective

This activity is designed for use with adolescents who identify as transgender or gender nonconforming and are contemplating disclosing their gender identity to friends or family. Disclosing as trans or genderqueer to parents, caregivers, guardians, or loved ones is an important step toward empowering youth to feel confident in their gender identity. This activity was designed to be used with individuals who have not completed a gen­ der role transition. The exercise can be used in indi­ vidual or group therapy or can be assigned as home­ work for clients to engage in privately. Clients will be asked to articulate and explore their feelings related to changing gender identity during a letter-writing exercise to allow them to practice finding the words they would like to use to deliver this message, as well as explore any fears or concerns that may need to be addressed in the therapeutic process before initiating the disclosure process. Rationale for Use

Much of the literature related to the coming-out pro­ cess that aims to be inclusive of transgender experi­ ences treats sexual orientation and gender identity disclosures as parallel (Liang, 1997; Wood, 1997). How­ ever, Zimman (2009) challenges the assumption that the coming-out processes for those who identify as trans are analogous to the coming-out process for sex­ ual identity. For those who identify with a gender that does not match their natal sex assignment, there is frequently great societal pushback related to failure

to “enact gender in socially prescribed ways” (Gagné, Tewksbury, & McGaughey, 1997, p. 479). Any varia­ tion from traditional male and female gender roles, gender identity or expression, and heterosexuality is met with condemnation, control, modification, pun­ ishment, or efforts of behavioral extinction (ChenHayes, 2001). It is important to note that researchers have identified critical differences between the com­ ing-out processes for gender identity and those for sexual identity, which emphasizes the need to consider all individuals on their own terms and not make assumptions of commonalities with other queer groups (Zimman, 2009). Beals, Peplau, and Gable (2009) found that indi­ viduals reported lower psychological well-being (self­ esteem, positive affect, and satisfaction with life) on days when they concealed rather than disclosed their gender identity. Research has shown that negative reactions from close friends and family following dis­ closure happened less frequently than anticipated (Gagné et al., 1997), findings that offer a positive per­ spective on the benefits of disclosure. However, ther­ apists cannot discount the reality that hate violence is a prevalent and deadly issue faced by transgender com­ munities. The 2013 report on hate violence (NCAVP, 2014) highlights the incidence of hate violence against trans individuals at disturbingly high rates. In addition, trans people are frequently targets for fatal hate vio­ lence. For example, the report indicates that transgen­ der people of color are six times more likely to expe­ rience physical violence from the police than white cisgender survivors and victims. Transgender women are 1.8 times more likely to experience sexual violence when compared with other survivors. Additionally,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

22

transgender women are more likely to experience police violence, discrimination, harassment, threats, and intimidation. These startling statistics demon­ strate the pervasive violence and harassment that those in the trans community face from both the police and overall society. According to FBI statistics, in 2014 there were 218 reported hate crimes in the United States related to gender identity and gender noncon­ formity (U.S. Department of Justice, 2014). Aggres­ sion such as verbal harassment can be pretty terrify­ ing under certain conditions. Thus, incorporating a therapeutic exercise designed to facilitate thorough exploration of the coming-out process allows clients to express themselves without interruption, choose and revise their words until they feel comfortable with them, and explore potential reactions within the safety of the therapeutic environment before initiating a formal disclosure. According to Erikson (1963), identity formation is the most significant developmental task during ado­ lescence. For gender-nonconforming adolescents, an additional task is developing a positive gender iden­ tity (Dispenza & O’Hara, 2016). Gender identity for­ mation is complicated for many adolescents who feel pressures to conform to an assigned gender identity and societal gender norms. This pressure to conform often conflicts with an internal need to express authen­ tic feelings of self (Gagné et al., 1997). When youth disclose their nonconforming identity to parents, they know they must deal with their parents’ immediate and long-term reactions (D’Amico, Julien, Tremblay, & Chartrand, 2015). Managing the transition into a minority identity status can be stressful, especially if adolescents fear potential change in significant fam­ ily relationships or relationships with friends and other caring adults (Russell, 2003). Because trans ado­ lescents often lack access to identity-affirming resources (dickey, Singh, Chang, & Rehrig, 2017), many of them feel alienated. Klein, Holtby, Cook, and Travers (2015) have captured themes common in counseling litera­ ture for adolescents struggling with identity develop­ ment. These themes include feeling different from peers and experiencing a need to disclose these dif­ ferences. Additionally, the process of gender-identity

development typically includes a rejection of societal norms, which may include shocking acting-out behavior before becoming comfortable in their own identity (Maguen, Shipherd, Harris, & Welch, 2007). The professional counselor’s role includes advocat­ ing for social justice and challenging oppression and violence (Chen-Hayes, 2001). Affirmative practice includes advocating against oppression and violence that targets gender-nonconforming and transgender youth. Clinicians are ethically bound to promote envi­ ronments that affirm all gender identities. Although the American Counseling Association’s (ACA, 2014) Code of Ethics (C.5) states that counselors must pro­ vide nondiscriminatory services that are based on variables inclusive of gender identity, the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) (2009) competencies for counseling transgender clients offer a comprehensive guide for use in counseling transgender clients. Coming out or disclosing a nonconforming gender identity is one indicator that identity development is crystalizing (Bussey, 2011). In accordance with the ALGBTIC (2009) competency A.1, counselors should affirm that all persons “have the potential to live full functioning and emotionally healthy lives through­ out their lifespan while embracing the full spectrum of gender identity expression, gender presentation, and gender diversity beyond the male-female binary” (p. 4). While disclosing nonconforming gender iden­ tity to parents is considered a difficult process, there can be many psychological benefits (dickey et al., 2017). However, it is critical for clinicians to recognize and understand the importance of using appropriate language (e.g., correct name and pronouns) with transgender clients; be aware that language in the transgender community is constantly evolving and varies from person to person; seek to be aware of new terms and definitions within the transgender community; honor clients’ definitions of their own gender; seek to use language that is the least restrictive in terms of gender (e.g., using clients’ names as opposed to assum­ ing which pronouns the clients assert are gender affirm­ ing); recognize that language has historically been used to oppress and discriminate against transgender

Transgender Teens and Gender-Identity Disclosure

23

people; understand that the counselor is in a position of power and should model respect for the client’s declared vocabulary (ALGBITIC, 2009, B.1, p. 15). Unfortunately, unlike gender-nonconforming peo­ ple, whose developmental experience emerges from an intrinsic need for identity authenticity, family mem­ bers are often unwilling participants on this journey (Gagné, Tewksbury, & McGaughey, 1997). Supporting adolescents who choose to disclose gender nonconformity to their caregivers promotes the emotional well-being of these youth. Identity dis­ closure allows adolescents to acknowledge a noncon­ forming identity to others. According to the American Psychological Association (APA, 2011), though devel­ opment, expression, and disclosure often occur sequen­ tially, others may display nonconforming identity behavior but not identify themselves as transgender or genderqueer. APA (2011) further suggests that others may define and disclose their gender identity but choose not to express it. Adolescents often choose not to reveal a gender-nonconforming identity, opt­ ing instead to withdraw from friends and family and withhold sharing their true identity. This withdrawal is often grounded in fear of parental rejection and abuse and a desire to avoid hurting or disappointing parents (D’Amico et al., 2015). Disclosing one’s gender identity to those closely connected (or not so closely) is rarely a onetime event. It is a process that clients often find continues throughout their life, as they dis­ close to many people over time. Coming out refers to the lifelong process of the development of a positive transgender identity or gender-nonconforming iden­ tity. Unfortunately, some young people perceive this as an isolated event that is characterized by simply say­ ing the words out loud and setting the record straight (Morrow, 2006). For some, it is a very long and diffi­ cult struggle because they often have to confront many transphobic attitudes and discriminatory practices along the way. Before initiating the process of informing others, clients need to explore any of their own existing nega­ tive stereotypes and feelings of transphobia that they learned growing up. To learn to feel good about who they are, individuals ideally need to feel movement away from repulsion and pity, and tolerance toward feelings of appreciation and admiration (Corrigan & 24

Haddock

Matthews, 2003). However, therapists must remem­ ber that because the adolescent is identified as the cli­ ent, they should carefully adhere to ACA (2014) ethics code B.5.b. and remain sensitive to the “cultural diver­ sity of families and respect the inherent rights and responsibilities of parents/guardians regarding the wel­ fare of their children/charges according to law” (p. 7). Counselors will ideally work to establish, as appro­ priate, “collaborative relationships with parents/guard­ ians to best serve clients” (p. 7). There are multiple issues counselors should be aware of that have the potential to create barriers to disclosure to parents or to complicate the emotional well-being of trans or genderqueer clients. For exam­ ple, friends or family could demonstrate transphobia such as emotional disgust, fear, anger, or discomfort felt or expressed toward people who do not conform to society’s gender expectations (Fisher et al., 2016). Negative reactions can include a variety of behaviors that range from disapproval to criticism for not com­ ing out sooner. If, after disclosing gender identity, an individual is accused of not coming out sooner as a result of a perceived gain acquired by continuing to hide the nonconforming identity, the result is a loselose situation for the client (Corrigan & Matthews, 2003). Under this logic, courageously opening up about personal identity constitutes evidence of dishon­ esty. “People come out when they are ready to do so, and shaming them for not doing so sooner constitutes a rejection of their own experience with their iden­ tity” (Ford, 2014, p. 1). If deemed appropriate, the following activity is designed to promote an explora­ tion of thoughts, feelings, and potential fears related to coming out as gender nonconforming, the initial act of disclosure, and life following initial disclosure. Instructions

This exercise can be used in individual or group ther­ apy or can be assigned as homework for clients to engage in privately. The two main purposes of the exer­ cise are to empower clients to articulate their identity in their own words and to illuminate any unresolved fears related to the coming-out process. The exercise of writing the letter is broken into three primary top­ ics: self-awareness, self-affirmation, and action steps. Suggestion 1 facilitates exploration of the client’s self-

awareness and offers an opportunity to reflect on child­ hood memories that are meaningful in relation to gender-identity development. Suggestion 2 provides an opportunity for clients to build confidence related to their gender identity and offer reassurance to oth­ ers, if appropriate, that a shift in gender identity does not mean an end to the person they have known. Suggestion 3 invites clients to determine which actions they would like to see occur following the disclosure, including name and pronoun changes. Finally, Suggestion 4 gives clients the opportunity to set boundaries with regard to those with whom they are comfortable having the information shared. If the exercise is used in session, the client may be given the questions one at a time or all at once. Ideally, allow the client to read all the questions in the session before completing the exercise so they can give thoughtful consideration to the topics before for­ mally answering the questions. When executing the exercise, the client should be provided with the exer­ cise in printed form and allowed some quiet time to complete the answers. Because most sessions are lim­ ited to roughly an hour, that is probably not enough time to fully answer and explore all four parts of the draft of the letter. Thus, one session may be devoted to having the client draft the letter and another to explor­ ing the content. Alternatively, administer the ques­ tions and explore the answers one at a time over the course of several sessions. If the exercise is assigned as homework, give consideration to the same conditions for administration, determining whether to offer all questions at once or to administer them independently in a series of assignments. Brief Vignette

Jessica is a sixteen-year-old white adolescent who was assigned female at birth. She currently resides with her paternal grandmother, who became Jessica’s pri­ mary caregiver after the death of Jessica’s mother and the incarceration of her father. Jessica and her grand­ mother reside in a rural area and are part of the white racial majority that appears to have little tolerance for racial diversity. Jessica reports she holds conservative Christian views, and she is currently living in depressed socioeconomic conditions: the primary income is provided by government assistance. Jessica is an only

child, and Jessica’s parents married when they were teenagers after her mother became pregnant. Neither parent completed high school. Jessica is very assertive about her Christian beliefs; her grandmother has not expressed any indication of assigning the same mean­ ing to her own spiritual beliefs, which she defines only as “believing in God.” Jessica reports that her mother also identified as Christian when she was alive, though she displays distress when reporting that her father claims he has converted to Islam while in prison. Jessica was referred to outpatient individual counseling as aftercare following a brief inpatient hospitaliza­ tion for depression and suicidal ideation. Jessica has a history of cutting herself on multiple occasions and withdrawing from friends and family, and she has a deteriorating relationship with her grandmother. Through the course of therapy, Jessica shares the information that for several months she has strug­ gled with feeling that she does not fit in at school and that her family does not understand her. It proves to be fairly easy to establish a therapeutic rapport with Jessica, as she seems to desire genuine connection and acceptance. During the therapeutic process, she is increasingly open about her interests and identity. She reports that she is interested in trying out for the power-lifting team, which has been met with confu­ sion by her school because she is the only girl who has expressed a desire to participate. Her grandmother, who has allowed her to pursue the sport, expresses confusion over why she wants to participate in a “sport for boys.” Jessica also mentions being sexually attracted to a girl whom she identifies as her best friend. Ulti­ mately, as Jessica begins to explore her sexual identity, she reports that she does not identify as gay. This report is somewhat incongruent with her sexual inter­ est in her female friend. At this point, Jessica reveals that she identifies as male. She goes on to explain that her pronouns are male and asks to be called Jesse. During exploration of his gender-identity devel­ opment, Jesse reveals that his depression and isolation are primarily a result of the assumed rejection and reprimand he has felt from his grandmother related to his interests and identity, which do not align with traditional female gender norms. He reports making an effort to introduce his grandmother to the concept of transgenderism by making vague references and Transgender Teens and Gender-Identity Disclosure

25

comments. He reports that his grandmother’s response was passive, and he perceived her attitude to be one of disdain and disapproval, although her attitude was not entirely clear because she refused to be open to any discussion. She assertively responded that being transgender was a “sin” and that Jesse is simply “con­ fused.” She now insists that Jesse wear makeup and nail polish, “like girls are supposed to,” which offends Jesse’s sense of self. Jesse verbalizes a desire to commu­ nicate with his grandmother about his gender identity. Jesse and his therapist determine that writing a letter will be the first step toward articulating his thoughts about his identity and the steps he would like to take moving forward. He has specifically expressed a desire to secure a binder and investigate the option of hor­ mone blockers. The therapist asks Jesse to write the letter as a homework assignment after establishing that he has a secure and confidential way to do so and does not feel that his private writing is at risk of being discovered. Jesse reports that he has a password-pro­ tected tablet and that he is comfortable completing the exercise at home. He is motivated to complete the exercise, as he is determined to “accept myself and move forward.” Jesse returns to his next therapy appointment in two weeks and has completed all four components of the letter. He describes those two weeks as “two of the most agonizing weeks of my life.” He describes the activity as simultaneously painful and liberating. He admits that he did not expect giving words to thoughts that had lived only in his head would be so challenging. He reports having difficulty even reading his own words without crying. The focus of therapy for several weeks following the exercise is exploring Jesse’s thoughts and feelings as articulated in the letter and subsequently addressing his grief and fear about what will happen after disclosing his identity to his grandmother and other family members. He worries what his aunts and cousins might say; however, he is convinced that his school peer group will be accepting, which leaves him feeling more confident that he will have a solid support system. Ultimately, he expresses a desire and willingness to give the letter to his grand­ mother and formally come out to her as transgender.

26

Haddock

Suggestions for Follow-up

The exercise of writing the letter may unleash a flood of emotion for the client. Following the creation of the client’s disclosure script, you may want to follow up with an exploration of the client’s thoughts and feel­ ings, discussing the client’s authentic self as an affir­ mative practice that facilitates client empowerment. The process of writing the letter may be quite pain­ ful, and you should follow up and allow the client to spend time processing their thoughts and feelings before determining readiness to deliver the letter to the intended recipients. After crafting the disclosure letter and evaluating the timing for coming out, an additional follow-up could include facilitating an opportunity to prepare for various types of responses to the disclosure. It is impos­ sible to predict how others will respond to it. Thus, consideration for the reactions anyone could have, as well as how the client might plan to deal with them, are a good follow-up to the activity. Cultural norms inform belief systems, frames, perceptions, under­ standings, and behaviors, which can result in a com­ plex challenge for even the most culturally sensitive counselor. Explore the client’s feelings and potential responses if someone reacts with hate, unconditional love, or apathy. Contraindications for Use

Because of the sensitive and confidential nature of the exercise, it is important to carefully weigh the risk of discovery with the benefit of the exercise. Carefully exploring the client’s vulnerability to discovery is crit­ ical before assigning this exercise as homework. In addition, this exercise can be deeply emotional; thus, it is important to weigh the potential for activating a powerful emotional response that would be better managed in the presence of the therapist before assign­ ing this exercise as homework. Every therapist should thoroughly consider whether there is a risk for the parent or caregiver to discontinue treatment or respond violently if the letter is discovered. If therapists are concerned that the client’s emotional or physical safety would be at risk in any way, this exercise may not be appropriate for use as homework.

Professional Readings and Resources D’Amico, E., Julien, D., Tremblay, N., & Chartrand, E. (2015). Gay, lesbian, and bisexual youths coming out to their parents: Parental reactions and youths’ outcomes. Jour­ nal of GLBT Studies, 11, 411–437. doi:10.1080/1550428 X.2014. 981627. dickey, l., Singh A., Chang, S., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gender non­ conforming clients. In A. Singh & l. dickey (eds.), Affirma­ tive counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psychological Association. Dispenza, F., & O’Hara, C. (2016). Correlates of transgender and gender nonconforming counseling competencies among psychologists and mental health practitioners. Psychology of Sexual Orientation and Gender Identity, 3 (2), 156–194. doi:10.1037/sgd0000151. Jia, L., Strachan, S., Griffin, S., & Easton, A. (n.d.). Coming out: A coming out guide for trans young people. LGBT Youth Scotland. www.teni.ie/attachments/664c0589-3011-46a5­ a6a3-28269015b71b.PDF. Lev, A. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Press. Safe Schools Coalition. (n.d.). A public-private partnership in support of gay, lesbian, bisexual, and transgender queer and questioning youth. www.safeschoolscoalition.org/. TransPulse. (2017). Transgender resources. http://transgender pulse.com/. True Colors. (2016). Sexual minority youth and family services. www.ourtruecolors.org. Winch, G. (2014). Emotional first aid: Healing rejection, guilt, failure, and other everyday hurts. New York: Hudson Street Press.

Resources for Clients Brown, M. (2003). True selves: Understanding transsexualism— For families, friends, coworkers, and helping professionals. San Francisco: Jossey-Bass. Evelyn, J. (2007). Mom, I need to be a girl, 2nd edition. Long­ mont, CO: Just Evelyn. Herman, J. (2009). Transgender explained to those who are not. Bloomington, IN: Authorhouse. International Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Youth and Student Organisation. (2017). www. iglyo.com/. The International Lesbian, Gay, Bisexual, Transgender, Queer, and Intersex Youth & Student Organisation (IGLYO) is a pan-European network, working with over ninety-five LGBTQI youth and student organizations. It is run for and by young people. Krieger, E. (2011). Helping your transgender teen: A guide for parents. New Haven, CT: Genderwise Press.

Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Tando, D. (2016). The conscious parent’s guide to gender identity: A mindful approach to embracing your child’s authentic self. Avon, MA: Adams Media. Trans Youth Equality Foundation. (n.d.). Education, advocacy, and support for transgender youth and their families. www.transyouthequality.org. Wipe Out Transphobia. (2015). www.wipeouttransphobia. com/. Wipe Out Transphobia (WOT) is an international volunteer-led project with the sole aim of reducing and wiping out the transphobia in society that regularly affects anyone who strays from the traditional binary idea of gender as assigned at birth.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. https://www.counseling. org/resources/aca-code-of-ethics.pdf. American Psychological Association (APA). (2011). Answers to your questions about transgender people, gender iden­ tity, and gender expression. www.apa.org/topics/lgbt/ transgender.aspx. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. Beals, K. P., Peplau, L. A., & Gable, S. L. (2009). Stigma man­ agement and well-being: The role of perceived social sup­ port, emotional processing, and suppression. Personality and Social Psychology Bulletin, 35, 867–879. doi:10.1177/ 0146167209334783. Bussey, K. (2011). Gender identity development. In S. J. Schwartz, K. Luykcx, & V. L. Vignoles (eds.), Handbook of identity theory and research. New York: Springer. California State University at Long Beach. (n.d.). The coming out process. http://web.csulb.edu/colleges/chhs/safe-zone/ coming-out/. Chen-Hayes, S. (2001). Counseling and advocacy with trans­ gendered and gender-variant persons in schools and fam­ ilies. Journal of Humanistic Counseling, Education, and Development, 40 (1), 34–49. Corrigan, P., & Matthews, A. (2003). Stigma and disclosure: Implications for coming out of the closet. Journal of Mental Health, 12, 235–248. D’Amico, E., Julien, D., Tremblay, N., & Chartrand, E. (2015). Gay, lesbian, and bisexual youths coming out to their parents: Parental reactions and youths’ outcomes. Journal of GLBT Studies, 11, 411–437. doi:10.1080/1550428X.2014. 981627. dickey, l., Singh A., Chang, S., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gender noncon­ forming clients. In A. Singh & l. dickey (eds.), Affirmative

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counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: Ameri­ can Psychological Association. Dispenza, F., & O’Hara, C. (2016). Correlates of transgender and gender nonconforming counseling competencies among psychologists and mental health practitioners. Psychology of Sexual Orientation and Gender Identity, 3 (2), 156–194. doi:10.1037/sgd0000151. Erikson, E. (1963). Childhood and society. New York: Norton. Fisher, A., Castellini, E., Casale, H., Tagliagambe, M., Benni, L., Vittoria, L., Giovanardi, G., Ricca, V., & Maggi, M. (2016). Transphobia and homophobia levels in gender dysphoric individuals, general population, and health care providers. Journal of Sexual Medicine, 13 (5), S124. doi:10.1016/j.jsxm.2016.03.118. Ford, Z. (2014, April 2). Why coming out is a question of safety, not honesty. Think Progress. https://thinkprogress.org/why­ coming-out-is-a-question-of-safety-not-honesty-269d37 ca46d4#.w95tmgjl4. Gagné, P., Tewksbury, R., & McGaughey, D. (1997). Coming out and crossing over: Identity formation and proclama­ tion in a transgender community. Gender and Society, 11 (4), 478–508. Klein, K., Holtby, A., Cook, K., & Travers, R. (2015). Compli­ cating the coming out narrative: Becoming oneself in a heterosexist and cissexist world. Journal of Homosexual­ ity, 62 (3), 297–326. doi:10.1080/00918369.2014.970829. Liang, A. C. (1997). The creation of coherence in coming-out stories. In A. Livia and K. Hall (eds.), Queerly phrased: Lan­ guage, gender, and sexuality, 287–309. New York: Oxford University Press.

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Maguen, S., Shipherd, J., Harris, H., & Welch, L. (2007). Prev­ alence and predictors of disclosure of transgender identity. International Journal of Sexual Health, 19 (1), 3–13. doi:10. Prevalence19n01_02. Morrow, D. (2006). Coming out as gay, lesbian, bisexual, and transgender. In D. Morrow & L. Messinger (eds.), Sexual orientation and gender expression in social work practice: Working with gay, lesbian, bisexual, and transgender peo­ ple. New York: Columbia University Press. National Coalition of Anti-Violence Programs (NCAVP). (2014). Lesbian, gay, bisexual, transgender, queer, and HIV-affected hate violence in 2013. http://avp.org/wp-content/uploads/ 2017/04/2013_ncavp_hvreport_final.pdf. Russell, S. T. (2003). Minority youth and suicide risk. American Behavioral Scientist, 46, 1241–1257. doi:10.1177/000276420 2250667. U.S. Department of Justice. (2014). Uniform Crime Reporting Program: Hate crime statistics. https://ucr.fbi.gov/hate­ crime/2014. Winch, G. (2014). Emotional first aid: Healing rejection, guilt, failure, and other everyday hurts. New York: Hudson Street Press. Wood, Kathleen M. (1997) Narrative iconicity in electronicmail: Lesbian coming-out stories. In A. Livia and K. Hall (eds.), Queerly phrased: Language, gender, and sexuality, 257–273. New York: Oxford University Press. Zimman, L. (2009). “The other kind of coming out”: Transgender people and the coming out narrative. Gender and Language, 3 (1), 53–80. doi:10.1558/genl.v3i1.53.

GUIDELINES FOR THE LET TER Making the decision to come out as trans or genderqueer to your friends and family is an important first step toward embracing your authentic self. Here are some suggestions to get you started: 1. Describe how long you’ve known you were different and how you came to realize that trans/gender­ queer/etc. is the term that best communicates your identity. This can help others understand this is not a stage, an impulsive decision, or an act of teenage rebellion. 2. Reassure family and friends that you are and will always be the same person inside. Tell them that you will be okay and know you can still have a happy life that includes your future goals, such as going to college, having a career and a family, travel. Anything you want for your future is still possible! 3. End your letter with “action steps.” • What do you want or need from your family? • You may also want them to start using a different name or pronouns for yourself. Let them know

what they are and why these things are important to you.

4. Be specific about whom you do or do not want them sharing this information with. Here are some helpful hints to remember as you are writing: a. Your goal is to share this aspect of your identity with your loved ones, not ask for their permission to be who you are. b. Keep a respectful tone. You are looking for respect and support, so show the same toward those you are writing to. c. This information or even the concept might be new to them, and they may have a lot to learn about gender identity before they fully understand. Be simple. Transgender identities can seem completely foreign to many people. Stick to the basics as you begin. d. Your family loves you and, consequently, they worry about you. Negative reactions often come from their being worried about you, your future, and your safety. e. Be yourself. The most important thing is to relax and just tell your story! Keep it personal and about you. f. Your loved ones will also need emotional support, so it’s unfair to ask them not ever to tell anyone at all. It is appropriate to ask that they let you have your own conversation with a sibling, other parent, or family member first. Try not to wait too long, though, because withholding information about something important and emotional can be quite stressful. g. Finally, remember that this will not be a “one and done” conversation. Think of this as your “opening monologue.”

Laura R. Haddock

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4 ASSISTING YOUTH WITH DISCLOSING THEIR SEXUAL ORIENTATION AND/OR GENDER IDENTITY USING AN ECOMAP Richard A. Brandon-Friedman and M. Killian Kinney Suggested Uses: Activity, homework Objective

This activity is designed to help youth visualize their social environment in order to assist them with man­ aging the disclosure of their sexual orientation and/ or gender identity to others. Through this exercise, youth and therapists will be able to identify individ­ uals within youth’s environments to whom youth would like to come out and to whom they do not feel comfortable doing so. It will also assist youth and ther­ apists with understanding the interactions between the myriad parties involved in youth’s lives. Rationale for Use

Ecomaps are a way for individuals to diagram the systems and people within those systems that are involved in their lives. Through dynamic representa­ tion, individuals can picture themselves as the center of a complex web of relationships, each of which is unique yet interdependent on the others (Hartman, 1978; Ray & Street, 2005). Ecomaps can also demon­ strate the strength or conflict-ladenness of relation­ ships and interactions, allowing individuals and pro­ fessionals to explore relationship patterns (Hartman, 1978). As cocreated products, ecomaps enhance col­ laboration between clients and therapists and provide clients with feelings of empowerment because they are able to depict their social environments as they experience them (Hartman, 1978; Ray & Street, 2005). Ecomaps can also be used to monitor changes in rela­

tionships over time, thereby allowing for exploration of these changes (Ray & Street, 2005). When used with sexual and/or gender minority individuals, ecomaps provide a baseline for discus­ sion of relational processes, disruptions in family and social relationships, experiences of homophobia and discrimination tied to specific individuals, and the relationship individuals and their families have with other social systems (Grafsky & Nguyen, 2015). Eco­ maps also provide a greater understanding of the con­ text of sexual and/or gender minority youth’s lives and thus allow for a multilevel assessment of the sup­ ports available to the individuals and the areas in which intervention may be desired (Nguyen, Grafsky, & Munoz, 2016). Perhaps most important, the feel­ ings of empowerment can be beneficial to youth nav­ igating the complex coming-out process because they can translate this therapeutic experience to feeling con­ trol over disclosing their sexual and/or gender minority identities to others (Matthews & Salazar, 2012). With the number of interacting systems and the myriad people involved in youth’s lives, it can be diffi­ cult for the youth and professionals working with them to determine which individuals know the youth’s sex­ ual orientation and/or gender identity. To reduce the confusion that can occur and to help both the youth and professionals manage this situation, this activity involves the completion of an ecomap that can be used as a reference during discussion of the youth’s sexual orientation and/or gender identity. The activity will also help youth to systematically examine their

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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relationships with others and how their sexual ori­ entation and/or gender identity may be affecting those relationships. Within this exercise, additional information regard­ ing the degree to which youth have disclosed their sexual orientation and/or gender identity will also be collected. This is a novel extension of ecomap use, intentionally taking advantage of the ecomap’s ability to assess where interventions or changes may be best directed. With this information, the youth and their therapists will be able to examine patterns in the youth’s disclosure of their sexual orientation and/or gender identity, the youth’s desires regarding disclosure in the future, and the youth’s relationships that may be signifi­ cantly affected by others’ reactions to this disclosure. The healthy development of youth’s sexual and/ or gender minority identities is crucial for their wellbeing. Positive development of these identities has been closely tied to the amount and quality of social, familial, and professional supports that youth receive, and both are related to improved psychosocial func­ tioning, increased school attendance and perfor­ mance, reduced self-harm, reduced risk behaviors, and enhanced overall well-being (Brandon-Friedman & Kim, 2016; Higa et al., 2014; Roe, 2015). Alternatively, hiding these identities has been linked with increased mental health issues, substance abuse, and risky-behav­ ior concerns (Rosario, Schrimshaw, & Hunter, 2011). These supports may be especially important to sexual and/or gender minority youth who are also racial or ethnic minorities. Beliefs about and support for sexual and/or gender minority individuals vary sig­ nificantly among racial and ethnic groups, and research has suggested variations in participation in gay-re­ lated social activities, level of disclosure of sexual ori­ entation, mental health concerns, familial and peer acceptance, and prevalence of bullying, assault, and homelessness among youth from different racial and ethnic groups (Bostwick et al., 2014; Kosciw, Greytak, Palmer, & Boesen, 2014; Rosario, Schrimshaw, & Hunter, 2004). Racial and ethnic minorities may also feel excluded from the predominantly white main­ stream gay culture while also being stigmatized by others within the same racial or ethnic category owing to their sexual orientation and/or gender identity, which can lead to further feelings of isolation (Gray,

Mendelsohn, & Omoto, 2015; Han, 2006; Hunter, 2010). To work with these youth effectively, profes­ sionals must be attuned to how individuals experience the intersectionality of their identities and how these experiences affect their relationships with others. Another essential area to consider is the degree to which religion and spirituality play a role in youth’s lives or the lives of those with whom they have close relationships. Conflict between youth’s sexual orienta­ tion and/or gender identity and their religious or spiritual convictions, or between their identities and the religious or spiritual convictions of others in their lives, is related to heightened psychosocial diffi­ culties and relationship dysfunction and increased prevalence of running away and entrance into the child welfare system (Bozard & Sanders, 2014; Super & Jacobson, 2011). Alternatively, youth who are able to integrate their religious or spiritual beliefs with their sexual orientation and/or gender identity may experience improved overall well-being (Page, Lindahl, & Malik, 2013). Thus, professionals should inquire about the place of religion and spirituality in the lives of these youths and others with whom they are close and how religion or spirituality affects their relationships and their level of disclosure. Given the complex interactions among youth’s disclosure of their sexual orientation and/or gender identity, their psychosocial functioning, and their interpersonal relationships, professionals must encour­ age youth to determine the extent to which they wish to reveal their sexual orientation and/or gender iden­ tity to others, and they should work with youth to ensure this disclosure occurs in a safe and healthy man­ ner (Matthews & Salazar, 2012). Doing so not only involves assessing the various environments in which youth live, but also the youth’s relationships with oth­ ers and the effects that their racial or ethnic identity and their religious or spiritual beliefs may have on their experiences. Using an ecomap to assist with this process is consistent with ethical practice as delineated by the National Association of Social Workers (NASW), the American Association for Marriage and Family Therapy (AAMFT), and the American Mental Health Counseling Association (AMHCA). The Code of Eth­ ics of the NASW (2017) emphasizes the importance Assisting Youth with Disclosing Using an Ecomap

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of human relationships and obligates social workers to seek to enhance relationships among individuals and their surrounding social systems. Youth’s role in the construction of the ecomap and their determina­ tion of the relationships on which to focus enhance their self- determination (NASW, 2017, 1.02) and ensures them autonomy in decision making (AAMFT, 2015, 1.8; AMHCA, 2015, A1a), while the use of eco­ maps to monitor progress assists with practice evalu­ ation (AMHCA, 2015, B1b; NASW, 2017, 5.02). Instructions

Part 1: This activity can be completed using the pro­ vided template (see page 39) or on a separate sheet of paper. When using the template, have youth follow these steps to develop the ecomap: 1. Write their name in the middle circle. 2. Identify relevant individuals within each of the cat­ egories noted in the four quadrants (family, peers, professionals, and others). Professionals can include service providers, teachers, mentors, or others with whom the youth interacts within a formal relationship. 3. Write the names of these individuals within an oval in the appropriate quadrant. The names of those who have a closer relationship with the youth should be written in the ovals closer to the center, whereas the names of those with more distant relationships should be written in the outer ovals. There may be some left­ over ovals, depending on the number of relationships the youth currently has. If additional ovals are needed, they can be drawn in. 4. Identify which individuals are already aware of the youth’s sexual orientation and/or gender identity. The ovals containing these individuals’ names should be colored green. The ovals containing the names of indi­ viduals who do not know the youth’s sexual orienta­ tion and/or gender identity should be colored red. If the youth is unsure if an individual knows or not, that circle should be colored yellow. 5. Using a scale from 1 (extremely important) to 5 (not very important), the youth should rate how important it is to disclose their sexual orientation and/or gender identity to each individual whose name appears in a red or yellow oval. 32

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6. Using the simplified ecomap key shown below, indicate the direction of communication between the youth and each individual and the strength of that relationship. Bidirectional communication Unidirectional communication Strong relationship Weak relationship Stressful relationship

Ensure that there is a line connecting the youth to each oval, that the direction of communication is noted for each relationship, and that all individuals in a yellow or red oval have a number on the scale of importance of disclosure associated with them. Note: If there is a desire not to use the provided tem­ plate, the same steps should be followed, with an oval drawn for each person noted. There are two advan­ tages to drawing an individualized ecomap: there can be additional variance in the distance between the youth’s center circle and the ovals that contain indi­ viduals’ names, and there will not be any empty circles. Part 2: Once the ecomap is complete, open a dialogue with the youth regarding what has been drawn, in the following order: 1. Ask the youth to describe the emotions experi­ enced while constructing the ecomap. Questions to consider include: a. What was it like to write out the names of those important to you and then classify your relationship with them? b. Is the number of individuals in each quadrant approximately equal? If not, where do the majority of individuals cluster? What might be the reasons for this? c. Did you find yourself questioning who knows your sexual orientation and/or gender identity and who does not? If so, how do you feel about that? If not, what made it so easy to know who is aware of your sexual orientation and/or gender identity?

d. Are there more people who know your sexual ori­ entation and/or gender identity or more people who do not know? What does the level of your disclosure mean to you? e. What are your relationships with the people who fall into each category? Is there a connection be­ tween those who know and the type of relationship you have with them? 2. Focus the youth on those who are aware of the youth’s sexual orientation and/or gender identity (shaded green). Ask the youth to consider how the individuals learned about the youth’s sexual orienta­ tion and/or gender identity, whether this disclosure had been desired, and what effects, if any, the disclo­ sure had on the relationship between the youth and those individuals. Pay particular attention to the ways in which the relationship between the youth and the individuals discussed are classified and the direc­ tion of communication between them. If most of these relationships are distant, weak, or strenuous, this may be an indication of conflict regarding the youth’s sexual orientation and/or gender identity. Those who know about the youth’s sexual orien­ tation and/or gender identity and with whom the youth has a strong bidirectional relationship are supports that can be used during future disclosures, while the characteristics of the individuals or relationship types of those who had a negative reaction can guide future decision making. Those with whom the youth has strong relationships but to whom they have not dis­ closed their sexual orientation and/or gender identity are ideal targets to consider for future disclosure, as they may become important supports as the youth comes to further understand their sexual orientation and/or gender identity. Similarly, identifying those with whom the youth has tenuous relationships may provide guidance regarding the people to whom the youth may not wish to disclose their sexual orienta­ tion and/or gender identity. Finally, by comparing eco­ maps created over several months, youth will be able to see how the disclosure of their sexual orientation and/or gender identity affects their relationships, which can provide further guidance in determining with whom they wish to build relationships as they age and gain more control over their environment.

3. Focus the youth on those who are not aware of their sexual orientation and/or gender identity (shaded red). Ask them to describe these relationships. Are they mostly tenuous, distant relationships of minor importance to the youth (labeled 4 or 5)? Are there some located nearer to the youth and with whom they have a strong relationship? If so, did the youth indi­ cate a desire to disclose to these individuals or not? Those who are near the youth but whose ovals are shaded red should be noted for the next step regard­ less of the level of desire to disclose. Also note any individuals whose ovals are shaded red but to whom the youth wants to disclose sexual orientation and/or gender identity. Part 3: Explain to the youth that in this part of the exercise, the discussion will focus on those noted as important in the previous step. This may be the most therapeutically intense part of the activity, as the youth will be challenged to articulate the reasons the noted individuals were labeled as they were and what the classifications of various individuals reveal about the youth’s relationships with others. 1. Ask the youth to consider those labeled 1 or 2. What makes disclosure of the youth’s sexual orienta­ tion and/or gender identity to each of these individ­ uals so important? What does the youth see as the likely outcome of disclosure to each individual? Are the relationships likely to be affected in a positive or negative manner? 2. Prompt the youth to consider any individuals who are close to the center of the ecomap but to whom the youth does not wish to disclose. Work with the youth to explore the reasons behind this desire. What emo­ tions are raised when considering these relationships? Is the youth fearful of the possible response? Are there indications that disclosure may lead to an unsafe situation? Is the youth reacting to a previous situa­ tion with the individual and making decisions based on those interactions? 3. Are there any individuals to whom the youth feels it is not safe to disclose sexual orientation and/or gender identity? If so, the youth must determine how to prevent them from learning this information. This

Assisting Youth with Disclosing Using an Ecomap

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may include discussion with others of the importance of not disclosing to these individuals. A safety plan may need to be written in case disclosure does occur. 4. Ask the youth to consider how individuals in the different quadrants are classified. Is there a pattern regarding the people to whom the youth wishes to dis­ close sexual orientation and/or gender identity? Is the youth avoiding more intimate, personal relationships and focusing only on those that are more temporary? If so, what are the reasons behind such decisions? 5. Ask the youth if this discussion has changed their mind regarding how the relationships with individuals were labeled or if changes to the level of importance of disclosure to any individuals are needed. Adjust­ ments should be made before moving on to Part 4. Part 4: At this time, the youth should develop a plan for the disclosure of sexual orientation and/or gender identity to those identified as people to whom it is important to disclose. 1. On the basis of the previous discussion, develop a list of those to whom the youth wishes to disclose. The list should be ordered in terms of importance of the disclosure to the youth. If the youth is unsure and does not feel ready to fully disclose to anyone who does not know, this should be explored theraputically to understand and process the youth's reasoning. It may be useful to begin with those who were shaded yellow, as communicating the youth’s sexual orienta­ tion and/or gender identity to these individuals may be easier. 2. Once the list has been created, work with the youth to develop a plan for disclosing sexual orientation and/ or gender identity to each individual. If the youth works best with well-defined plans, help identify a specific time, location, and method of disclosure for each individual. Setting a deadline may be useful if the youth is feeling pressure to make a disclosure to a spe­ cific individual, but the youth should not be admon­ ished for not meeting the deadline. Instead, the reasons for the delay should be explored with the youth. 3. Work with the youth to implement the plan one step at a time. Disclosure of sexual orientation and/or gender identity can be a difficult step, and the youth may need support during the process. 34

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While the youth should initially begin speaking with those who will probably be supportive, the youth must be prepared to deal with any possible reaction. Individuals may react to the youth’s disclosure in unexpected ways, and the youth needs to understand this. Strategies should be developed for how to deal with poor reactions, should they occur. Brief Vignette

Chris, a fourteen-year-old white, able-bodied, cisgender male, began therapy nine months ago as part of his placement into treatment foster care as a result of legal difficulties. Chris has been in foster care since age twelve, when he was removed from his mother’s cus­ tody because of substantiated physical abuse. At the time of his removal, Chris’s father was unable to care for Chris owing to financial struggles. Chris main­ tains a strong, positive relationship with his father, but he has a strained and problematic relationship with his mother. He has a positive but more distant relation­ ship with his foster parents, with whom he has been living for two years. Chris’s father is working to regain custody of Chris, which will probably happen within the next six months. Chris disclosed his sexual orientation to his ther­ apist and Department of Child Services (DCS) case manager three weeks ago and has since expressed concerns about who knows that he is gay and how he should proceed with telling others. He noted that he has told some friends and family, but he is worried about how others will react. Given the number of peo­ ple in Chris’s life and the complexity of his relation­ ships with those individuals, his therapist felt an eco­ map would help him visualize his relationships with others and determine how to proceed. Working with his therapist, Chris developed an ecomap. He described strong positive relationships with his sister, Rachel; two friends, Alisha and Robert; his therapist; his father; and a neighbor, James. To denote the strength of these relationships, he drew bold lines to these individuals. He described positive but weak relationships with his foster parents, his men­ tor, and Robert’s mother. He drew a thin line between himself and these individuals to represent these rela­ tionships. Because all these relationships were posi­ tive and bidirectional, he added arrows to both ends of the connecting lines. Chris then listed strained

relationships with his grandma, his biological mother, and his DCS worker. He indicated these difficulties with slashed lines and added arrows to represent the direction of the conflict. Chris’s therapist asked him to consider who he knew was aware of his sexual orientation, those who might be aware, and those he felt did not know. Those he knew were aware were shaded green (shown in the sample ecomap as diagonal lines running down­ ward left to right), those who possibly knew, yellow (shown in the sample as diagonal lines running down­ ward right to left), and those who did not know, red (shown in the sample as dotted with asterisks). Chris also indicated how important it felt to tell each of the people listed using a scale from 1 to 5. Chris’s therapist noted that those close to Chris were mostly shaded green or yellow, indicating that there has been some disclosure by him directly or that he felt that they may know his sexual orientation. Those who are close to him and shaded yellow were categorized as 1s or 2s, showing that he has a desire to ensure those with whom he has a close relationship know his sexual orientation. The therapist also recog­ nized that the individuals shaded red were mostly on the periphery and labeled with higher numbers. The one exception to this pattern was Chris’s rela­ tionship with Robert. Chris marked this relationship as strong and bidirectional, but he shaded the oval red and labeled his desire to disclose to Robert a 5. The therapist prompted Chris to consider the reasons for not wanting to disclose his sexual orientation to Robert given the strength of their relationship. As Chris con­ sidered this, the therapist also observed that Chris had indicated that he did want to disclose his sexual orientation to Robert’s mother. Chris reported that he and Robert had grown up together, and Robert is his best friend. He stated that he would like to tell Robert, but he has heard Robert make disparaging comments about gay peo­ ple before, and he does not want to lose his friend­ ship as a result of disclosing his sexual orientation. He noted this is his biggest struggle, but he had not mentioned it to the therapist before out of concern that the therapist would focus on that relationship only. He reported he wanted to tell Robert’s mother first, as she might be able to assist him with talking to Robert.

Respecting Chris’s desires to focus on other rela­ tionships first, the therapist worked with him to develop a plan for disclosing his sexual orientation to those identified as important to him. When ranking the desired time frame of disclosure to others, Chris listed his biological father, his foster parents, and Robert’s mother, in that order. His therapist noted that, given that Chris’s sister is already aware of his sexual orientation, she may be able to assist him with dis­ closing to his father. Chris and his therapist also devel­ oped a plan to speak with Chris’s DCS caseworker together to ask for her help in facilitating the disclo­ sure to Chris’s foster parents. Chris indicated that once this plan was completed, he would consider if and how to disclose to Robert. Suggestions for Follow-up

As therapy progresses, the ecomap should be used to guide interventions relating to the disclosure of the youth’s sexual orientation and/or gender identity. As disclosure plans are completed, the ecomap should be updated. Additional individuals may be added to the ecomap over time, and relationships between the youth and others may change, which would require a revision. Given that the ecomap also provides a snapshot of the youth’s interpretations of their relationships with others, it can also be used to guide therapeutic interventions focused on improving tenuous or stress­ ful relationships, regardless of their connection to the youth’s sexual orientation and/or gender identity. Because the ecomap will change over time, it can be used to monitor the stability of the youth’s relation­ ships with others and to note when significant changes occur. The meanings of these changes can be addressed in therapy. The ecomap can also be used as a reference docu­ ment by professionals working with the youth to mon­ itor who knows the youth’s sexual orientation and/or gender identity and who does not. Those who know should be made aware of who does not so that they can safeguard the youth’s privacy. If the youth has a goal of disclosing sexual orientation and/or gender identity to everyone listed, the ecomap can serve as a checklist to track progress toward that goal.

Assisting Youth with Disclosing Using an Ecomap

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Contraindications for Use

This activity has no specific contraindications. For youth who have a disability, the therapist can make accommodations such as reading or writing for them. One caution is that this activity foregrounds youth’s sexual orientations and/or gender identities and their disclosure to others. Many youth who present for therapy may be there for concerns completely unrelated to their sexual orientation and/or gender identity. While the professional literature suggests that disclosing individuals’ sexual orientation and/or gender identity to others is beneficial to psychosocial functioning, it must also be recognized that sexual orientation and/or gender identity is but one aspect of an individual’s global identity and should not be a primary focus of therapeutic services if there are no indications of concerns regarding this aspect of their lives. It is also imperative that therapists work with the youth to realistically appraise the likely conse­ quences of disclosing their sexual orientation and/or gender identity to others. Negative reactions to this kind of disclosure are one of the largest contributors to youth homelessness, and many youth report suf­ fering abuse after disclosures (Choi, Wilson, Shelton, & Gates, 2015). Unfortunately, these negative experi­ ences also occur within professional systems (Mountz, 2011), which highlights the all too real concerns that sexual and/or gender minority youth have. Both therapists and youth should be aware of the possible repercussions of disclosure, and plans should be made accordingly. Therapists should also ensure that any reports of abuse or harassment by individuals that are revealed during this exercise are reported to the appropriate authorities. Professional Readings and Resources Bilodeau, B. L., & Renn, K. A. (2005). Analysis of LGBT iden­ tity development models and implications for practice. New Directions for Student Services, 2005 (111), 25–39. doi:10.1002/ss.171. Fostering Transitions: A CWLA/Lambda Legal Joint Initiative. (2012). Getting down to basics: Tools to support LGBTQ youth in care. New York: Lambda Legal and Child Welfare League of America. Legate, N., Ryan, R. M., & Weinstein, N. (2011). Is coming out always a “good thing”? Exploring the relations of auton­

36

Brandon-Friedman & Kinney

omy support, outness, and wellness for lesbian, gay, and bisexual individuals. Social Psychological and Personality Science, 3 (2), 145–152. doi:10.1177/1948550611411929. Mallon, G. P. (ed.). (2017). Social work practice with lesbian, gay, bisexual, and transgender people, 3rd edition. New York: Routledge. Shilo, G., & Savaya, R. (2011). Effects of family and friend sup­ port on LGB youths’ mental health and sexual orientation milestones. Family Relations, 60 (3), 318–330. doi:10.1111/ j.1741-3729.2011.00648.x.

Resources for Clients Belge, K., & Bieschke, M. (2019). Queer: The ultimate LGBT guide for teens, 2nd edition. San Francisco: Zest Books. Genogram Analytics, LLC. (2014). Standard ecomap symbols. http://genogramanalytics.com/ecomap_symbols.html. Huegel, K. (2018). GLBTQ: The survival guide for gay, lesbian, bisexual, transgender, and questioning teens, 3rd edition. Minneapolis: Free Spirit Publishing. Owens-Reid, D., & Russo, K. (2014). This is a book for parents of gay kids: A question and answer guide to everyday life. San Francisco: Chronicle Books.

References American Association for Marriage and Family Therapy (AAMFT). (2015). Code of ethics. Alexandria, VA: Author. American Mental Health Counselors Association (AMHCA). (2015). AMHCA code of ethics. Alexandria, VA: Author. Bostwick, W. B., Meyer, I., Aranda, F., Russell, S., Hughes, T., Birkett, M., & Mustanski, B. S. (2014). Mental health and suicidality among racially/ethnically diverse sexual minority youths. American Journal of Public Health, 104 (6), 1129–1136. doi:10.2105/AJPH.2013.301749. Bozard, R. L., Jr., & Sanders, C. J. (2014). When out in church means out of church: Religious rejection and resilience as wellness factors among Christian sexual minority youth. In M. T. Garret (ed.), Youth and adversity: Psychology and influences of child and adolescent resilience and coping, 27–46. Hauppauge, NY: Nova Science Publishers. Brandon-Friedman, R. A., & Kim, H.-W. (2016). Using social support levels to predict sexual identity development among college students who identify as a sexual minority. Journal of Gay and Lesbian Social Services, 28 (4), 1–25. doi:10.1080/10538720.2016.1221784. Choi, S. K., Wilson, B. D. M., Shelton, J., & Gates, G. J. (2015). Serving our youth 2015: The needs and experience of lesbian, gay, bisexual, transgender, and questioning youth experi­ encing homelessness. Los Angeles: Williams Institute, UCLA School of Law, and True Colors Fund. Grafsky, E. L., & Nguyen, H. N. (2015). Affirmative therapy with LGBTQ+ families. In S. Browning & K. Pasley (eds.), Contemporary families: Translating research into practice, 196–212. New York: Routledge.

Gray, N. N., Mendelsohn, D. M., & Omoto, A. M. (2015). Community connectedness, challenges, and resilience among gay Latino immigrants. American Journal of Community Psychology, 55 (1–2), 202–214. doi:10.1007/ s10464-014-9697-4. Han, C.-S. (2006). Being an Oriental, I could never be com­ pletely a man: Gay Asian men and the intersection of race, gender, sexuality and class. Race, Gender, and Class, 13 (3–4), 82–97. Hartman, A. (1978). Diagrammatic assessment of family rela­ tionships. Social Casework, 59 (8), 465–476. Higa, D., Hoppe, M. J., Lindhorst, T., Mincer, S., Beadnell, B., Morrison, D. M., . . . & Mountz, S. (2014). Negative and positive factors associated with the well-being of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth. Youth and Society, 46 (5), 663–687. doi:10.1177/0 044118X12449630. Hunter, M. A. (2010). All the gays are white and all the blacks are straight: Black gay men, identity, and community. Sexuality Research and Social Policy, 7 (2), 81–92. doi:10. 1007/s13178-010-0011-4. Kosciw, J. G., Greytak, E. A., Palmer, N. A., & Boesen, M. J. (2014). The 2013 National School Climate Survey: The experiences of lesbian, gay, bisexual, and transgender youth in our nation’s schools. New York: Gay, Lesbian, & Straight Education Network (GLSEN). Matthews, C. H., & Salazar, C. F. (2012). An integrative, empow­ erment model for helping lesbian, gay, and bisexual youth negotiate the coming-out process. Journal of LGBT Issues in Counseling, 6 (2), 96–117. doi:10.1080/15538605.2012. 678176. Mountz, S. (2011). Revolving doors: LGBTQ youth at the inter­ face of the child welfare and juvenile justice systems. LGBTQ Policy Journal at the Harvard Kennedy School, 1, 29–45.

National Association of Social Workers (NASW). (2017). Code of ethics of the National Association of Social Workers. https://www.socialworkers.org/About/Ethics/Code-of­ Ethics/Code-of-Ethics-English. Nguyen, H. N., Grafsky, E. L., & Munoz, M. (2016). The use of ecomaps to explore sexual and gender diversity in couples. Journal of Family Psychotherapy, 27 (4), 308–314. doi:10. 1080/08975353.2016.1235433. Page, M. J., Lindahl, K. M., & Malik, N. M. (2013). The role of religion and stress in sexual identity and mental health among lesbian, gay, and bisexual youth. Journal of Research on Adolescence, 23 (4), 665–677. doi:10.1111/jora.12025. Ray, R. A., & Street, A. F. (2005). Ecomapping: An innovative research tool for nurses. Journal of Advanced Nursing, 50 (5), 545–552. doi:10.1111/j.1365-2648.2005.03434.x. Roe, S. L. (2015). Examining the role of peer relationships in the lives of gay and bisexual adolescents. Children & Schools, 37 (2), 117–124. doi:10.1093/cs/cdv001. Rosario, M., Schrimshaw, E. W., & Hunter, J. (2004). Ethnic/ racial differences in the coming-out process of lesbian, gay, and bisexual youths: A comparison of sexual identity development over time. Cultural Diversity and Ethnic Minority Psychology, 10 (3), 215–228. doi:10.1037/1099­ 9809.10.3.215. Rosario, M., Schrimshaw, E. W., & Hunter, J. (2011). Different patterns of sexual identity development over time: Impli­ cations for the psychological adjustment of lesbian, gay, and bisexual youth. Journal of Sex Research, 48 (1), 3–15. doi:10.1080/00224490903331067. Super, J. T., & Jacobson, L. (2011). Religious abuse: Implica­ tions for counseling lesbian, gay, bisexual, and transgen­ der individuals. Journal of LGBT Issues in Counseling, 5 (3–4), 180–196. doi:10.1080/15538605.2011.632739.

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VIGNET TE ECOMAP WORKSHEET

FA MI LY

PE E R S Sam (mother) 5 Carsen 1

Pat (grandma) 3 Rachel (sister)

Robert 5

Jeffrey (father) 1

Alisha

Foster parents 2 Chris (15)

Karen (Robert's mom) 2

Ry (therapist)

Sarah (DCS)

James (neighbor) 2

David (mentor) 3

PROFESSIO N ALS

OTH E R S

Bidirectional communication

Important to disclose

1 = extremely important

Unidirectional communication

their sexual orientation

2 = very important

and/or gender identity

Strong relationship

3 = moderately important

Weak relationship

4 = slightly important

Stressful relationship

5 = not very important

Awareness of sexual orientation and/or gender identity Not aware Unsure if aware Aware

Designed by R. A. Brandon-Friedman, MSW. LCSW, LCAC and M. K. Kinney, MSW, LSW (2017)

38

Richard A. Brandon-Friedman and M. Killian Kinney

ECOMAP WORKSHEET

FA MI LY

PE E R S

PROFESSIO N ALS

O TH E R S

Bidirectional communication

Important to disclose

1 = extremely important

Unidirectional communication

their sexual orientation

2 = very important

and/or gender identity

Strong relationship

3 = moderately important

Weak relationship

4 = slightly important

Stressful relationship

5 = not very important

Awareness of sexual orientation and/or gender identity Not aware Unsure if aware Aware

Designed by R. A. Brandon-Friedman, MSW. LCSW, LCAC and M. K. Kinney, MSW, LSW (2017)

Richard A. Brandon-Friedman and M. Killian Kinney

39

5 MUST BE THE MUSIC: MUSICAL AUTOBIOGRAPHY AND CRITICAL LYRIC ANALYSIS Kiahni Nakai Suggested Uses: Activity, homework Objective

This musical autobiography assessment activity and critical lyric analysis homework assignment are created for practitioners who would like to build rapport and process emotions with LGBTQ (lesbian, gay, bisexual, transgender, questioning) clients. The musical auto­ biography assessment activity assesses psychological coping strategies through musical interests and pref­ erences. The critical lyric analysis homework assign­ ment engages the client in dialogue about the lyrics of a song in order to build therapeutic rapport. These activities can be especially helpful for clients who have difficulty expressing their feelings through traditional talk therapy or for clients who have not come out to family and friends. They can also be help­ ful when the therapist and client have hit a communi­ cation roadblock. These activities are applicable for use with teens and young adult LGBTQ clients. They can also be used for multiple-minority clients who come from cultural backgrounds where music is a central component of self-expression and a coping mechanism of their culture. Rationale for Use

Music has been used for centuries to express sorrow, joy, love, and shared life experiences. Music can lower anxiety by decreasing levels of the stress hormone cortisol and improving the body’s immune system function. New studies are using music to treat pain and manage a host of mental and physical health ailments (Novotney, 2013). Chanting, clapping, and singing in unison have been used by many cultures as traditional

methods of healing, managing grief, and bolstering group cohesion (Armstrong, 2016). Music and the arts in general can also provide a safe space for the LGBTQ community. Aronoff and Gilboa (2015) note that gay, lesbian, bisexual, and transgender Americans have been keen participants in choirs, where music provides a sense of unity and community. Using music within counseling and ther­ apy sessions can provide an outlet for LGBTQ clients, regardless of culture, who identify music as a central component of their identity. According to Gonzalez and Hayes (2009), music can also be useful for building rapport with clients who are resistant to traditional counseling interventions. Music can also offer an alter­ native for those who may have difficulty expressing their emotions through casual conversation, as music may convey the complexity of a person’s feelings better than words can (Armstrong, 2016). A musical autobiography assessment is an effective method to gain a holistic picture of a client’s needs and can assist in the development of an intervention plan (Bain, Grzanka, & Crowe, 2016). By analyzing the lyrics of songs, a critical lyric analysis can help facilitate dialogue and engage clients in conversations about their identity and experiences of prejudice and discrimination (Bain et al., 2016). As a result, clients can discuss their opinions on whether the song lyrics are irrelevant, helpful, or empowering. The client can share how important, or unimportant, the song is as it relates to processing feelings, healing, and moving forward throughout the counseling process. Lesbian, gay, bisexual, transgender, and ques­ tioning clients can benefit from the use of music in counseling sessions especially to express opinions,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

40

experiences, and identities that may be difficult to dis­ cuss in their friend and family circles, as many LGBTQ clients struggle with being accepted within their com­ munities. LGBTQ clients still receive negative criticism and messages and are vulnerable to social exclusion, physical harassment, and verbal harassment, which cause many clients to struggle with opening up and sharing with others (Bain et al., 2016). Integrating music into therapeutic sessions can also provide clients with an alternative way to share their personal narra­ tive and to support practitioner-client communication (Lenes, Swank, & Nash, 2015). Therapists must be aware of their own attitudes toward LGBTQ clients in order to avoid any issues with countertransference throughout the therapeutic process. Counselors respect the diversity of clients and seek training in areas in which they are at risk of imposing their values on clients, especially when the counselor’s values are inconsistent with the client’s goals or are discriminatory (ACA, 2014). Best prac­ tices with clients should emphasize inclusivity, cre­ ation of safe space, use of preferred language, knowl­ edge of LGBTQ culture and music, and affirmative therapy (Whitehead-Pleaux et al., 2012). According to Bain and colleagues (2016), queer music therapy suggests that when working with LGBTQ clients to combat heteronormativity by emphasizing the complexity and fluidity of sexual orientation, therapists should support expression of unique personal and social conflicts that result from oppression. Therapists should also empower queer individuals to find strength in differences by freely expressing and performing their gender and sexual identity. Queer music therapy can also be used to positively affect interpersonal relationships, to counteract neg­ ative social pressures, and to emphasize common cause rather than commonality of identity (Bain et al., 2016). Music therapy provides a unique and engaging way to discuss clients’ presenting concerns and brain­ storm constructive interventions. When music ther­ apy is coupled with queer theory, the intricacies of sex­ ual orientation can be discussed in a way that affirms LGBTQ clients’ experiences, addresses heterosexism, and explores oppression in a way that music therapy

does not address alone (Bain et al., 2016). It is important that psychologists and counselors maintain objectivity when listening to the musical selection chosen by their client and not impose their own beliefs, personal tastes, and values on their client, especially with musical genres that may be stereo­ typed as controversial or negative (e.g., rap and heavy metal music) (Kimbel & Protivnak, 2010). Psycholo­ gists must be aware of and respect cultural, individual, and role differences and should avoid imposing their values on their clients (APA, 2013; ACA, 2014). Instructions

This worksheet can be used with individuals, groups, couples, and families. This activity can also be used in school counseling settings. Print the first handout, “Musical Autobiography Assessment Activity” (page 44), and use it in session only after confirming that music is important or useful to the client. Provide cli­ ents with enough time to complete the handout and to share their responses with the counselor, social worker, or psychologist while in session. Print the second handout, “Critical Lyric Analysis Homework Assignment” (page 45), and give it to the client to take home and complete. Ask the client to return to the following session with the completed handout and a piece of music to share with the therapist (e.g., on a CD, on a mobile device, on a musical instrument, or by singing). Begin the session by reading over the lyrics written on the worksheet. Then listen to the song brought to the session by the client without inter­ ruptions or distractions. Provide enough time to review the lyrics with the client after the song is played and ensure that there is enough time for the client to share their interpretation of the music and/ or lyrics. Ask the client to complete the “Review/ Comments” section at the end of the therapeutic ses­ sion. Repeat this activity when needed and if requested in the “Review/ Comments” section. Brief Vignette

Kendrick has recently come out to his family and friends, but he can see that his sexuality makes them feel uncomfortable, and he has been unable to discuss his feelings with them. Kendrick sought therapy

Musical Autobiography and Critical Lyric Analysis

41

because he feels alone. The people he used to rely on for support and guidance have become distant and quiet. The counselor explored questions with Kendrick about his musical preferences, and Kendrick noted in session that when he is sad, he is able to seek refuge in the soul and blues songs that his parents and grand­ parents played in the home. He observed that he is able to remember the times when he was a child and felt comforted by his family members. With the assis­ tance of the “Must Be the Music” activity and home­ work assignment, Kendrick was able to identify his feelings, how he uses music to cope with his current feelings, and how he uses music to improve his mood and outlook. This understanding helped Kendrick identify the musicians and genres that provide themes of comfort, positivity, and LGBTQ empowerment. By using the autobiography assessment activity and the critical lyric homework assignment with Kendrick, the therapist received more information about the client’s family dynamics and coping mechanisms. Kendrick was able to share themes of love, motivation, confidence, and pride that may have been difficult to share with his family and friends. The music ther­ apy exercise helped build client-practitioner rapport and understanding. Suggestions for Follow-up

These worksheets can be useful for LGBTQ clients who are resistant to counseling or have difficulty express­ ing their emotions. If clients continue to have difficulty sharing their thoughts throughout later sessions, or if the client and counselor have reached an impasse, repeat this exercise and ask the client to share addi­ tional songs. Therapists should plan time to read the lyrics provided at the beginning of the session and should also plan time for clients to share their inter­ pretation of the musical piece provided. Contraindications for Use

Before presenting these worksheets, it is important that the therapist understands that music is an impor­ tant part of the client’s life, coping mechanisms, selfexpression, and/or identity. Music may not be relevant to all LGBTQ clients and may not be a central factor in their lives. Instead, some clients may cite the Inter­ net, books, television, and movies as central to their 42

Nakai

identity formation (Aronoff & Gilboa, 2015). Last, any indications of threats to self or others should be assessed before beginning this activity. If musical themes of self-harm or harm to others are pres­ ent during this activity, it is important to follow proper ethical guidelines and local legal steps to ensure the client is safe from harm. Professional Readings and Resources American Counseling Association (ACA). (2014). American Counseling Association code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2013). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Armstrong, C. (2016, February 29). Music: A powerful ally in your counseling sessions. Counseling Today. http://ct. counseling.org/2016/02/music-a-powerful-ally-in-your­ counseling-sessions/. Aronoff, U., & Gilboa, A. (2015). Music and the closet: The roles music plays for gay men in the “coming out” process. Psychology of Music, 43 (3), 423–437. https://doi.org/10. 1177/0305735613515943. Bain, C. L., Grzanka, P. R., & Crowe, B. J. (2016). Toward a queer music therapy: The implications of queer theory for radically inclusive music therapy. Arts in Psychotherapy, 50, 22–33. https://doi.org/10.1016/j.aip.2016.03.004. Gonzalez, T., & Hayes, G. (2009). Rap music in school coun­ seling based on Don Elligan’s rap therapy. Journal of Cre­ ativity in Mental Health, 4 (2), 161–172. https://doi.org/ 10.1080/1540138092945293. Kimbel, T. M., & Protivnak, J. J. (2010). For those about to rock (with your high school students), we salute you: School counselors using music interventions. Journal of Creativity in Mental Health, 5 (1), 25–38. Lenes, E., Swank, J. M., & Nash, S. (2015). A qualitative explo­ ration of a music experience within a counselor educa­ tion sexuality course. Journal of Creativity in Mental Health, 10 (2), 216–231. https://doi.org/10.1080/15401383.2014. 983255. National Association of Social Workers (NASW). (2017). National Association of Social Workers code of ethics. https://www.socialworkers.org/About/Ethics/Code-of­ Ethics/Code-of-Ethics-English. Novotney, A. (2013, November). Music as medicine. https:// www.apa.org/monitor/2013/11/music.aspx. Ocean, F. (2012). “Forrest Gump.” On Channel Orange. Warner/ Chapel Music. Ross, S. (2016). Utilizing rhythm-based strategies to enhance self-expression and participation in students with emo­ tional behavioral issues: A pilot study. Music Therapy Per­ spectives, 34 (1), 99–105. https://doi.org/10.1093/mtp/ miv021.

Secret Weapon. (1982). Must Be the Music. New York: Prelude Records. Thaut, M. H. (2015). Music as therapy in early history. Progress in Brain Research, 217, 143–158. https://doi.org/10.1016/ bs.pbr.2014.11.025. Whitehead-Pleaux, A., Donnenwerth, A., Robinson, B., Hardy, S., Oswanski, L., Forinash, M., . . . & York, E. (2012). Les­ bian, gay, bisexual, transgender, and questioning: Best prac­ tices in music therapy. Music Therapy Perspectives, 30 (2), 158–166. https://doi.org/10.1093/mtp/30.2.158.

Resources for Clients American Psychological Association (APA). (n.d.). Answers to your questions for a better understanding of sexual orientation and homosexuality. https://www.apa.org/ topics/lgbt/orientation.aspx. American Psychological Association (APA). (n.d.). Lesbian, gay, bisexual, and transgender health. https://www.apa. org/pi/lgbt/resources/lgbt-health.aspx. American Psychological Association (APA). (n.d.). Reducing sexual prejudice: The role of coming out. https://www. apa.org/pi/lgbt/resources/reducing-sexual-prejudice.aspx. Boylan, J. F. (2003). She’s not there: A life in two genders. New York: Broadway Books. Coleman, E., Bockting, W., Botzer, M., Cohen-Kettenis, P., DeCuypere, G., Feldman, J., . . . & Zucker, K. (2012). Stan­ dards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. International Journal of Transgenderism, 13 (4), 165–232. https://doi. org/10.1080/15532739.2011.700873. Dasgupta, R. K., & Gokulsing, K. M. (2014). Masculinity and its challenges in India: Essays on changing perceptions. Jefferson, NC: McFarland. Mishima, Y. (1958). Confessions of a mask. Translated by M. Weatherby. Norfolk, CT: New Directions. Mock, J. (2014). Redefining realness: My path to womanhood, identity, love, and so much more. New York: Atria Books. Morris, B. J. (n.d.). History of lesbian, gay, and bisexual social movements. https://www.apa.org/pi/lgbt/resources/his tory.aspx. Moskowitz, H. (2015). Not otherwise specified. New York: Simon Pulse. Okparanta, C. (2015). Under the udala trees. New York: Houghton Mifflin Harcourt. Pai, H.-Y. (1993). Crystal boys. San Francisco: Gay Sunshine Press. Pitman, G. (2014). This day in June. Washington, DC: Magination Press.

Plett, C. (2015). A safe girl to love. New York: Topside Press. Rivera, G. (2016). Juliet takes a breath. Riverdale, NY: Riverdale Avenue Books. Roy, S. (2015). Don’t let him know. New York: Bloomsbury USA. Ryan, C. (2009). Helping families support their lesbian, gay, bisexual, and transgender (LGBT) children. https://docs. google.com/viewer?url=http://nccc.georgetown.edu/ documents/LGBT_Brief.pdf.

References American Counseling Association (ACA). (2014). American Counseling Association code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2013). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Armstrong, C. (2016, February 29). Music: A powerful ally in your counseling sessions. Counseling Today. http://ct. counseling.org/2016/02/music-a-powerful-ally-in-your­ counseling-sessions/. Aronoff, U., & Gilboa, A. (2015). Music and the closet: The roles music plays for gay men in the “coming out” process. Psychology of Music, 43 (3), 423–437. https://doi.org/10. 1177/0305735613515943. Bain, C. L., Grzanka, P. R., & Crowe, B. J. (2016). Toward a queer music therapy: The implications of queer theory for radically inclusive music therapy. Arts in Psychotherapy, 50, 22–33. https://doi.org/10.1016/j.aip.2016.03.004. Gonzalez, T., & Hayes, G. (2009). Rap music in school coun­ seling based on Don Elligan’s rap therapy. Journal of Cre­ ativity in Mental Health, 4 (2), 161–172. https://doi.org/10. 1080/1540138092945293. Kimbel, T. M., & Protivnak, J. J. (2010). For those about to rock (with your high school students), we salute you: School counselors using music interventions. Journal of Creativity in Mental Health, 5 (1), 25–38. Lenes, E., Swank, J. M., & Nash, S. (2015). A qualitative explo­ ration of a music experience within a counselor education sexuality course. Journal of Creativity in Mental Health, 10 (2), 216–231. https://doi.org/10.1080/15401383.2014. 983255. Novotney, A. (2013, November). Music as medicine. https:// www.apa.org/monitor/2013/11/music.aspx. Whitehead-Pleaux, A., Donnenwerth, A., Robinson, B., Hardy, S., Oswanski, L., Forinash, M., . . . & York, E. (2012). Les­ bian, gay, bisexual, transgender, and questioning: Best practices in music therapy. Music Therapy Perspectives, 30 (2), 158–166. https://doi.org/10.1093/mtp/30.2.158.

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“M US T BE T H E M US IC”:

M U SIC AL AU TO BIO GRA P H Y A S S ES S M ENT ACT IVIT Y

Answer the following questions. Which musical artists, songs, or genres do you listen to when you are feeling sad and are struggling with issues related to your sexual orientation and/or gender identity?

What do you enjoy the most about these songs and artists?

Which musical artists, songs, or genres do you listen to when you want to feel empowered about your sexual orientation and/or gender identity?

What do you enjoy the most about these songs and artists?

Which musical artists, songs, or genres do you listen to when you are in love?

What do you enjoy the most about these songs and artists?

Which musical artists or songs do you listen to when you want to feel energized (e.g., work out or dance) to manage any stress related to your sexual orientation and/or gender identity?

What do you enjoy the most about these songs and artists?

Which LGBTQ artists do you enjoy listening to?

What do you enjoy about these LGBTQ songs and artists?

Does your social class, ethnicity, religion, nationality, ability, or age influence the music that you enjoy or identify with? If so, how?

Which artists, genres, or songs do you avoid listening to that may be harmful or oppressive?

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Kiahni Nakai

“M US T BE T H E M US IC”:

C RITIC AL LYRIC A NA LYS IS H O M EWO RK A S S IGNM ENT

Step 1: Select a song to share with your counselor, social worker, or psychologist that reflects your identity, current feelings, a difficult time in your life, or your hopes for the future. Your song can also reflect any experiences you’ve had with prejudice or discrimination. Musical artist: Song and album: Genre: Step 2: Include the lyrics or notes to this song below. (If you run out of space, use the back of this sheet.)

I like this song/artist because

This song makes me feel

I would recommend this song to another person because

What would you like your therapist to understand about this song and how it relates to your identities, thoughts, beliefs, or experiences?

Kiahni Nakai

45

“M US T BE T H E M US IC”:

REVIEW/ CO M M ENT S

Did you like this exercise? n YES

n NO

n MAYBE

n NOT SURE

Would you like to bring in another song to share during your next session? n YES

n NO

n MAYBE

n NOT SURE

Would you like to use this exercise again sometime in the future? n YES

n NO

n MAYBE

Comments:

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Kiahni Nakai

n NOT SURE

“MU ST BE TH E M US IC”: S A M P L E CO M P L ET ED

AC TIVIT Y MU SIC AL AUT O BIO GRA P H Y A S S ES S M ENT ACT IVIT Y

Answer the following questions. Which musical artists, songs, or genres do you listen to when you are feeling sad and are struggling with issues related to your sexual orientation and/or gender identity? I like to listen to Aretha Franklin or old blues songs from the 1960s. What do you enjoy the most about these songs and artists? I like that these songs talk about loss, sadness, or how difficult love and life can be. It makes me feel like I am not alone in my sadness when I am going through a tough time. I heard these songs played at home when I was a little boy. Which musical artists, songs, or genres do you listen to when you want to feel empowered about your sexual orientation and/or gender identity? I like to listen to rap, hip-hop, and mid-tempo to upbeat R&B songs. I especially like Curtis Mayfield “Move on Up” whenever I feel like I need a boost of confidence or motivation. I also like “Formation” by Beyoncé. Even though these songs aren’t about my sexuality, they make me feel uplifted. What do you enjoy the most about these songs and artists? I like rap and hip-hop because many artists discuss having pride in themselves, their families, and the places that they come from. I also like the R&B songs where singers speak about hav­ ing fun and staying motivated. Which musical artists, songs, or genres do you listen to when you are in love? Why? I like to listen to Corinne Bailey Rae, Beres Hammond, Jhene Aiko, and Chaka Khan when I am in love. What do you enjoy the most about these songs and artists? I like that these artists talk generally about love, but they also discuss their expectations of rela­ tionships and how they want to love and be loved.

PAGE 1

Kiahni Nakai

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“MU ST BE TH E M US IC”: S A M P L E CO M P L ET ED

AC TIVIT Y M U SIC AL AUT O BIO GRA P H Y A S S ES S M ENT ACT IVIT Y

Answer the following questions. Which musical artists or songs do you listen to when you want to feel energized (e.g., work out or dance) to manage any stress related to your sexual orientation and/or gender identity? I listen to Afrobeats, danceball, rap, and electronic dance music when I want to dance. I like Yemi Alade, Calvin Harris, Davido, and Drake. What do you enjoy the most about these songs and artists? I like that these songs make me feel like dancing, or they motivate me to complete a workout that helps me feel better and more confident. Which LGBTQ artists or songs do you enjoy listening to? I like listening to Frank Ocean, Sam Smith, and the Internet. What do you enjoy about these LGBTQ songs and artists? I enjoy that these artists make great music and talk about relationships that I identify with. I like that they are there and that there are more LGBTQ artists coming out, making music about their relationships and perspectives, and becoming popular and successful. Does your social class, ethnicity, religion, nationality, ability, or age influence the music that you enjoy or identify with? If so, how? I feel like my age and my ethnicity both influence the music that I enjoy and identify with. Music has been a big part of African American culture. I grew up seeing it used as a way to express feelings, have a good time, and manage sorrow. I also usually enjoy listening to artists that are closer to my age group, but not always. Which artists, genres, or songs do you avoid listening to that may be harmful or oppressive? Although I do like hip-hop and reggae, I avoid listening to certain artists that may say negative things. I prefer the love songs or songs about partying, pride, and motivation instead from these genres.

PAGE 2

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Kiahni Nakai

“M U ST BE TH E M US IC”: S A M P L E CO M P L ET ED

A SSIGN ME N T C RITIC AL LY RIC A NA LYS IS H O M EWO RK A S S IGNM E N T

Step 1: Select a song to share with your counselor, social worker, or psychologist that reflects your identity, current feelings, a difficult time in your life, or your hopes for the future. Your song can also reflect any experiences you’ve had with prejudice or discrimination. Musical Artist: Frank Ocean Song and Album: “Forrest Gump”—Channel Orange Genre: R&B

Step 2: Include the lyrics or notes to this song below. (If you run out of space, use the back of this sheet.) (Lyrics)

I like this song/artist because I like this song because it talks about being in love and about how exciting it is to root for someone that you are in love with. This song makes me feel Happy I would recommend this song to another person because It’s nice to have R&B songs written by men and sung by a man about his love for another man. There aren’t a lot of songs out there like this one. It’s also a fun positive song and I like Frank Ocean’s voice. What would you like your therapist to understand about this song and how it relates to your identity, thoughts, beliefs, or experiences? This song reminds me of my first love and how I felt being in love. This song reminds me of the butterflies I felt and makes me eager to discuss my past and current relationships in session. I am not used to discussing them at all because I can’t talk about these things with my friends and family. It makes them uncomfortable.

Kiahni Nakai

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“MU ST BE TH E M US IC”: CO M P L ET ED S A M P L E

REVIEW/ CO M M ENT S

Did you like this exercise?

n YES ü

n NO

n MAYBE

n NOT SURE

Would you like to bring in another song to share during your next session? n YES ü

n NO

n MAYBE

n NOT SURE

Would you like to use this exercise again sometime in the future? n YES ü

n NO

n MAYBE

n NOT SURE

Comments: I enjoyed this exercise. It made me think about how much music is a part of my life. It helped me to share a lot of things that I’ve thought about even though I didn’t exactly have the right words to share them with my counselor.

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Kiahni Nakai

6 CINEMATHERAPY FOR LGBT CLIENTS Jennifer Lancaster and Angelica Terepka Suggested Uses: Homework, activity Objective

The purpose of this activity is to provide a safe space for LGBT persons to explore their identity through the use of a popular medium (film). Films and related media may provide a means of normalization of sexual and gender-identity development. Rationale for Use

This intervention is intended for clinical use with indi­ viduals seeking to explore their sexual identity through the lens of popular media and may provide a means to generate dialogue about sexual identity in thera­ peutic work. Lesbian, gay, and bisexual individuals have less access to visible role models than their het­ erosexual counterparts (Grossman & D’Augelli, 2004). Further, minority stress theory suggests that those clients who belong to minority groups (including sex­ ual minorities) experience unique stressors that may increase the experience of mental health issues (Meyer, 2003). These stressors are particularly evident when clients experience the social discrimination and stigma that often accompany membership in these groups (Bridges, Selvidge, & Matthews, 2003; Hatzenbuehler, 2009). Furthermore, individuals who identify as multi­ ple minorities may be subjected to varying types of discrimination. Balsam and colleagues (2011) found that individuals of color who identify as LGBT expe­ rience (a) racism within their LGBT communities, (b) heterosexism within their racial or ethnic com­ munities, and (c) racial or ethnic discrimination in dating and close relationships. These unique combi­ nations of stressors are likely to negatively affect psy­ chological and mental health, particularly for LGBT

people of color who are more likely to rely on their racial or ethnic communities for support (Balsam et al., 2011). Clients who identify in multiple minority groups may be further marginalized and, as a result, may have trouble envisioning a positive life path that incorporates these aspects of their identity. Research examining the influence of LGBT-rep­ resentative media on LGBT identity suggests that LGBT individuals connect with the experience of LGBT-identified characters and celebrities (Gomillion, & Giuliano, 2011). Additionally, visibility of LGBTidentified persons in the media provides a sense of social support for LGBT youth (Gomillion & Giuliano, 2011). Members of marginalized groups who experi­ ence stigma and discrimination on the basis of sex­ ual and racial minority membership may be in further need of characters with whom they can identify in film (Bostwick et al., 2014). Films depicting characters identifying as LGBT individuals of color may be particularly powerful given the research highlighting multiple stressors experienced by individuals who identify as both sexual and racial minorities. Clients can come to understand themselves and gain new insights into their own concerns by view­ ing characters in a film who are experiencing similar circumstances (Egeci & Gencoz, 2017). While a movie is not likely to be a replica of the client’s life and cur­ rent circumstances, it can serve as a metaphor for some relevant aspect. Metaphor is often used in psycho­ therapy (particularly in CBT interventions) to aid cli­ ents in processing issues significant to them (Sharp, Smith, & Cole, 2002). Kuriansky, Vallarelli, DelBuono, and Ortman (2010) suggest that “film presents an opportunity for change by revealing issues in a non­ threatening way within the safety of distance so that

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

52

difficult material and alternate ideas and behaviors can be processed indirectly at first, and then more directly processed” (p. 91). In addition to some empirical support for the technique as part of the therapeutic toolkit (e.g., Egeci & Gencoz, 2017; Gramaglia et al., 2011; Heston & Kottman, 1997; Kuriansky et al., 2010), movies can also provide an experience that is shared between thera­ pist and client and can help improve or solidify the therapeutic alliance (Berg-Cross, Jennings, & Baruch, 1990). The process of cinematherapy is similar to other psychotherapeutic interventions, with some important distinctions. Ulus (2003) states that viewers of films engage in three phases while viewing: pro­ jection, identification, and introjection. Projection is a process in which the viewer’s thoughts and affect are activated by the film’s plot or characters. Identifica­ tion allows the viewer to relate to the experiences of the film’s characters. Introjection is the process in which viewers apply the lessons learned from the film to their personal experiences. Therapists are encour­ aged to work through each of these processes with clients, addressing the emotions evoked in the projec­ tion phase, helping the client identify with the film and make meaning of the film as it relates to the client’s life. The proposed activity requires review of several ethical codes included in the American Psychological Association’s (APA) ethical principles of psychologists (2017). Specifically, codes pertaining to clinician competence (2.01) and informed consent (10.01) are relevant. APA’s guidelines for psychotherapy with lesbian, gay, and bisexual clients include special atten­ tion to recognizing risk factors associated with this population, including those related to identity devel­ opment (APA, 2017, 2.01). These guidelines mandate that therapists recognize and respect the special chal­ lenges faced by LGBTQIA youth and older adults, as well as the life challenges that may be encountered when clients experience conflicting cultural norms (APA, 2000). Those with less experience working with this population are encouraged (according to APA guideline 2.01 and Division 44 guideline 15) to seek supervision. Additionally, therapists must consider obtaining informed consent throughout the process of therapy (APA, 2017, 10.01). For this activity it is suggested that therapists be intimately familiar with

the suggested film, its content, its themes, and the official Motion Picture Association of America film rating (e.g., PG-13, R). The therapist’s knowledge of the film will allow for a more accurate procurement of informed consent: therapists can discuss themes within the movie to help clients decide if they want to partake in the activity. Instructions

Therapists should choose a few films that they feel are likely to resonate with the client. The client chooses from this list, watches the film between sessions, and completes the film analysis worksheet. This work­ sheet is designed to elicit reactions to the film and can be modified to meet the client’s needs. The client should bring this worksheet to the next session for processing with the therapist. Film selection is an important component of this process. Caron (2005) suggests that the practitioner consider the assessment of clients and their goals in therapy before implementing the assignment. Some more specific areas to consider include age-appropri­ ateness, MPAA rating, language, and relatedness to the client’s treatment goals (e.g., identity, coming-out process, relationships). Therapists should also con­ sider the ways in which the film’s characters may or may not mirror the client’s multiple and, at times per­ haps, conflicting identities. A list of suggested films can be found at the end of this chapter or by consult­ ing the Suggested Reading section below. Clinicians should be thoroughly familiar with the film’s content before assigning a viewing activity. Following the view­ ing of the film, debriefing should be specific to the individual, and the issues and emotions associated with viewing the film should be thoroughly discussed. The discussions might include identification with the characters, the issues presented, or any other aspect that the client determines is significant. Choosing a film in which the features of the main characters (e.g., race, age, and gender) closely resemble the client’s would be ideal; however, finding such films may be difficult. Clients may thus be exposed to films featur­ ing characters with different (possibly more privi­ leged) identities than their own. Clinicians should speak with their clients about discrepancies in the rela­ tive experiences of the client and the film’s protagonist, Cinematherapy for LGBT Clients

53

focusing particularly on aspects of the film that evoke feelings of further marginalization of certain identities. It may be equally beneficial for the client to view characters with varying demographics and in vari­ ous cultural contexts in order to better identify dif­ ferences and similarities in the session. In fact, pro­ moting the use of “film as metaphor” will often allow for sufficient identification to meet clients’ needs. It should be noted that therapeutic discussion following film viewing, rather than simply watching a movie, is thought to be the active component promoting the effectiveness of cinematherapy interventions (Egeci & Gencoz, 2017). Therefore, clinicians are expected to thoroughly process the client’s experience of viewing the film by focusing on these matters along with other pertinent issues relevant to individual clients. When viewing the film, clients should make notes, which may help in the recollection of specific aspects of the film to which they had an emotional reaction. It is also recommended that clients process the movie on their own immediately after viewing the film and before completing the worksheet. Some relevant prompts for clients in completing this processing are included in the worksheet at the end of this chapter and can be customized for each client and film. Brief Vignette

Sara is a twenty-seven-year-old Latina American cisgender lesbian seeking therapy for symptoms of anx­ iety. She is currently in a serious relationship with a woman. Her parents believe that Sara lives with her “roommate.” Sara is preparing to come out to her par­ ents about her sexuality and the nature of her rela­ tionship with her partner but fears rejection from her parents. After several sessions of speaking to her ther­ apist about her anxiety, Sara continues to feel alone in her struggle and unsure of how to tell her parents about her sexuality. After assessing Sara’s relative interest in and not­ ing a hobby of watching movies, the therapist sug­ gests that she view a film in which the main character is a young Asian American male whose traditional Chi­ nese mother moves in with him following a divorce. Once the mother moves in, the character is forced to come out about his sexuality, and the remainder of

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the film presents the relationship dynamics between mother and son who eventually come to accept one another despite initial struggles within their relation­ ship. In the post-viewing therapy session, Sara and the therapist process her experience of watching the film. Sara describes feeling anxious before viewing the movie; she believes part of her anxiety arose from knowing that the plot of the movie involves an LGBT character. She also reports having felt intrigued by the movie because she has had little exposure to films that openly present LGBT issues. Sara is also able to identify anger she felt toward the character of the mother in the film but feels dis­ tressed by the fact that she did not know why she was angry with the character; through discussion with the therapist, she acknowledges that some of the anger she felt toward the mother character in the film early in the viewing was derived from her feelings toward her own mother (i.e., the projection phase). Sara admits that she identified strongly with the main character in sev­ eral respects, including feeling the need to keep her sexuality a secret from her parents, and empathizing with the cross-cultural aspects that made it difficult for the main character to come out to his mother. She discusses the anxiety she felt for the character when he first disclosed his sexuality to his mother as well as the relief she felt toward the end of the movie when mother and son were able to come to a place of accep­ tance of each other (i.e., the identification phase). Sara also tells her therapist that after viewing the film, she was finally able to visualize a future relationship with her parents after she discloses her sexuality to them. In addition, Sara discloses connecting to the char­ acter’s identity as a first-generation American. In particular, she recognized the experience of being a child of immigrant parents, whose conservative cul­ tural values are not necessarily in line with her current social context. Though Sara recognizes differences between her experiences and that of the character depicted in the film (i.e., gender, family structure), sim­ ilarities in the identity-development process resonate with her. Therapy ensued with steps toward helping Sara come out to her parents and adjust to new or changing dynamics in her parental relationship (i.e., the introjection phase).

Suggestions for Follow-up

Professional Readings and Resources

If this intervention proves useful for the client, this exercise can be used to address additional client con­ cerns as they arise, using films depicting related topics. Therapists may wish to have clients choose a movie for themselves and repeat the exercise. In addition, in the context of this intervention, clients may view favorite films and discuss in session the messages about sexuality and gender that are conveyed in these films and make comparisons.

American Psychological Association (APA). (2000). Guide­ lines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440–1451. doi:10.1037//0003-066X.55.12.144. Bridges, S. K., Selvidge, M. M. D., & Matthews, C. R. (2003). Lesbian women of color: Therapeutic issues and chal­ lenges. Journal of Multicultural Counseling and Develop­ ment, 31, 113–130. Dermer, S. B., & Hutchings, J. B. (2000). Utilizing movies in family therapy: Applications for individuals, couples, and families. American Journal of Family Therapy, 28, 163–180. Niemiec, R. M., & Wedding, D. (2014). Positive psychology at the movies: Using films to build character strengths and well-being, 2nd edition. Boston: Hogrefe Publishing. Wedding, D., & Niemiec, R. M. (2014). Movies and mental illness: Using films to understand psychopathology, 4th edition. Boston: Hogrefe Publishing.

Contraindications for Use

This exercise is appropriate for clients of all educa­ tional levels and may be used as an alternative to bib­ liotherapy for clients who have poorer reading skills or disabilities preventing them from engaging in bib­ liotherapy. Special attention should be paid to film selection so that the film is appropriate to the client’s level of maturity and reflects the client’s values, reli­ giosity, and similar characteristics. Clinicians should also be aware of a client’s access to films and the equipment necessary to view a film; professionals working with certain populations should be sensitive to client financial concerns that inhibit their film-viewing ability. Last, use of cinematherapy may be inappropriate for clients with certain present­ ing problems such as trauma or sexual abuse, as view­ ing films relating to these issues may result in retrau­ matization. Therapists should keep in mind that some films may have themes that evoke difficult emotions in clients (e.g., depression, anger, anxiety). Therefore, clinicians are urged to have a thorough understand­ ing of the history of their clients and where they are in the processing and healing of previous traumatic experiences and use caution in recommending certain types of films. Therapists should avoid assigning films that have the potential to cause harm to clients. If clinicians choose to pursue an intervention based in cinematherapy for a client with a past trauma history, they are encouraged to discuss the choice of inter­ vention, details of the film, and potential discomfort the client may feel to fully assess the appropriateness of the intervention and obtain informed consent from the client to continue with the therapeutic intervention.

Resources for Clients Advocate. (2014, June 23). The top 175 essential films of all time for LGBT viewers. www.advocate.com/arts­ entertainment/film/2014/06/23/top-175-essential-films-all­ time-lgbt-viewers. Letterboxd. Your life in film. https://letterboxd.com/. Niemiec, R. M., & Wedding, D. (2014). Positive psychology at the movies: Using films to build character strengths and well-being, 2nd edition. Boston: Hogrefe Publishing.

References American Psychological Association (APA). (2000). Guide­ lines for psychotherapy with lesbian, gay, and bisexual clients. American Psychologist, 55, 1440–1451. doi:10. 1037//0003-066X.55.12.144. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diver­ sity and Ethnic Minority Psychology, 17 (2), 163–174. Berg-Cross, L., Jennings, P., & Baruch, R. (1990). Cinematherapy: Theory and application. Psychotherapy in Private Practice, 8, 135–157. Bostwick, W. B., Meyer, I., Aranda, F., Russell, S., Hughes, T., Birkett, M., & Mustanski, B. (2014). Mental health and sui­ cidality among racially/ethnically diverse sexual minority youths. American Journal of Public Health, 104 (6), 1129–1136. https://ajph.aphapublications.org/doi/abs/ 10.2105/AJPH.2013.301749.

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Bridges, S. K., Selvidge, M. M. D., & Matthews, C. R. (2003). Lesbian women of color: Therapeutic issues and chal­ lenges. Journal of Multicultural Counseling and Develop­ ment, 31, 113–130. Caron, J. J. (2005). DSM at the movies: Use of media in clini­ cal and educational settings. https://www.counseling.org/ docs/default-source/vistas/vistas_2005_vistas05-art38. pdf?sfvrsn=e67177d9_11. Egeci, S., & Gencoz, F. (2017). Use of cinematherapy in deal­ ing with relationship problems. Arts in Psychotherapy, 53, 64–71. Gomillion, S. C., & Giuliano, T. A. (2011) The influence of media role models on gay, lesbian, and bisexual identity. Journal of Homosexuality, 58 (3), 330–354. doi:10.1080/0 0918369.2011.546729. Gramaglia, C., Abbate-Daga, G., Amianto, F., Brustolin, A., Campisi, S., De-Bacco, C., & Fassino, S. (2011). Cinematherapy in the day hospital treatment of patients with eating disorders: Case study and clinical considerations. Arts in Psychotherapy, 38 (4), 261–266. Grossman, A. H., & D’Augelli, A. R. (2004). The socialization of lesbian, gay, and bisexual youth: Celebrity and person­ ally known role models. In E. Kennedy & A. Thornton (eds.), Leisure, media, and visual culture: Representations and contestations. Eastbourne, UK: Leisure Studies Asso­ ciation Publications.

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Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation frame­ work. Psychological Bulletin, 135, 707–730. Heston, M. L., & Kottman, T. (1997). Movies as metaphors: A counseling intervention. Journal of Humanistic Education and Development, 36, 92–99. Kuriansky, J., Vallarelli, A., DelBuono, J., & Ortman, J. (2010). Cinematherapy: Using movie metaphors to explore real relationships in counseling and coaching. In M. B. Gre­ gerson (ed.), The cinematic mirror for psychology and life coaching. New York: Springer. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. Newton, A. K. (1995). Silver screens and silver linings: Using theatre to explore feelings and issues. Gifted Child Today, 18 (2), 14–19. Schulenberg, S. E. (2003). Psychotherapy and movies: On using films in clinical practice. Journal of Contemporary Psycho­ therapy, 33, 35–48. Sharp, C., Smith, J. V., & Cole, A. (2002). Cinematherapy: Metaphorically promoting therapeutic change. Counseling Psychology Quarterly, 15, 269–276. Ulus, F. (2003). Movie therapy, moving therapy! The healing power of film clips in therapy settings. Victoria, BC: Traf­ ford Publishing.

F IL M DEBRIEF ING

WO RKS H EET

Did my breathing change during the viewing? If so, when and how?

What were the major themes of the movie?

Which of these themes were most important to me? Why? Do these themes relate to my life in any way?

With which character(s) did I identify? In what ways? Do any of these characters face what I face?

What did I like about the film? What did I dislike?

Did I notice any change in my emotions? What types of emotions came up for me while watching the film? Which aspects of the film brought these emotions up?

What would I tell someone watching this film for the first time?

Which issues would I like to explore further?

Jennifer Lancaster and Angelica Terepka

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L I S T OF SU GGE STE D M OVIE S BY CAT EGO RY

It is strongly recommended that clinicians be thoroughly familiar with the chosen film before assigning viewing of the film to clients.

Family

LGB Elders

The Kids are All Right (2010)

The Birdcage (1996)

The Family Stone (2005)

Beginners (2010)

Philomena (2013)

Eat with Me (2014)

Fried Green Tomatoes (1991)

Jenny’s Wedding (2015)

The Beginners (2010)

Grace & Frankie (TV Series, 2015)

Cloudburst (2011)

Love Is Strange (2014)

Desert Hearts (1985)

Relationships

Brokeback Mountain (2005)

Blue Is the Warmest Color (2013)

Weekend (2011)

Fried Green Tomatoes (1991)

Happy Together (1997)

Freeheld (2015)

The Girl King (2015)

Carol (2015)

Now and Then (1995)

Coming Out

Kissing Jessica Stein (2001)

Pariah (2011)

The Way He Looks (2014)

Eat with Me (2014)

The Imitation Game (2014)

Wish Me Away (2011)

I Love Her (2013)

The Out List (2013)

Out in the Line-Up (2014)

Jenny’s Wedding (2015)

Bend It Like Beckham (2002)

Transgender and Gender Identity

Special Concerns

The Falls (2012)

Latter Days (2003)

Pariah (2011)

Eat with Me (2014)

Paris Is Burning (1990)

Rent (2005)

LGB Youth

Transparent (TV, 2014) Boys Don’t Cry (1999) Women in Revolt (1971) Paris Is Burning (1990) 52 Tuesdays (2013) The Crying Game (1992) The Danish Girl (2015) Tomboy (2011) Transamerica (2005)

The Edge of Seventeen (2016)

Tomboy (2011)

But I’m a Cheerleader (1999)

Beautiful Thing (1996)

Pariah (2011)

Perks of Being a Wallflower (2012)

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7 HOW DOES GOD SEE ME? A REFLECTIVE EXERCISE Hannah B. Bayne and Anita A. Neuer Colburn Suggested Uses: Activity, homework Objective

This activity facilitates clients’ self-exploration of per­ sonal faith as well as traditional religious teachings as they apply to clients’ sexual identity. It assists clients in progressing through stages of faith development by encouraging critical analysis of religious texts, reflection on personal beliefs, and discussion of how values and religious communities interact to inform clients’ views of the intersectionality of their spiritual or religious self and sexual identity. Through broach­ ing religious themes, assigning the worksheet as home­ work, and then processing the experience with the client, a counselor can use this activity to address important elements of the client’s religious and sexual identities. The activity is helpful for clients identify­ ing with a theistic spirituality or religion, including Protestantism, Catholicism, Judaism, and Islam. Because of our own understanding of the extant liter­ ature, we refer to “God” in this chapter, although some clients may use different nomenclature (e.g., “Allah”). Rationale for Use

Scholarly research, affirmative-practice competency documents, and ethical codes provide a solid rationale for the use of this activity, which is designed to address the intersectionality of clients’ spiritual or religious and LGBTQ identities. Researchers at the Pew Forum (2015) found that 89 percent of Americans claim a belief in God. The World Values Survey (2011) showed that 67.9 percent of people in the United States iden­ tify as religious, and 66.3 percent belong to a particular religious denomination. For many clients who are religious, faith is often an integral part of their per­

sonal and social identity, and counselors are encour­ aged to integrate religion and spirituality into the counseling process when it is appropriate for clients (ASERVIC, 2009, no. 12; Bayne & Neuer Colburn, 2012; Bayne, Neuer Colburn, & Conley, 2016; Hartwig Moorhead & Neuer Colburn, 2016; Kyle, 2013; Snow & Neuer Colburn, 2015; Wood & Conley, 2014). How­ ever, most religious groups have traditionally and historically upheld nonheterosexual identities as sinful and abhorrent, which leaves LGBTQ clients without much support to wrestle with questions of sexuality, morality, and their place within their religion (Beagan & Hattie, 2015; Frame, 2003; Love, Bock, Jannarone, & Richardson, 2005; Wood & Conley, 2014). In fact, many LGBTQ adults have reported experiencing sig­ nificant psychological and emotional harm from organized religions (Beagan & Hattie, 2015; Wood & Conley, 2014). Thus, clients who identify as LGBTQ may internalize negative messages from their religious communities. This conflict of doctrine with personal beliefs and experiences can leave clients feeling torn between parts of themselves and can lead to internal­ ized homophobia, self-hatred, or abandonment of their religious faith and community (Abu-Raiya, Par­ gament, Krause, & Ironson, 2015; Barret & Logan, 2002; Bayne, 2016; Frame, 2003). Wood and Conley (2014) suggested that sexual microaggressions are a form of religious or spiritual abuse leading to loss of religious or spiritual identity among LGBT people, and Abu-Raiya and colleagues (2015) found that all types of religious or spiritual struggles were positively associated with depressive symptoms and generalized anxiety and negatively associated with satisfaction with life and happiness (p. 571). Conversely, an integrated faith that allows for an affirming view of sexual iden-

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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tity can connect clients with the positive benefits of a faith community and the personal wellness resources associated with spiritual and religious foundations (Barret & Logan, 2002; Bayne, 2016; Frame, 2003; Hartwig Moorhead & Neuer Colburn, 2016; Ivtzan, Chan, Gardner, & Prashar, 2013; Kyle, 2013; Love et al., 2005). For example, Ivtzan and colleagues (2013) reported that higher levels of spirituality and religi­ osity predicted self-actualization, meaning in life, and personal growth initiative, and Kyle (2013) found that spirituality helped increase coping among suicidal college students. Professional codes of ethics and lists of clinical com­ petencies obligate counselors to provide an accepting and affirming space for clients to explore their own beliefs of how sexuality and religion intersect. The Association for Lesbian, Gay, Bisexual, and Transgen­ der Issues in Counseling (Harper et al., 2013) com­ petencies call for counselors to develop relationships with clients that foster self-acceptance, based on the understanding that normative developmental tasks of LGBQQ persons are often “complicated or com­ promised by social isolation and invisibility” (A.8). Specifically, standards A.16, A.17, and B.8 point to the importance of intentionally tending to the multi­ ple identity statuses of LGBQQ individuals and inte­ grating coming-out identity development with other areas of development, including race, gender, and spirituality. Cultural communities, defined through common racial or ethnic identities, can hold similar beliefs of homosexuality as counter-normative, thereby compounding a client’s experience of judg­ ment and fear of losing social supports (Barret & Logan, 2002, Harper et al., 2013). Clients who are already affected by racial discrimination and preju­ dice may find that an LGBQQ identity further adds to their experience of discrimination and oppression (Barret & Logan, 2002; Wood & Conley, 2014), and counselors should therefore consider how these inter­ secting identities influence the coming-out process. Regarding spirituality, ALGBTIC (Harper et al., 2013) standard C.5 states that competent counselors will acknowledge the spiritual stressors that may interfere with LGBQQ individuals’ ability to achieve their goals. The ASERVIC (2009) competencies also apply, as they stress the importance of acknowledg­

ing the centrality of clients’ beliefs regarding spiritual­ ity and religion to overall worldview and psychosocial functioning (no. 2), the ability of professional coun­ selors to describe and apply various models of spiri­ tual or religious development (no. 6), and the clinical skill of therapeutically applying theory and current research supporting the inclusion of a client’s spiritual or religious perspectives and practices (no. 14). Further, the ACA (2014) Code of Ethics compels practitioners to protect client welfare (A.1) and, spe­ cifically, to adjust their style of communication in a manner that is developmentally and culturally appro­ priate for clients (A.2.c). Counselors should thus engage in assessment of client development, under­ stand clients within their cultural context, and adjust interventions accordingly. Affirmative counseling practices for LGBTQ clients also stress this need for counselors to first have knowledge and awareness of clients’ multiple identities (racial, ethnic, gender, sex­ ual, religious, and spiritual, to name a few), and then to affirm these identities in practice through respect­ ing the unique ways clients experience both their sex­ uality and their religion as part of their whole sense of self (APA, 2012; Beagan & Hattie, 2015; Frame, 2003; Johnson, 2012). This means understanding LGBT clients in the context of faith development, sex­ ual identity development, racial identity development, experiences of micro- or macroaggressions, presence of social supports, and personal goals in order to determine how these components intersect for each client. Ignoring any part of the client’s identity (sexu­ ality or religion) would probably not be in the cli­ ent’s best interest. Counselors must be open to client definitions and conceptualizations and not impose their own expectations or agenda on the counseling process (ACA, 2014; APA, 2012; ASERVIC 2009; Johnson, 2012). Clients often do not have an avenue or model for critically examining components of their faith. Clients may feel as though sexuality and spirituality are mutu­ ally exclusive as a result of messages they have received within faith communities, and they may therefore be unaware of how these two identities can successfully intersect (Wood & Conley, 2014). Beagan and Hattie (2015) found that in response to negative messages from the church, LGBTQ participants in their study How Does God See Me? A Reflective Exercise

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“put their sexual selves and exploration of their bod­ ies on hold, and some denied or separated from whole aspects of themselves” (p. 100). However, models of faith development, such as Allport’s (1950), stress crit­ ical examination of religious texts and belief sys­ tems as important processes for continued faith mat­ uration. Allport encouraged a progression from full and unquestioning acceptance of religious doctrine to a more nuanced acceptance of faith informed by research, reflection, and personal decision making (Bayne, 2016; Love et al., 2005). Allport’s stages include raw credulity (blind acceptance from authority fig­ ures), satisfying rationalism (the process of beginning to question beliefs and being open to new meanings), and religious maturity (tolerating ambiguity and uncertainty with a critical engagement in a personal faith). In this activity we use the Allport (1950) model as a tool to support adaptive integration of clients’ religious or spiritual and LGBTQ identities. This activity, then, is designed to help clients explore key components of their faith tradition as they embrace the intersectionality of their sexual and spiri­ tual identities. Sexual and spiritual identities should also be examined through the lens of racial or ethnic identity. This activity does not require the counselor to be in a position of religious authority, or to pre­ scribe any meanings for the client. Indeed, such a posi­ tion would be inappropriate for the counselor’s role (ASERVIC, 2009; Bayne, 2016). Instead, the counselor offers a safe, affirming, and reflective space to first broach the topics of religion and spirituality, and then to invite clients to begin to identify, examine, and inte­ grate their own beliefs. Processing questions can assist clients in determining whether, and to what extent, the exercise has affected client understandings. Instructions

The activity is based on the work of Allport (1950) and uses several websites to help LGBT clients critically evaluate biblical passages that have been used to con­ demn homosexuality. Counselors should peruse these websites before advising their clients to do so. The “How does God see me?” worksheet includes refer­ ences to the websites, and the exercise could be sepa­ rated into two different activities (one for each of the two main websites). Also, while the worksheet can be 62

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used as a homework activity, it might better be initially used as an in-session tool to guide clients through the exercise, gauging their reactions. Counselors should understand Allport’s theory well enough to introduce the exercise by explaining the differences between immature faith and mature faith, and explor­ ing client reactions to this construct before moving forward. Rather than being an exhaustive list, the ques­ tions offered here can be altered for individual use, and, depending on client responses, counselors may develop further questions to help the client process the material more deeply. Brief Vignette

Jackie, a cis female, is third-generation Peruvian Amer­ ican and grew up within the Catholic church in her hometown of Washington, D.C. Jackie’s earlier attempts at relationships with men had failed, and she consis­ tently fought her attraction to women, convincing herself it would just “go away.” She’d been hoping her sexual orientation would change since she was in high school. All the while, her friends couldn’t under­ stand why she was seemingly “challenged” in the rela­ tionship department, because she was quite attrac­ tive and intelligent, and men seemed drawn to her. Her parents frequently lamented that they just wanted her to find a nice young man and settle down, partic­ ularly because she had just turned thirty and the other women in her community were typically mar­ ried by then. Jackie was very active at her church. As a teen, she had participated in the youth group, and her family stressed the importance of weekly atten­ dance at church. However, as her sexual attraction to women increased, she became more and more uncom­ fortable at church. Whenever the topic of dating or mating came up at church, the priest talked about the sinfulness of homosexuality and the importance of honoring God in personal relationships by avoid­ ing sex before marriage. Ultimately, Jackie resigned from her volunteer job as the youth group adviser, and she started skipping worship services whenever she could come up with an excuse. But it didn’t seem to help. Jackie felt isolated without the familiarity of her church community, and even though she was no longer attending the church, she still wrestled internally with her attraction to women. Furthermore, many of

her friends and neighbors attended her church, and they had begun to notice her absence. She prayed to God to take away her feelings and began to wonder if she had done something wrong, and if perhaps this attraction to women was some kind of punishment. She began to feel distant from God, convinced she could not be loved or accepted, and felt powerless to change. Within a few months she had developed low self-esteem, become isolated from some of the most important people in her life, and was depressed with thoughts of suicide. Finally, the continued struggle was too much, and Jackie went to counseling to address her attraction to other women and her discomfort with the conser­ vative biblical teachings of her family and church. She reported her desire to be able to be in a relationship with another woman but also continue to be a Chris­ tian, though she did not know a way that could be possible. After viewing the video excerpt on the Reli­ gious Tolerance website, she wept from the pain and confusion she had endured that the video seemed to affirm. The woman in the video whose religious belief system was ultimately changed after her own exam­ ination of biblical passages especially affected her. Jackie said she was open to trying to learn something new about the Bible. When she read the Introduction section from the Whosoever site, she appreciated the possibility that some of the terms used in the Bible had different connotations (based on the context and culture within which they were written) from those that she had been taught all her life. Still, she expressed some discomfort with the thought of critically exam­ ining and potentially disagreeing with concepts rooted in her past and present understanding of her faith. After reading the material and responding to the ques­ tions, Jackie felt hopeful that there could be a way for her to still be loved by God, even if she allowed her­ self to date and possibly fall in love with a woman. After several sessions, Jackie decided to start attending a different, more inclusive church whose members promoted and modeled different concep­ tualizations of same-sex relationships within the con­ text of a religious community. While she still was not out to her parents or the people she worked with, she had embarked on a journey of self-acceptance, and she began dating women. Through a process of self-

discovery and affirmation, then, Jackie was able to progress in both areas of identity that had been in con­ flict. Her sexual-identity development progressed through the counselor’s creation of an accepting and affirming space to process her feelings, hopes, and desires. Likewise, by allowing her spiritual and reli­ gious identity to be seen as an equally important and nonmutually exclusive part of herself, Jackie was able to feel safe examining her faith and pursuing a contin­ ued relationship with God. Her own faith developed as a result. She still maintained some distrust of others in her faith community, knowing they still adhered to judgments against LGBTQ individuals, and the loss of these relationships was still painful for her. Her new faith community, however, offered her the oppor­ tunity to be in relationship with others and continue to grow in her own personal faith. Suggestions for Follow-up

For some clients who grew up in conservative religious environments, this may be the first time they are read­ ing these passages through a different lens. We rec­ ommend that the counselors facilitate the client’s jour­ ney at a pace that is best for the client. Some may need to process only one of the passages per week, while others may want to read all the passages and consider them in their entirety. Also, the resolution of spiri­ tual and sexual identities can lead some clients to a new issue: that of coming out to parents or other loved ones. As with any other client considering coming out, we suggest counselors help clients strengthen their support systems while they help their clients plan when, how, and to whom they want to come out. For clients who are already out, this exercise could lead them to make changes to their worship attendance, which might also influence their current relationships in a variety of ways. For many people from conser­ vative backgrounds, reading and accepting new inter­ pretations of familiar scriptures can take a good bit of time and introspection. Counselors and/or clients may consider consultation with community clergy representing inclusive churches. Contraindications for Use

Counselors should refrain from moving into this exer­ cise too quickly, before a trusting therapeutic workHow Does God See Me? A Reflective Exercise

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ing alliance with the client has been built. If a client is self-injuring or suicidal, those issues should obviously be dealt with first and foremost. This exercise is best recommended following a thorough assessment of the client’s religious or spiritual history. Professional Readings and Resources Barret, B., & Logan, C. (2002). Counseling gay men and lesbi­ ans: A practice primer. Belmont, CA: Brooks/Cole Thomson Learning. Bayne, H. (2016). Helping gay and lesbian students integrate sexual and religious identities. Journal of College Coun­ seling, 19, 61–75. Fallon, K., Dobmeier, R., Reiner, S., Casquarelli, E., Giglia, L., & Goodwin, E. (2013). Reconciling spiritual values con­ flicts for counselors and lesbian and gay clients. ADULTSPAN Journal, 12, 38–53. Lemoire, S. J., & Chen, C. P. (2005). Applying person-cen­ tered counseling to sexual minority adolescents. Journal of Counseling & Development, 83, 146–154.

Resources for Clients: Books Bawer, B. (1993). A place at the table: The gay individual in American society. New York: Poseidon. Brown, A. (ed.). (2004). Mentsh: On being Jewish and queer. Los Angeles: Alyson Books. Chellew-Hodge, C. (2008). Bulletproof faith: A spiritual sur­ vival guide for gay and lesbian Christians. San Francisco: Jossey-Bass. Kugle, S. (2010). Homosexuality in Islam: Islamic reflections on gay, lesbian, and transgender Muslims. Oxford, UK: Oneworld Publications. Miner, J., & Connoley, J. T. (2002). The children are free: Reexamining the biblical evidence on same-sex relation­ ships. Indianapolis: Jesus Metropolitan Community Church. White, M. (1995). Stranger at the gate: To be gay and Chris­ tian in America. New York: Plume.

Resources for Clients: Websites Christian

Directory of Gay-Affirming Churches. (2017). Gaychurch. org. Ministering to LGBTQI Christians and our allies around the globe. https://www.gaychurch.org. Metropolitan Community Churches. (2013). Transforming ourselves as we transform the world. www.mccchurch.org. Q Christian Fellowship. (n.d.). https://www.qchristian.org. Religious Tolerance. (2017). Ontario Consultants on Religious Tolerance. www.religioustolerance.org. Whosoever. (n.d.). An online magazine for gay, lesbian, bisex­ ual, and transgender Christians. www.whosoever.org.

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Catholic

DignityUSA. (2017). Gay, lesbian, bisexual, and transgender Catholics. www.dignityusa.org. Jewish

Institute for Judaism and Sexual Orientation. (n.d.). Jewish LGBT organizations. www.huc.edu/ijso/SynOrg/Jewish LGBT/. World Congress: Keshet Ga’avah. (2017). www.glbtjews.org. Muslim

Queer Jihad. (2005). https://people.well.com/user/queerjhd/.

References Abu-Raiya, H., Pargament, K. I., Krause, N., & Ironson, G. (2015). Robust links between religious/spiritual struggles, psychological distress, and well-being in a national sample of American adults. American Journal of Orthopsychiatry, 85, 565–575. doi:10.1037/ort0000084. Allport, G. W. (1950). The individual and his religion. New York: Macmillan. American Counseling Association (ACA). (2014). ACA Code of Ethics. Alexandria, VA: Author. American Psychological Association (APA). (2012). Guidelines for psychological practices with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. Association for Spiritual, Ethical, and Religious Values in Counseling (ASERVIC). (2009). Competencies for address­ ing spiritual and religious issues in counseling. Alexandria, VA: Author. Barret, B., & Logan, C. (2002). Counseling gay men and lesbians: A practice primer. Belmont, CA: Brooks/Cole Thomson Learning. Bayne, H. (2016). Helping gay and lesbian students integrate sexual and religious identities. Journal of College Coun­ seling, 19, 61–75. Bayne, H., & Neuer Colburn, A. A. (2012, November). Bridging the divide: Helping clients explore and integrate religious and non-heterosexual identities. Content session, Virginia Counseling Association annual conference, Fredericks­ burg, VA. Bayne, H. B., & Neuer Colburn, A. A. (2014, November). Eth­ ical supervision practices for counselors working with LGBT issues. Postconference session, Virginia Counsel­ ing Association annual conference, Williamsburg, VA. Bayne, H. B., Neuer Colburn, A. A., & Conley, A. H. (2016, October). Helping students address values conflicts through education and supervision. Content session, Southern Association for Counselor Education & Super­ vision biennial conference, New Orleans. Beagan, B. L., & Hattie, B. (2015). Religion, spirituality, and LGBTQ identity integration. Journal of LGBT Issues in Counseling, 9 (2), 92–117. doi:10.1080/155386605.2015.1 029204.

Frame, M. W. (2003). Integrating religion and spirituality into counseling: A comprehensive approach. Belmont, CA: Brooks/Cole. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., . . . & Hammer, T. R. (2013). Association for Les­ bian, Gay, Bisexual, and Transgender Issues in Counseling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:10.1080/15 538605.2013.755444. Hartwig Moorhead, H. J., & Neuer Colburn, A. A. (2016). Let’s get spiritual: Addressing spirituality ethically and compe­ tently in group supervision. In M. Luke & K. Goodrich (eds.), Group work experts share their favorite activities for supervision, vol. 2, 96–104. Alexandria, VA: Association for Specialists in Group Work. Ivtzan, I., Chan, C. P., Gardner, H. E., & Prashar, K. (2013). Linking religion and spirituality with psychological well­ being: Examining self-actualisation, meaning in life, and personal growth initiative. Journal of Religion and Health, 52 (3), 915–929. doi:10.1007/s10943-011-9540-2. Johnson, S. D. (2012). Gay affirmative psychotherapy with les­ bian, gay, and bisexual individuals: Implications for con­

temporary psychotherapy research. American Journal of Orthopsychiatry, 82 (4), 516–522. Kyle, J. (2013). Spirituality: Its role as a mediating protective factor in youth at risk for suicide. Journal of Spirituality in Mental Health, 15 (1), 47–67. doi:10.1080/19349637.2 012.744620. Love, P., Bock, M., Jannarone, A., & Richardson, P. (2005). Identity interaction: Exploring the spiritual experiences of lesbian and gay college students. Journal of College Student Development, 46, 193–209. Pew Forum on Religion and Public Life. (2015, November 3). U.S. becoming less religious. www.pewforum.org/2015/ 11/03/u-s-public-becoming-less-religious/. Snow, K., & Neuer Colburn, A. A. (2015, October). Spiritual competence beyond traditional definitions: A conversa­ tion on teaching inclusive spirituality. Content session, Association for Counselor Education & Supervision conference, Philadelphia. World Values Survey. (2011). www.worldvaluessurvey.org/. Wood, A. W., & Conley, A. H. (2014). Loss of religious or spiritual identities among the LGBT population. Coun­ seling and Values, 59, 95–111. doi:10.1002/j.2161-007X. 2014.00044.x.

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EX PLORIN G MY SP IRITUAL SEL F Part I Gordon Allport (1950) encouraged mature faith. Regardless of one’s belief system, this type of faith is characterized by the following attributes: • Differentiation—critically analyzing what has been taught about one’s religion; asking questions • Dynamic in character—rather than being driven by fear or impulse, embracing a stance directed more broadly outside oneself • Consistent in morality—motivated by internal, personal values • Comprehensive—accounting for matters central to all existence • Integral—all aspects of the human experience can be accounted for within the belief system • Heuristic—allowing for growth and change by tentatively holding beliefs until they can be confirmed, or until a more valid belief is introduced Overall, Allport urged people not to simply accept what is presented to them but, rather, to engage in an individual journey of self discovery. Allport’s stages of faith development include: • Raw credulity—blind acceptance of faith or doctrine from religious leaders or other authority figures • Satisfying rationalism—beginning to ask critical questions and challenge assumptions of faith; a decen­ tering process of analyzing, questioning, and exploring • Religious maturity—ability to place faith in context, tolerate ambiguity and uncertainty, and feel grounded in a personal faith Access the Religious Tolerance website (www.religioustolerance.org/introduction-to-what-the-bible­ says-and-means-about-homosexuality.htm) and view the excerpt from the 2007 documentary For the Bible Tells Me So. 1. Based on what you’ve been taught over the years, how do you think God sees you? What would God say about you? 2. As you consider this perception, what feelings come up for you? 3. What do you think about Allport’s model? How would you describe a “mature faith” for yourself? Part II Access one of these links, according to your religious tradition. Protestant: Whosoever magazine, www.whosoever.org Catholic: DignityUSA: www.dignityusa.org Jewish: Institute for Judaism and Sexual Orientation, www.huc.edu/ijso/SynOrg/JewishLGBT/, or World Congress of Gay, Lesbian, Bisexual, and Transgender Jews: www.glbtjews.org Muslim: Queer Jihad: www.well.com/user/queerjhd/ 1. What thoughts and feelings came up for you when reading through content on the site? 2. How, if at all, do these passages affect the way you think God sees you? 3. How, if at all, do these passages affect the way you see yourself? 4. Review your responses to these question. As you reflect on the exercise, how are you now feeling about your own faith journey? What would you like to do differently at this point in your development?

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Hannah B. Bayne and Anita A. Neuer Colburn

SECTION II

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

MANAGING OPPRESSION AND

BUILDING RESILIENCE

How Does God See Me? A Reflective Exercise

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Oppression and marginalization of sexual and gender minority individuals are unfortunately very prevalent (Gattis & Larson, 2017), and these problems are com­ pounded for those who have multiple, intersecting marginalized identities (Sarno, Mohr, Jackson, & Fassinger, 2015). The destructive effects of such treat­ ment are well documented and include severe emo­ tional distress (Liao, Kashubeck-West, Weng, & Deitz, 2015). The contributors in this section highlight numerous ways to transform the internalization of injustices into resilience through a focus on self-care, advocacy, social support, and validation. Many of the chapters focus specifically on helping clients externalize the source of the oppression they are enduring. Jessica Chavez addresses the gap between structural failures in society and individual resilience in her chapter, “Survival in an Unjust World: A Tool for Coping with Multiple Forms of Oppression” (Chap­ ter 8). She provides a well-considered handout for clients to use in their efforts to hold the calm pres­ ence of the therapist between sessions as they work through the emotional effects of discrimination. In another approach, Jayleen Galarza notes in “Managing the Intersections: A Narrative Approach to Guiding Queer People of Color in Navigating Multiple Oppres­ sions” (Chapter 9) that LGBTQ people of color often experience within-group oppression in their various social identity groups. Given the complexity of work­ ing through the trauma of being marginalized within one’s own community, she advocates the use of cre­ ative storytelling to empower clients to re-author their narratives of their experiences. Kathleen M. Collins, Meredith R. Maroney, Tangela S. Roberts, Brianna M. Wadler, and Heidi M. Levitt also centralize the client’s narrative in their expressive writing exercise, “Healing from Heterosexism: An Empirically Based Exercise for Processing Heterosexist Experiences” (Chapter 17). In this exercise, the act of labeling events as hetero­ sexist and understanding the painful influence of heterosexism are the vehicles for empowerment. In “Exploring Multiple Marginalized Identities in LGBT Clients of Color” (Chapter 12), Vanessa Dabel also explores the ways in which clients are affected by the intersecting forms of oppression they experi­ ence. Using a relational approach in which she high­ lights therapists’ need to be aware of how their own 68

sociocultural experiences affect the therapeutic rela­ tionship, she provides a helpful set of questions for therapists to use as they embark on this journey of healing with their clients. In a similar vein, Zully A. Rivera Ramos, Amanda Lawson-Ross, and Carlos Hernández use liberation psychology to tease apart the influence on identity of both traditional cultural values in the Latinx community and those reflected in the LGBTQ community (Chapter 13, “Somos Latinx: Exploring Cultural Values of Sexual and GenderDiverse Latinx Clients”). Their exercise is designed to help clients integrate their various and sometimes con­ flicting cultural values, facilitating self-acceptance and thereby enhancing resilience. Other contributors stress the importance of incor­ porating supportive community in developing resil­ ience. Caroline Carter and Diane Sobel endeavor to increase social support with the group activity in “From Stress to Strength: A Group Intervention for Process­ ing Minority Stress Experiences with Transgender and Gender-Nonconforming Individuals” (Chapter 11). They strongly encourage in-group identification with the LGBT community as a source of empower­ ment, using minority stress theory as a means of pro­ viding psychoeducation for the group members. The power of community is also emphasized in Kristin N. Bertsch’s chapter, “Building Resilience with Clients Who Face Multiple Forms of Oppression” (Chapter 14). Her exercise, designed for use with individual clients, capitalizes on clients’ strengths and values for use in collective action, because the construction of a strong social network is key to decreasing the deep isolation of oppression. Because many organized religions have historically viewed nonheterosexual relationships as sinful (Bea­ gan & Hattie, 2015), the intersection of faith or spiri­ tuality and gender and sexual identities can be fraught with pain, isolation, and confusion for many LGBTQ clients. Chapter 20, “Value-Driven Exploration of Intersections between Sexual and Religious Identity,” by Angela Terepka and Jennifer Lancaster, helps cli­ ents work through some of this distress so that they can more fully access the wealth of positive benefits inherent in connecting both to their personal faith and perhaps to a larger faith community. Building on the tenets of Acceptance and Commitment Therapy

(ACT), their activity is designed to assist clients in clar­ ifying their own values and identifying negative mes­ sages that in some cases can come from within the LGBTQ community. Issues of emotional and physical safety are para­ mount, insofar as clients cannot thrive until their sense of security is enhanced. As Wendy Ashley, Allen Lipscomb, and Sarah Mountz point out in “A Toolkit for Collaborative Safety and Treatment Planning with Transgender Youth of Color” (Chapter 16), clients with these intersecting identities experience great stigma, oppression, and violence. They make a strong case for attending to safety issues as a top priority, and they have created the outstanding “Inclusive Safety Plan of Care” for use in therapy with clients who do not feel safe in this world. In “Building a Stronger Advocacy Role for Older LGBT+ Adults in Nursing Home Settings” (Chapter 15), Angela Schubert dis­ cusses the ways in which vulnerable older LGBT+ adults face ageism as well as other forms of discrimi­ nation that prevent them from receiving the level of care that they need in nursing homes. She uses rela­ tional cultural theory as a framework to understand both the context of the client’s social identities and the culture of the nursing home as she guides therapists to strengthen advocacy for older adults in these settings. Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne guide readers through the complex cultural and clinical considerations for working with political refugees in Chapter 19, “Clinical Work with LGBTQ Asylum Seekers.” Their activity aids therapists in determining any areas of their competency that need further development and clients in setting goals for the work ahead. Given that these clients have often experi­ enced persecution related to their social identities or political beliefs (or both), understanding their unique experiences of trauma and learning how to effectively build trust are essential to helping this population. Using another powerful and evidence-based form of self-care, Eve M. Adams, Tracie L. Hitter, and Virginia Longoria outline the importance of a selfcompassionate stance in “A Lovingkindness Meditation to Heal from Heterosexism, Transphobia, and Other Forms of Oppression” (Chapter 10). They explain that perceived discrimination is associated with increased psychic distress when individuals feel personally

rejected. Using a beautiful guided meditation tailored to the LGBT community, their activity promotes a greater sense of internal safety and ease. This activity is grounded in the research on mindfulness, which has shown that a shift in perspective to a more selfcompassionate stance is yet another meaningful way to externalize painful experiences and gain some distance (Shapiro & Carlson, 2009). Finally, Eva Mendes and Meredith R. Maroney’s “At the Intersection of the Autism Spectrum and Sex­ ual and Gender Diversity: Case Studies for Use with Clinicians and Clients” addresses another intersec­ tion of identities that are often marginalized. In this chapter (Chapter 18), the authors provide therapists with vital information regarding the issues faced by sexual and gender minorities who are on the autism spectrum in order to enhance their competency and generate therapeutic dialogues with clients. They sug­ gest that therapists should invite clients to explore the intersections of their sexual and gender identities with their autistic identities. References Beagan, B. L., & Hattie, B. (2015). Religion, spirituality, and LGBTQ identity integration. Journal of LGBT Issues in Counseling, 9 (2), 92–117. doi:10.1080/155386605.2015.1 029204. Gattis, M. N., & Larson, A. (2017). Perceived microaggressions and mental health in a sample of black youths experiencing homelessness. Social Work Research, 41, 7–17. doi:10. 1093/swr/svw030. Liao, K. Y., Kashubeck-West, S., Weng, C., & Deitz, C. (2015). Testing a mediation framework for the link between per­ ceived discrimination and psychological distress among sexual minority individuals. Journal of Counseling Psychol­ ogy, 62 (2), 226–241. doi:10.1037/cou0000064. Sarno, E. L., Mohr, J. J., Jackson, S. D., & Fassinger, R. E. (2015). When identities collide: Conflicts in allegiances among LGB people of color. Cultural Diversity and Ethnic Minority Psychology, 21 (4), 550–559. doi:10.1037/cdp0000026. Shapiro, S. L., & Carlson, L. (2009). The art and science of mind­ fulness: Integrating mindfulness into psychology and the helping professions. Washington, DC: American Psycho­ logical Association.

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8 SURVIVAL IN AN UNJUST WORLD: A TOOL FOR COPING WITH MULTIPLE FORMS OF OPPRESSION Jessica Chavez Suggested Use: Handout Objective

This handout provides a tool to help clients regulate the emotional effects of discrimination and reminders of structural violence. It was created in response to the needs of gender-diverse people of color, but it can be modified for use with any client who experiences one or more forms of systematic oppression. Rationale for Use

This chapter introduces a clinical tool that was devel­ oped using intersectionality and structural compe­ tency frameworks and designed to help people cope with the negative effects of multiple oppressions. The American Psychological Association’s (APA) “Guide­ lines for Psychological Practice with Transgender and Gender Nonconforming People” recommends that clinicians take an “interdisciplinary approach” (APA, 2015, p. 850) by collaborating with medical and social service providers (e.g., surgeons and caseworkers), and this chapter expands this definition of interdisci­ plinary practice by presenting a novel intervention that is informed by interdisciplinary social science research as well as clinical science. There is extensive evidence documenting the influ­ ence of racism on economic, health-care, legal, and educational systems in the United States (Alexander, 2012; Washington, 2006). Research on racialized health and health-care disparities indicates that people of color tend to receive inadequate care and are dis­ proportionately burdened by poorer health and pre­ mature death (Gravlee, 2009; Roberts, 2013; Williams

& Mohammed, 2013). Research has also documented the specific ill effects of racism on mental health (Paradies et al., 2015). For gender-nonconforming and trans people, transphobia and cisgenderism also lead to physical health problems, exposure to violence, and negative mental health outcomes (Bockting et al., 2013; Grant et al., 2011). Activists and scholars, particularly black feminists, have long offered the insight that any sufficient anal­ ysis of oppression must account for multiple intersect­ ing identities (e.g., Collins, 2000; Crenshaw, 1989; Truth, 1851). As intersectionality theory predicts, gen­ der-diverse people of color face uniquely detrimental intersections of oppression, as well as unique oppor­ tunities for resilience (Singh & McKleroy, 2011). The field of public health, however, has been slow to adopt intersectional frameworks to study the social deter­ minants of health (Bowleg, 2012). Research on the health effects of transphobia and cisgenderism still forms a limited, albeit growing, body of work (APA, 2015), and the field has yet to thoroughly document the specific combined influence of transphobia, cis­ genderism, and racism. Unfortunately, when trans and gender-nonconforming people of color seek mental health treatment, they too often enter systems that are simultaneously shaped by transphobia, cisgenderism, and racism, and emerging research indicates that trans and gender-nonconforming people of color can be particularly vulnerable in health-care settings (Ansara & Hegarty, 2012; Grant et al., 2011). Mental health providers can help clients address the psychological, physiological, and social effects of structural injustices. To help clinicians conceptualize

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the relationship between individual-level interven­ tions and structural racism, the psychiatrist and social scientist Jonathan Metzl (2009) introduced the notion of structural competency. Structural competency addresses the shortcomings of cultural competency models, which tend to assume that, if health-care practitioners acquire enough knowledge about the cul­ ture of the Other, then they can adequately treat patients from diverse backgrounds (Metzl, 2009; Metzl & Hansen, 2014). Metzl’s concept of structural com­ petency, expanded by Metzl and Hansen (2014), asserts that good clinical practice requires that clinicians understand how social structures perpetuate social inequalities and shape one-on-one interactions in health-care settings. Metzl and Hansen (2014) also argue that clinicians ought to be trained in imagining and implementing structural interventions that change the social practices that create harm. Therapists are uniquely positioned to help trans and gender-nonconforming clients of color regulate their emotional responses, thereby mitigating stress, which is one of the factors that links structural-level racism to individual health outcomes (Dressler, Oths, & Gravlee, 2005; Williams & Mohammed, 2013). It is important for clinicians to be cautious, however, about promoting individual adaptation or resilience without acknowledging that widespread social change is necessary. For example, scholars have documented how some stereotypical representations of black women emphasize their resilience (e.g., Collins, 2000). While being perceived as resilient or experiencing resilience does not necessarily lead to oppression, these stereotypes have been used to justify policies that harm black women and create conditions that sideline the needs of black cisgender women who are sexually assaulted (Donovan & Williams, 2002). Thus, focus­ ing on the individual and on adaptation while ignor­ ing a structural analysis can perpetuate oppression. Evidence suggests that engagement with activist communities and social movements supports mental health for trans and gender-nonconforming people (Pflum et al., 2015; Singh & McKleroy, 2011), and the work we do in therapy can support clients in their fights for justice by helping them cope with the emo­ tional toll of structural violence. Additionally, the APA’s “Guidelines for Psychological Practice with Trans-

gender and Gender Nonconforming People” (2015) and the American Counseling Association’s (ACA) Competencies for Counseling with Transgender Clients (ALGBTIC, 2009) both suggest that clinicians have an ethical obligation to act not just as clinicians, but also as advocates for trans and gender-nonbinary people. For many clinicians, particularly those who identify as trans or gender-nonbinary people of color, this kind of advocacy may already be an important part of their lives. Nevertheless, clinicians using this handout, particularly those who experience multi­ ple forms of privilege in relation to their clients, would benefit from asking themselves the following questions before using this handout: Is my work lim­ ited to helping this person adapt to an unjust world? What am I doing to make my community a place where this person can experience justice, support, and well­ being? Indeed, individual-level interventions made in our offices alone are not likely to dismantle larger structures of racism, transphobia, and cisgenderism, so it is also our responsibility to do what we can to help change social contexts that perpetuate systematic oppression. This handout was created to help bridge this gap between clients’ individual-level emotional regulation and structural-level factors that perpetu­ ate oppression. Instructions

This handout should be used in the context of a strong therapeutic alliance that supports collaboration and open communication. It is most useful as an addi­ tion to treatment with clients who routinely become overwhelmed with intense emotion when faced with experiences or reminders of oppression, including those who tend to act on these emotions with impul­ sive self-harm or by lashing out at others. The therapist should explain that this handout is a tool to help reg­ ulate emotions and remember strategies for self-care, as well as a resource to help remind clients of the broader struggle for social change. It is recommended that the therapist introduce the handout and have clients complete each section collaboratively in ses­ sion. This will allow clients to discuss any reactions or thoughts they have in response to the handout and allow the therapist to offer support, encouragement, and even humor (when appropriate). The therapist and

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the client may also work together to make any neces­ sary adaptations to the handout on the basis of the client’s specific experience or identity. Allow ample time to debrief with the client before the end of the session. Brief Vignette

K. is a twenty-seven-year-old graduate student. They identify as queer, gender nonbinary (and use they, them, and their as pronouns), and Asian American. They were assigned female at birth. K. identified as a lesbian for much of their adult life and began to iden­ tify as queer and nonbinary while in graduate school. K. was born and grew up on the West Coast but moved to the Northeast to attend a small liberal arts college. Following their first year of graduate school, K. sought therapy for the first time to address difficulty con­ centrating, disappointment with their caregivers, and pervasive feelings of anger and distrust. At home, K. was often in spaces where Asian peo­ ple made up the majority, but in the Northeast, K. struggled to adjust to living among so many white people. In therapy K. talked about missing the West Coast because they felt that Asian American history “meant something” there. They felt that, on the West Coast, Asian people held positions of power, and Asian culture had a visible influence on the mainstream. In the Northeast, K. often felt tokenized or found them­ selves among white people who seemed to be made nervous by K.’s willingness to openly address racism. K. often felt angry after interactions with white cisgen­ der men. They felt that white cis men treated them in a condescending manner and belittled them, especially in professional settings. These encounters brought back early memories of K.’s first encounters with rac­ ist, objectifying portrayals of Asian women, depicted as sexualized, submissive, and weak in television shows and movies. Their anger at these moments felt unbear­ able, and K. would notice their heart rate rise, feel sweaty, and have difficulty focusing on anything but the rage. K. often worried that their anger would lead them to lose control and “cause a scene” that would lead them to lose their part-time job, become embar­ rassed, or damage relationships. In therapy sessions, K. would frequently tell stories about these encounters, and they would become overwhelmed with angry thoughts about the combined effects of cisgenderism 72

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and racism in their life. At these times, K.’s therapist would help them slow down and reflect on the anger that had become overwhelming, thereby offering scaf­ folding to help K. regulate their emotions. To help K. regulate these intense feelings on their own between sessions, however, the therapist presented the idea of using this handout in their tenth session. K. and their therapist had built a strong working alliance, and they used humor to explore K.’s initially skeptical reaction to the idea of a handout, which K. associated with their desire to be seen as strong and invulnerable. K. and their therapist laughed together while exploring how using a worksheet made K. feel that their therapist was playing the “teacher” role and reminded K. of being a powerless grade-school stu­ dent. This provided an opportunity for K. and their therapist to explore the emotions connected to these memories, and K. decided that accepting the role of “student” and using the handout would help them achieve greater independence and agency over power­ ful negative emotions. K. completed the handout in session in collaboration with their therapist and took a picture of it with their phone so that they could easily access it in moments of distress. The handout provided an opportunity for K. and their therapist to closely examine K.’s most difficult emotions and accept them in the context of a supportive therapeutic rela­ tionship. Accepting these emotions and learning to manage them outside of session allowed K. to become more aware and accepting of their anger—not just as a potentially destructive part of their experience as a person of color facing multiple oppressions, but also as a productive, creative emotion that bound K. to other queer people of color in their work as an activist and scholar. Suggestions for Follow-up

After presenting this handout in session, therapists should check in with clients to determine whether they used it to manage difficult feelings between sessions. The handout can be useful, not just for emotional regulation between sessions, but also as a starting point for in-session therapeutic metacommunication, or here-and-now explorations that help the client and therapist develop a mutual understanding of the ther­ apeutic relationship (Safran & Muran, 2000). As thera­

pists elicit feedback from clients about the handout’s utility, they may also encourage clients to modify its contents when necessary. For example, while attempt­ ing to complete the section of the handout that asks clients to identify people they can call or text who understand their perspective on oppression, a client may tell their therapist that they do not feel they are able to reach out for help at the times they feel most vulnerable. The client may be too ashamed to share difficult feelings with others or find that reaching out when they are feeling angry inevitably leads to dis­ appointing interactions with people close to them. In this example, the therapist using the handout might work collaboratively with the client to alter this section and, instead of listing people to call or text for sup­ port, the client may make a list of the people who care about their well-being and validate their pain. Rather than calling or texting for help, the client might, for example, decide to spend time recalling one or more memories of times when they felt supported and loved by others. In therapy sessions, the therapist and client can work on understanding the feelings and patterns of relating that make it difficult to find social support and reach out for help, but in the meantime, altering the handout offers a way for clients to be a coauthor of their individualized treatment plan. Contraindications for Use

This handout is intended for use with clients who believe that racism, cisgenderism, and transphobia are factors contributing to their presenting problems. For clients who are not consciously aware of the structurallevel factors affecting their experience, this handout will probably not be a useful clinical tool. For suicidal clients, clients who engage in self-harm, and clients with thoughts of harming others, this protocol is not intended to be a substitute for safety planning. Professional Readings and Resources Cole, E. R. (2009). Intersectionality and research in psychology. American Psychologist, 64 (3), 170. Gravlee, C. C. (2009). How race becomes biology: Embodiment of social inequality. American Journal of Physical Anthro­ pology, 139 (1), 47–57. Metzl, J. M. (2009). The protest psychosis: How schizophrenia became a black disease. Boston: Beacon Press.

Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103, 126–133. Roberts, D. (2013). Fatal invention: How science, politics, and big business re-create race in the twenty-first century. New York: New Press. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on black Americans from colo­ nial times to the present. New York: Doubleday.

Resources for Clients Bornstein, K. (2006). Hello, cruel world: 101 alternatives to suicide for teens, freaks, and other outlaws. New York: Seven Stories Press. Downs, K. (2016, July 22). When black death goes viral, it can trigger PTSD-like trauma. PBS News Hour: The Rundown. https://www.pbs.org/newshour/rundown/ black-pain-gone-viral-racism-graphic-videos-can-cre ate-ptsd-like-trauma/. Icarus Project. http://theicarusproject.net/. Lorde, A. (1988). A burst of light: Essays. Ithaca, NY: Fire­ brand Books. Romero, F. (2013). Self care list: How to take care of your self while learning about oppression (with unaware people). https://fabianswriting.tumblr.com/post/69798253522/ self-care-list-how-to-take-care-of-your-self. Walker, I. (2016, July 8). Tips for self-care: When police bru­ tality has you questioning humanity and social media is enough. Root. www.theroot.com/articles/cuture/2016/07/ tips-for-self-care-when-police-brutality-has-you­ questioning-humanity-and-social-media-is-enough/.

References Alexander, M. (2012). The new Jim Crow: Mass incarceration in the age of colorblindness. New York: New Press. American Psychological Association (APA). (2015). APA guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. Ansara, Y. G., & Hegarty, P. (2012). Cisgenderism in psychol­ ogy: Pathologising and misgendering children from 1999 to 2008. Psychology and Sexuality, 3 (2), 137–160. doi:10. 1080/19419899.2011.576696. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. https://www.counseling.org/Resources/Competencies/ ALGBTIC_Competencies.pdf. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Ham­ ilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender popu­ lation. American Journal of Public Health, 103 (5), 943– 951. doi:10.2105/AJPH.2013.301241.

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Bowleg, L. (2012). The problem with the phrase women and minorities: Intersectionality—an important theoretical framework for public health. American Journal of Public Health, 102 (7), 1267–1273. Collins, P. H. (2000). Black feminist thought: Knowledge, con­ sciousness, and the politics of empowerment. New York: Routledge. Crenshaw, K. (1989). Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. University of Chicago Legal Forum, 1, 139–168. Donovan, R., & Williams, M. (2002). Living at the intersection: The effects of racism and sexism on black rape survivors. Women and Therapy, 25 (3–4), 95–105. Dressler, W. W., Oths, K. S., & Gravlee, C. C. (2005). Race and ethnicity in public health research: Models to explain health disparities. Annual Review of Anthropology, 34, 231–252. Grant, J. M., Mottet, L. A., Tanis, J., Herman, J. L., Harrison, J., & Keisling, M. (2011). National transgender discrimina­ tion survey report on health and health care. Washington, DC: National Center for Transgender Equality and the National Gay and Lesbian Task Force. Gravlee, C. C. (2009). How race becomes biology: Embodi­ ment of social inequality. American Journal of Physical Anthropology, 139 (1), 47–57. doi:10.1002/ajpa.20983. Metzl, J. M. (2009). The protest psychosis: How schizophrenia became a black disease. Boston: Beacon Press. Metzl, J. M., & Hansen, H. (2014). Structural competency: Theorizing a new medical engagement with stigma and inequality. Social Science and Medicine, 103, 126–133.

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Paradies, Y., Ben, J., Denson, N., Elias, A., Priest, N., Pieterse, A., Gupta, A., Kelaher, M., & Gee, G. (2015). Racism as a determinant of health: A systematic review and meta-anal­ ysis. PLoS One, 10 (9), 1–48. doi:doi.org/10.1371/journal. pone.0138511. Pflum, S. R., Testa, R. J., Balsam, K. F., Goldblum, P. B., & Bongar, B. (2015). Social support, trans community con­ nectedness, and mental health symptoms among transgender and gender nonconforming adults. Psychology of Sexual Orientation and Gender Diversity, 2 (3), 281–286. doi:10.1037/sgd0000122. Roberts, D. (2013). Fatal invention: How science, politics, and big business re-create race in the twenty-first century. New York: New Press. Safran, J. D., & Muran, J. C. (2000). Negotiating the therapeutic alliance: A relational treatment guide. New York: Guilford Press. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender peo­ ple of color who have survived traumatic life events. Traumatology, 17 (2), 34–44. https://doi.org/10.1177/ 1534765610369261. Truth, S. (1851). Ain’t I a woman? https://sourcebooks.ford ham.edu/mod/sojtruth-woman.asp. Washington, H. A. (2006). Medical apartheid: The dark history of medical experimentation on black Americans from colonial times to the present. New York: Doubleday. Williams, D. R., & Mohammed, S. A. (2013). Racism and health I: Pathways and scientific evidence. American Behavioral Scientist, 57 (8), 1152–1173.

H A NDO UT

We can survive in an unjust world, and we can cope without giving in. Oppression harms our health and well-being. Ending oppression is a long and difficult struggle. This worksheet is designed to help people cope with injustice without losing sight of the fact that the problem does not actually lie with us, but with a system that causes us harm. Triggers (e.g., situations, people, etc.) that lead me to feel distressed (i.e., situations that might lead me to use this handout):

Changes I notice when I am feeling overwhelmed by experiences and reminders of oppression (e.g., feelings, sensations, emotions, thoughts):

Things I can do to help me change the way I feel (e.g., what helps calm me when I’m anxious? What helps lift me up when I’m down?):

People I can call or text who understand my perspective on oppression:

People in my life who are unable to understand my perspective (i.e., people to avoid):

Quotes, book passages, or poems that remind me of values that are important to me:

People who fight injustice and inspire me to cope and to continue speaking my truth:

Reminders of why it is important to take time to care for myself:

Triggers or reminders of oppression that I should avoid right now so that I can care for myself:

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9 MANAGING THE INTERSECTIONS: A NARRATIVE APPROACH TO GUIDING QUEER PEOPLE OF COLOR IN NAVIGATING MULTIPLE OPPRESSIONS Jayleen Galarza Suggested Use: Activity Objective

By engaging in this activity, clients will be able to explore and process the influence of multiple oppres­ sions on their lived experience as well as to identify ways to actively resist internalizing oppression. This activity is appropriate for working with individual clients who relay experiences related to various layers of discrimination, such as those rooted in heterosex­ ism, racism, and sexism. This activity could also be adapted to work in a group setting with clients encoun­ tering similar experiences. Rationale for Use

In facing oppression, especially multiple oppressions, it can be a daunting and challenging task for a client to feel fully empowered, regain strength, and resist societal narratives that have been and continue to be imposed. Research has demonstrated that queer people of color often contend with multiple oppressions, including enduring racism within predominantly white LGBTQ spaces (Balsam et al., 2011; Bridges, Selvidge, & Matthews, 2003; Sarno, Mohr, Jackson, & Fassinger, 2015). At times, these oppressions include encounters with silence, invisibility, aggression, and violence in the various spaces they navigate (Balsam et al., 2011; Bridges et al., 2003; Singh & McKleroy, 2011). For some individuals, the silencing of either their racial/ ethnic identity within predominantly white LGBTQ spaces or their sexual/gender identities among fam­

ily, neighborhood, or other important communities may produce unique challenges to fully expressing their authentic selves (Balsam et al., 2011; Bridges et al., 2003; Sarno et al., 2015). For transgender people of color in particular, the additional layer of transphobia often leads to higher rates of trauma because of increased experiences of violence and abuse (Singh & McKleroy, 2011). This activity is designed to help guide clients who identify as queer people of color through the process of navigating multiple oppressions. The desired outcome of engaging in this collaborative process is to help clients reclaim their resiliency and resist the narratives that have dominated their stories throughout development, as well as to create more preferred narratives that honor their intersectional experiences (Galarza, 2013). Affirmative practice with queer-identified clients requires that therapists be mindful of their attitudes toward their clients and gain knowledge, awareness, and training about relevant cultural influences (Alessi, Dillon, & Kim, 2015; APA, 2012). Therefore, thera­ pists cannot neglect the significance and effects of clients’ experiences of multiple intersecting identities within the therapeutic relationship (Bridges et al., 2003; Ritter & Terndrup, 2002). To ensure affirmative prac­ tice with clients who may identify as queer people of color, therapists must increase their understanding of the intersecting oppressions, such as the dynamics of experiencing racism and heterosexism within daily life, that may pertain to the client. It is important to understand the effects of oppression on their world-

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view, wellness, and development (Bridges et al., 2003; Ritter & Terndrup, 2002). In addition, they must adopt practices and interventions that intentionally make space for relevant discussions about power, oppression, and discrimination at multiple levels (Galarza, 2013). The use of narrative techniques in clinical prac­ tice may offer the therapist an opportunity to affirm clients’ experiences and bear witness as they make further meaning of navigating the world as queer peo­ ple of color (Galarza, 2013). One of the key compo­ nents of narrative practice is awareness of the fluidity and social construction of realities (Madigan, 2011; Saltzburg, 2007), and an essential task of this approach is to collaborate with clients in re-authoring prob­ lem-saturated stories (Besley, 2002; Saltzburg, 2007). Within this process, clients are invited to reflect on and process the social, political, and cultural influ­ ences, as well as their own influence, on the life of the story (Madigan, 2011; Saltzburg, 2007). By using an activity rooted in narrative therapy techniques, ther­ apists thus bring the issues of power and marginaliza­ tion into focus (Galarza, 2013; Madigan, 2011). An important concept in narrative therapy is externalization. This process of externalization seeks to distinguish the identified problem as the problem, separate from the individual, which builds a founda­ tion for an alternative story line (Madigan, 2011). By externalizing and personifying the problem, such as identifying racism as a separate entity rather than inter­ nalizing it within the person, the therapist attempts to relieve the individual of internalized shame and oppression (Galarza, 2013; Madigan, 2011). As Saltz­ burg (2007) found in her practice, such externaliza­ tion and re-authoring offered individuals the ability to process the reactions of their families to their sex­ ual orientation and/or gender identities and expres­ sions as a product of heterosexist norms and values; therefore, they were able to situate themselves out­ side this problematic narrative to better understand that this was not a reflection of who they are as a per­ son. Saltzburg (2007) stated, “By engaging in this pro­ cess of self-reflection, we are able to join with clients in more authentic, collaborative ways” (p. 58). The incorporation of a writing activity comple­ ments this therapeutic process and integrates creativity and storytelling that are often culturally rooted (An­

zaldúa, 2012; Comas-Díaz, 2006; Galarza, 2013; Rodri­ guez, 2010). In addition, the use of expressive tech­ niques as an intervention assists in honoring the intersections of identity and navigating the multiple oppressions that are often encountered (Galarza, 2013). Writing, storytelling, and the collective expe­ rience are central to the experiences and cultures of many communities of color, including queer-identified people of color (Anzaldúa, 2012; Moraga & Anzaldúa, 2015). As this activity demonstrates, clients are encouraged to reclaim the rights to their story and col­ laborate in a process of re-authoring with the thera­ pist; in effect, clients are engaged in the process of dismantling the societal narratives of marginalization, including the intersections of racism, sexism, and heterosexism, that have been ingrained throughout their development. This dismantling is particularly important for queer-identified people of color, who often must contend with and navigate several forms of stigma and discrimination throughout their lives, including experiences of racism within LGBTQ com­ munities themselves (Balsam et al., 2011; Bridges et al., 2003; Sarno et al., 2015). For many queer people of color, such life events are significant to their under­ standing of identity (Bridges et al., 2003; Galarza, 2013) and therefore require particular attention within the therapeutic process (Bridges et al., 2003; Galarza, 2013; Ritter & Terndrup, 2002). These practices uphold the principles and ethics that guide the work of clinical social workers. Accord­ ing to the National Association of Social Workers’ “Code of Ethics” (2017), the mission of social work­ ers is to address the needs of vulnerable and diverse populations with particular attention to understand­ ing and intervening on issues of social injustice. By engaging in a collaborative, narrative approach with clients, clinical social workers will consistently meet the ethical foundations of the profession by helping individuals subvert the negative social, cultural, and political influences that have dominated their lives. Instructions

This activity can be used over the course of multiple sessions. The goal is to engage clients in reflecting on the ways each of their identities intersects and affects their lives. Managing the Intersections

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In preparation for this activity, the clinician should provide the client with a writing utensil and piece of paper. Begin this activity by asking the client to label each identity they find integral to their lived experi­ ence and to write each one on the piece of paper pro­ vided—for example, black, queer, woman, college educated, middle class. If the client has difficulty with this task, it may be useful to list some examples and brainstorm with them. As they continue to share, encourage them to continue writing down their various identities on the sheet of paper. Then ask the client: “If you could give a title to your life story so far (like a title given to the book of your life), one that integrates all these identities, what would it be?” Ask the client to write down the title on the same sheet of paper. If the client is struggling to identify a title that integrates all these identities, help the client construct a title that reflects each separate identity. Process the title that the client developed and use processing questions to further explore the mean­ ing. Also begin to map the life of the problem and the various influences. See the handout of related pro­ cessing questions (page 81). As you work with the client to explore these var­ ious questions, ask them to map out their responses on the same sheet of paper containing the title. The following are suggested subheadings: a. Characters: Who are the main characters? b. Plot: What’s important to influencing the life of the story? What path has it taken so far? Where do you see the plot headed? c. Chapters: How many have you accumulated? How would you title them? As you collaborate with the client on this activity, encourage them to observe and reflect on what they’ve written. Then ask: How do you feel about your story so far? What do you hope to be different as each chap­ ter progresses? In asking these questions, the thera­ pist opens the door for exploration within future sessions. For example, the therapist can follow a par­ ticular plot offered by the client to highlight oppres­ sion as a key character in the story. The client may not have initially thought to identify oppression, such as racism, sexism, heterosexism, or transphobia, as a character in the story; however, the therapist can sug­ 78

Galarza

gest this possibility by further exploring its influence on the life of the problem. In doing so, the therapist could ask, “How did racism present an additional bar­ rier to reaching your goal?” or “How did heterosexism convince you of your limited self-worth?” While engaging in this process with the client, it is important for the therapist to consistently tune in to the client’s language and accurately reflect what is heard. The purpose is to validate the client’s experi­ ences while deconstructing the dominant story pre­ sented within session without the therapist’s impos­ ing their own desires, belief systems, or influences on the client’s story. Therefore, the therapist must always use the language reflected by the client and periodically check to be sure the client feels heard and affirmed. Brief Vignette

Nina is a thirty-three-year-old Puerto Rican, lesbian, gender-nonconforming woman who originally sought individual counseling after a recent job loss and break­ up with her female partner of eight years. During the initial assessment, Nina reported difficulties sharing her experience with others, especially family, because they were not accepting of her relationship during this time and pressured Nina to date men. In addition, Nina reported that she has routinely experienced harassment from others because of her masculine appearance. She even shared an experience at her most recent job, the one she lost, in which her employer suggested that she try to dress “more feminine,” like the other Latinas employed at the agency. Nina reported, “I guess this just comes with the territory,” referring to her identity as a butch lesbian woman. To affirm the client’s story relating multiple chal­ lenges associated with her experience as a gendernonconforming, Puerto Rican lesbian, the therapist gauged the client’s interest in participating in a narra­ tive activity. The client agreed, stating, “I think it’d be cool to think of this as a story.” For the next few ses­ sions, the therapist helped Nina map the life of the problem, which was significantly tied to her experi­ ences of multiple oppressions. The various reflective, processing questions opened up opportunities for Nina to think about the larger societal, oppressive structures at play, which allowed for the externalization of the problem. The therapist was able to collaborate

with Nina to identify a larger story line, external to her personal experience, that might have influenced her understanding of self in different contexts. The therapist was able to achieve this result by asking Nina to think about how racism, sexism, and heterosexism could have possibly played a role in these situations. Through the processing of this activity, Nina was able to re-author her story and better understand these experiences as external to herself and not a product of her various identities. For example, she was able to let go of internalized shame associated with her gender expression, as she had blamed herself for los­ ing her job, and she understood that there was noth­ ing wrong with her masculinity. The story was found in her employer’s prejudice toward masculine-present­ ing Latina women, which was reflective of a larger societal discourse. Suggestions for Follow-up

Clients can find it difficult to re-author and change relationships with a dominant narrative; therefore, it is important to revisit the client’s role in the story throughout sessions. In doing so, the therapist may want to ask the client, “How do you see your role in this story evolving?” and “How has racism or sexism or heterosexism continued to influence this story?” In doing so, the therapist is better able to track the pro­ gression of the narrative and better understand how the client’s experiences with multiple oppressions are shifting. Furthermore, in using a narrative approach, it’s important to culminate therapy with the presen­ tation of the new or preferred story that has been revealed over the course of treatment (Madigan, 2011). In collecting new chapters, the therapist can ask clients to share their new story, and the therapist can adopt the role of bearing witness to this sharing. Contraindications for Use

Before implementing this activity, assess the client’s comfort with and ability to write. If an alternative format is needed, make necessary adjustments and offer additional assistance, such as the use of a com­ puter or dictation. The client may choose to speak while the therapist writes out the client’s responses. This activity is designed for queer-identified people of color who are struggling with the ways intersectional

oppression influences their life and who want to regain strength and power by developing a more preferred story. If clients do not struggle with these concerns, then this activity can be used to further validate their resiliency. Professional Readings and Resources American Psychological Association (APA). (2017). Practice guidelines for LGB clients. https://www.apa.org/pi/lgbt/ resources/guidelines.aspx. Anzaldúa, G. (2012). Borderlands/La frontera: The new mestiza. San Francisco: Aunt Lute Books. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Culturally Diverse Ethnic Minority Psychology, 17 (2), 163–174. doi:10. 1037/a0023244. Besley, A. C. (2002). Foucault and the turn to narrative therapy. British Journal of Guidance and Counselling, 30 (2), 125– 143. doi:10.1080/03069880220128010. Campus Pride. (2013, July 29). Being an ally to queer people of color. https://www.campuspride.org/resources/being­ an-ally-to-queer-people-of-color/. Dulwich Centre. (n.d.). A gateway to narrative therapy and community work. http://dulwichcentre.com.au/. Galarza, J. (2013). Borderland queer: Narrative approaches in clinical work with Latina women who have sex with women (WSW). Journal of LGBT Issues in Counseling, 7 (3), 274–291. doi:10.1080/15538605.2013.812931. Gremillion, H. (2004). Unpacking essentialisms in therapy: Lessons for feminist approaches from narrative work. Journal of Constructivist Psychology, 17, 173–200. doi:10. 1080/10720530490447112. Madigan, S. (2011). Narrative therapy. Washington, DC: American Psychological Association. Moraga, C., & Anzaldúa, G. (eds.). (2015). This bridge called my back: Writings by radical women of color, 4th edition. Albany: State University of New York Press. Saltzburg, S. (2007). Narrative therapy pathways for re-author­ ing with parents of adolescents coming-out as lesbian, gay, and bisexual. Contemporary Family Therapy, 29, 57–69. doi:10.1007/s10591-007-9035-1. White, M., & Epston, D. (1990). Narrative means to therapeutic ends. Adelaide, Australia: Dulwich Centre.

Resources for Clients Audre Lorde Project. (n.d.). About ALP. http://alp.org/about. Crossroads Initiative at the University of Wisconsin–Madison. (n.d.). Queer people of color (QPOC) resource guide. https://www.uwec.edu/files/3195/QPOC-Crossroads­ Resource-Guide.pdf. National Queer Asian Pacific Islander Alliance. (n.d.) About. http://www.nqapia.org/wpp/home/. Managing the Intersections

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Sylvia Rivera Law Project. (2017). Resources. http://srlp.org/ resources/. Zuna Institute. (2014). National advocacy organization for black lesbians. www.zunainstitute.org/.

References Alessi, E. J., Dillon, F. R., & Kim, H. M. (2015). Determinants of lesbian and gay affirmative practice among heterosexual therapists. Psychotherapy, 52 (3), 298–307. doi:10.1037/ a0038580. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. Anzaldúa, G. (2012). Borderlands/La frontera: The new mestiza. San Francisco: Aunt Lute Books. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Culturally Diverse Ethnic Minority Psychology, 17 (2), 163–174. doi:10.1037/a0023244. Besley, A. C. (2002). Foucault and the turn to narrative therapy. British Journal of Guidance and Counselling, 30 (2), 125– 143. doi:10.1080/03069880220128010. Bridges, S. K., Selvidge, M. M. D., & Matthews, C. R. (2003). Lesbian women of color: Therapeutic issues and chal­ lenges. Journal of Multicultural Counseling and Develop­ ment, 31, 113–130. Comas-Díaz, L. (2006). Latino healing: The integration of ethnic psychology into psychotherapy. Psychotherapy: Theory, Research, Practice, Training, 43 (4), 436–453. doi:10.1037/0033-3204.43.4.436.

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Galarza

Galarza, J. (2013). Borderland queer: Narrative approaches in clinical work with Latina women who have sex with women (WSW). Journal of LGBT Issues in Counseling, 7 (3), 274–291. doi:10.1080/15538605.2013.812931. Madigan, S. (2011). Narrative therapy. Washington, DC: American Psychological Association. Moraga, C., & Anzaldúa, G. (eds.). (2015). This bridge called my back: Writings by radical women of color, 4th edition. Albany: State University of New York Press. National Association of Social Workers. (2017). Code of ethics of the National Association of Social Workers. https:// www.socialworkers.org/about/ethics/code-of-ethics. Ritter, K. Y., & Terndrup, A. I. (2002). Handbook of affirmative psychotherapy with lesbians and gay men. New York: Guilford Press. Rodriguez, D. (2010). Storytelling in the field: Race, method, and the empowerment of Latina college students. Cul­ tural Studies, Critical Methodologies, 10 (6), 491–507. doi:10.1177/1532708610365481. Saltzburg, S. (2007). Narrative therapy pathways for re-author­ ing with parents of adolescents coming-out as lesbian, gay, and bisexual. Contemporary Family Therapy, 29, 57–69. doi:10.1007/s10591-007-9035-1. Sarno, E. L., Mohr, J. J., Jackson, S. D., & Fassinger, R. E. (2015). When identities collide: Conflicts in allegiances among LGB people of color. Cultural Diversity and Ethnic Minority Psychology, 21 (4), 1–10. doi:10.1037/cdp0000026. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender peo­ ple of color who have survived traumatic life events. Trau­ matology, 17 (2), 34–44. doi:10.1177/1534765610369261.

H A NDO UT

P RO C E SSIN G QU E ST IO NS : M A NAGING T H E INT ERS ECT IO NS

Title: If you could give a title to your life story so far (like a title given to the book of your life), one that integrates all of these identities, what would it be?

a. In which ways have marginalization and oppression played a role in influencing the title of this story?

b. How do racism, sexism, and heterosexism each play their parts?

c. What’s your role in this story?

d. How do you wish to see that role change in your story?

e. In which ways have you attempted to change the story in the past?

Suggested Subheadings a. Characters: Who are the main characters?

b. Plot: What’s important to influencing the life of the story? What path has it taken so far? Where do you see the plot headed?

c. Chapters: How many have you accumulated? How would you title them?

Reflection a. How do you feel about your story so far?

b. What do you hope to be different as each chapter progresses?

Jayleen Galarza

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10 A LOVINGKINDNESS MEDITATION TO HEAL FROM HETEROSEXISM, TRANSPHOBIA, AND OTHER FORMS OF OPPRESSION Eve M. Adams, Tracie L. Hitter, and Virginia Longoria Suggested Uses: Activity, homework, handout Objective

The goal of this activity is to help lesbian, gay, bisex­ ual, and transgender (LGBT) individuals, including those who have intersecting oppressed identities (e.g., ethnic and religious minorities, women), heal from oppression-based trauma. Healing occurs by helping individuals attend compassionately to themselves through the acts of noticing the effects of oppressive experiences on themselves and offering kind wishes for themselves and for others who have experienced similar difficulties. Rationale for Use

Despite recent gains in civil rights for sexual minori­ ties (e.g., gay marriage), heterosexism is still a con­ sistent aspect of the lives of many LGB individuals. Anti-LGB attitudes and behaviors have shifted from more overt acts of discrimination to more subtle forms of devaluation (Walls, 2008), which may cause peo­ ple to minimize the influence of heterosexist discrim­ ination in their lives. Heterosexism is defined as the beliefs and attitudes held by dominant groups that stig­ matize nonheterosexuality (Herek and Berrill, 1992). There are five different dimensions of heterosexism, and each serves to deny, stigmatize, and devalue nonheterosexual relationships (Walls, 2008). Hostile het­ erosexism is what was historically called homophobia and refers to attitudes of disgust, judgment of nonheterosexuality as immoral, and avoidance (Walls,

2008). Aversive heterosexism is a set of attitudes that seek to minimize the negative effect of stigmatization and oppression experienced by LGB individuals (Walls, 2008). Amnestic heterosexism refers to the belief that while LGB individuals once experienced discrimina­ tion, such prejudicial behavior no longer occurs (Walls, 2008). Paternalistic heterosexism is a more neutral attitude of viewing LGB individuals positively, but it includes an attitude of concern for the well-being and safety of LGB individuals and a desire for these indi­ viduals to be heterosexual to protect them from prej­ udice. Positive stereotypic heterosexism is an attitude of support and acceptance, along with an appreciation for stereotypic characteristics (e.g., lesbians are skilled at auto repair). Internalized heterosexism is the intro­ jection of these attitudes by those who are the target of these attitudes, which results in negative attitudes about being a sexual minority, which Herek (2007) calls internalized stigma. Similarly, prejudice against transgender individ­ uals is conceptualized as having affective, cognitive, and behavioral aspects (Hill & Willoughby, 2005). Transphobia refers to an attitude of disgust, fear, and/ or hatred toward transgender individuals (Hill & Willoughby, 2005). Genderism, similar to heterosex­ ism, is a cultural ideology that reinforces a negative evaluation of gender nonconformity, and it may be imposed on others or an internalized belief (Hill & Willoughby, 2005). Gender-bashing refers to physical or emotional assault (or both) against individuals who are gender nonconforming (Hill & Willoughby, 2005).

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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The stress associated with being a sexual or gen­ der minority is associated with increased risk of psy­ chological distress (Levitt et al., 2009), including depression, anxiety, suicidal behavior, and substance use (Bazargan & Galvan, 2012; Budge, Adelson, & Howard, 2013; Frost & Meyer, 2009; Moradi, Van den Berg, & Epting, 2009; Reisner, Gamarel, Nemoto, & Operario, 2014; Smith & Ingram, 2004). Furthermore, experiences of heterosexist discrimination among ethnic-minority sexual minorities have been found to be associated with increased psychological stress (Szymanski & Sung, 2010). Thus, the pernicious effects of heterosexism are amplified by its effect on individu­ als’ mental health, as well its commonality with other forms of oppression (e.g., racism). More specifically, perceived discrimination results in feelings of rejection, which may lead to psycho­ logical distress. In a sample of sexual minority individ­ uals, perceived discrimination was predictive of lower levels of self-compassion and increased psychologi­ cal distress (Liao, Kashubeck-West, Weng, & Deitz, 2015). Perceived rejection was associated with nega­ tive internal feelings, self-judgment, and a decrease in self-compassion (Liao et al., 2015). Stigma aware­ ness was found to be associated with more psycholog­ ical distress among a sample of transgender adults (Breslow et al., 2015). Thus, it is important when work­ ing with LGBT clients to work on cultivating greater self-compassion. Self-compassion interventions are grounded in Buddhist religion and have been secularized in mind­ fulness-based psychological interventions (Shonin, Van Gordon, & Griffiths, 2014). Mindfulness is “a particular way of paying attention on purpose to the present moment, non-judgmentally” (Kabat-Zinn, 1994, p. 4). There is a growing body of research liter­ ature demonstrating how acceptance and mindful­ ness principles are helpful for addressing a variety of medical and mental health issues (Chiesa & Serretti, 2011; Eberth & Sedlmeier, 2012; Hofmann, Sawyer, Witt, & Oh, 2010; Klainin-Yobas, Cho, & Creedy, 2012; Shonin, Van Gordon, Slade, & Griffiths, 2013). Inter­ ventions based on these approaches have been imple­ mented to treat depression, anxiety, eating disorders, chronic pain, borderline personality disorder, and other issues (Baer, 2006).

A recent meta-analysis of studies involving selfcompassion demonstrates that it is predictive of psy­ chological well-being (Zessin, Dickhäuser, & Garbade, 2015). Neff and Germer (2013) studied the effective­ ness of a mindful self-compassion program and found it to be effective for increasing cognitive wellbeing. Self-compassion includes three components: (a) self-kindness, showing kindness to oneself instead of criticism during difficult moments; (b) common humanity, viewing one’s experiences as a struggle com­ mon to others, as opposed to experiences that sepa­ rate and isolate one from others; and (c) mindfulness, approaching painful thoughts and emotions with awareness rather than overidentification (Neff, 2003). Research demonstrates that self-compassion can help people temper emotional reactions to events such as rejection, failure, and embarrassment, and it may provide more benefit than self-esteem does (Leary et al., 2007). Self-compassion helps strengthen resilience against difficulties and helps people accept undesir­ able outcomes (Leary et al., 2007), which may help them cope with experiences of discrimination related to their sexual orientation. While there is a great deal of evidence about the efficacy of self-compassion and mindfulness inter­ ventions in general (e.g., Neff & Germer, 2013), cur­ rently there is no clear evidence of such interventions for minority populations. Given the humanistic nature of mindfulness, self-compassion, and lovingkindness interventions, such activities are inherently affirming of LGBT individuals. The relevance of mindfulness and self-compassion to oppression-based suffering is just beginning to be examined, and results so far are promising (Brown-Iannuzzi et al., 2014; Lyons, 2016; Toomey & Anhalt, 2016). The shift in the last ten years is to explore the con­ struct of mindfulness with minority populations. A study of African Americans found that trait mindful­ ness (i.e., a characteristic of those whose personali­ ties are naturally mindful) was negatively correlated with both general anxiety and anxiety arousal (Gra­ ham, West, & Roemer, 2013). Brown-Iannuzzi and colleagues (2014) examined how trait mindfulness was a protective factor for individuals who were tar­ gets of discrimination that was based on race, gender, age, and other factors. Findings indicated that the A Lovingkindness Meditation to Heal from Oppression

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relationship between depressive symptoms and per­ ceived discrimination was reduced for individuals who exhibited higher levels of trait mindfulness (BrownIannuzzi et al., 2014). Similarly, in a sample of mid­ dle-aged and older gay men in Australia, another study found that trait mindfulness appeared to reduce the relationship between distress and discrimination that was based on age and sexual orientation (Lyons, 2016). Finally, a study of LGBT Latino youth’s expe­ riences of school victimization owing to their ethnic­ ity and sexual orientation found that trait mindfulness was protective in reducing the relationships between sexual orientation–based victimization and higher depressive symptoms and lower self-esteem (Toomey & Anhalt, 2016). Though trait mindfulness seems to be useful for minority populations, there are very few studies exam­ ining the effectiveness of mindfulness-based interven­ tions with minority populations. An adaptation of cognitive-behavioral treatment for traumatized refu­ gees and ethnic minorities was adapted to include a lovingkindness practice (Hinton et al., 2013). This case study illustrated how the inclusion of a lovingkindness practice could increase psychological flexi­ bility and improve efficacy with regard to affect regulation (Hinton et al., 2013). Findings from a qualitative study demonstrate how mindfulness practice facilitates a broadening of worldview and cultivates an ability to re-perceive social and cultural identities while simultaneously honoring them (Longoria, 2014). Participants in this study, all members of oppressed groups and teach­ ers of mindfulness, offered important insights about how mindfulness-based and -informed therapies can be delivered in culturally relevant ways and how they may help people manage the psychological con­ sequences of oppression (Longoria, 2014). Shapiro and Carlson (2009) propose that the healing effects of mindfulness are the result of a shift in perspective. This shift allows for a broadening of views that expands one’s view of the self, a shift that may be heal­ ing for individuals coping with the negative effects of heterosexism and genderism. Because there are limited studies on the effective­ ness of mindfulness-based interventions with minor­ ity populations, it is important to provide adequate 84

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informed consent to clients that these techniques are in development for use with various minority popu­ lations (APA, 2010, 10.01[b]). The other APA ethical code that is particularly relevant to therapists provid­ ing mindfulness interventions to LGBT populations is 2.01(b) Boundaries of Competence. Psychologists are expected to have competence when dealing with issues of diversity in clinical work (Bieschke & Mintz, 2012). In addition, it is essential to gain sufficient training in mindfulness interventions, which would include therapists practicing these interventions in their own lives. Instructions

Therapists can use the lovingkindness meditation as an antidote to heterosexist and transphobic experi­ ences initially as an in-session activity, although it can later be given as homework. It is best to allow at least fifteen minutes for the activity and at least another fifteen minutes to process the experience. The thera­ pist can give a general introduction that this is a medi­ tation that allows clients to attend to themselves when they have felt fundamentally devalued because of their gender identity or sexual orientation. This activity works best if the therapist and client have already engaged in other mindfulness activities, including mindful breathing or other similarly ground­ ing practices. In addition, if the client has already engaged in lovingkindness or self-compassion prac­ tices, then applying these practices to specific hetero­ sexist or transphobic experiences will be more famil­ iar. Thus, it is recommended that one or two sessions be spent in these more general mindfulness practices first. We also suggest that therapists engage in these practices in their own lives so that they have personal familiarity with the experiential learning that can occur with these practices. We advise that therapists engage in mindful breathing with the client, then guide the self-compassion meditation, so that both are expe­ riencing present-moment awareness. Thus, we recom­ mend that therapists explore the resources at the end of the chapter for themselves as well as for their clients. The signal for introducing this practice occurs when the client describes an experience of heterosex­ ist, transphobic, or intersectionality discrimination. It certainly is appropriate for the therapist to empathize

and express compassion for the client, but at some point it will be important for the therapist to help the client practice some self-compassion. Such a focus is needed particularly when clients are minimizing their pain, internalizing the oppression, or focused exclu­ sively on externalizing their experience. This guided meditation combines two mindful­ ness practices. The first is based on a mindful selfcompassion practice developed by Neff and Germer (2013), and the second is based on a lovingkindness practice developed by the Buddha over 2,500 years ago (Kornfield, 2008). At the end of the chapter, both an English version and a Spanish version of the sam­ ple wording for the guided meditation are included. Brief Vignette

Alex is an Asian American cisgender male client who identifies as gay. He reports feelings of low self-worth, distressing levels of anxiety, feelings of isolation, and experiences of ethnic discrimination within the gay community and heterosexism from the larger commu­ nity. Alex has no experience with any meditation prac­ tice and is open to learning something that would help him manage the distressing emotions he experiences. The intervention begins with the therapist asking Alex to close his eyes and focus his attention on his breath. After a minute or so, the therapist asks Alex to recall a recent experience in which he was devalued because of his sexual orientation and asks him to notice the emo­ tions and physical sensations that emerge as he recalls the experience. The therapist asks him to notice if there is any resistance that emerges, and encourages him to breathe into that feeling, supporting him in observing any thoughts, feelings, or sensations that arise. Next, the therapist walks him through the steps of the guided meditation. Note that Alex is asked not to verbally respond to any of the prompts during the meditation, but instead to reflect on them internally. After the meditation is completed, the therapist asks Alex again to focus on his breath to help him become more grounded in the present moment. Suggestions for Follow-up

When the practice is completed, the therapist should come back to a grounding meditation focused on the breath and the here-and-now experience. To process

the experience with the client, we recommend using the SIFT acronym as a framework to engage in a reflective dialogue with the client (Siegel, 2010). Here the therapist will first have the client describe the physical Sensations they noticed, followed by Images, Feelings, and then Thoughts. See the sample script of how to lead the SIFT discussion. Grounding in physical sensations is an important foundation to developing greater feelings of safety. We also recommend revisiting the questions posed during the guided meditation, such as how it might have felt different when offering the lovingkindness wishes to oneself versus the large demographic group. Then the therapist can explore any other insights. Finally, the therapist can discuss with clients how and when they might practice this meditation on their own. Contraindications

Though this is a secular activity of building self-com­ passion, it may not be appropriate for individuals who adhere to a religious belief that is inconsistent or incompatible with mindfulness activities. For some people, offering lovingkindness phrases feels very sim­ ilar to praying, which may not feel congruent with their values. However, extending lovingkindness phrases is not the same thing as praying, and it is not neces­ sary for someone to be spiritually focused in order to engage in and benefit from it, as meditation is not inherently spiritual (Kabat-Zinn, 1994). Additionally, this activity may be challenging for sexual abuse sur­ vivors as it does require that the clients focus on their bodily sensations. It may also be challenging for transgender clients who are not feeling connected to their bodies. Thus, it would be important not to introduce this activity until a great deal of safety and trust have been established and the client feels ready to focus on bodily sensations. Professional Readings and Resources American Psychological Association (APA). (2010). Ethical standards of psychologists. Washington, DC: Author. Baer, R. A. (ed.). (2006). Mindfulness-based treatment approaches: Clinician’s guide to evidence base and appli­ cations. Boston: Elsevier Associated Press. Germer, C. K., & Siegel, R. D. (eds.). (2012). Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice. New York: Guilford Press. A Lovingkindness Meditation to Heal from Oppression

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Germer, C. K., Siegel, R. D., & Fulton, P. R. (eds.). (2013). Mindfulness and psychotherapy, 2nd edition. New York: Guilford Press. Longoria, V. (2014). Contemplating culture: Exploring the use of mindfulness therapies with diverse groups. New Mexico State University, ProQuest Dissertations Publishing, 3582299.

Resources for Clients Dresser, M. (ed.). (1996). Buddhist women on the edge: Contemporary perspectives from the Western frontier. Berkeley, CA: North Atlantic Books. Germer, C. K. (2009). The mindful path to self-compassion: Freeing yourself from destructive thoughts and emotions. New York: Guilford Press. Germer, C., & Neff, K. (2017). Self-compassion break. San Diego: Center for Mindful Self-Compassion. https:// chrisgermer.com/wp-content/uploads/2017/02/MSC­ Self-Compassion-Break.pdf. Gutiérrez-Baldoquín, H. (ed.). (2004). Dharma, color, and culture: New voices in Western Buddhism. Berkeley, CA: Parallax Press. Kornfield, J. (2008). The wise heart: A guide to the universal teachings of Buddhist psychology. New York: Bantam Books. Neff, K. (2011). Self-compassion: The proven power of being kind to yourself. New York: William Morrow. Neff, K. (2018). Self-compassion mediations. http://self-com passion.org/. Nicole, C. (2017). Black Lives Matter meditation for healing racial trauma. http://drcandicenicole.com/2016/07/ black-lives-matter-meditation/. Salzberg, S., and Das, K. (2018). Power of the loving heart. www.sharonsalzberg.com/. Siegel, D. (2018). Dr. Dan Siegel. http://www.drdansiegel.com/. Siegel, D. J., and Bryson, T. P. (n.d.). Refrigerator sheet: The whole-brain child. https://www.drdansiegel.com/pdf/ Refrigerator%20Sheet--WBC.pdf. Yang, L. (n.d.). Awakening together. www.larryyang.org/.

References American Psychological Association (APA). (2010). Ethical standards of psychologists. Washington, DC: Author. Baer, R. A. (2006). Mindfulness training as a clinical inter­ vention: A conceptual and empirical review. Clinical Psychology: Science and Practice, 10, 125–143. doi:10. 1093/clipsy.bpg015. Bazargan, M., & Galvan, F. (2012). Perceived discrimination and depression among low-income Latina male-to-female transgender women. BMC Public Health, 12, 663. doi:10. 1186/1471-2458-12-663. Bieschke, K. J., & Mintz, L. B. (2012). Counseling psychology model training values statement addressing diversity: History, current use, and future directions. Training and 86

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Education in Professional Psychology, 6 (4), 196–203. doi: 10.1037/a0030810. Breslow, A. S., Brewster, M. E., Velez, B. L., Wong, S., Geiger, E., & Soderstrom, B. (2015). Resilience and collective action: Exploring buffers against minority stress for transgender individuals. Psychology of Sexual Orientation and Gender Diversity, 2 (3), 253–265. doi:10.1037/sgd 0000117. Brown-Iannuzzi, J. L., Adair, K. C., Payne, B. K., Richman, L. S., & Fredrickson, B. L. (2014). Discrimination hurts, but mindfulness may help: Trait mindfulness moderates the relationship between perceived discrimination and depressive symptoms. Personality and Individual Differ­ ences, 56, 201–205. doi:10.1016/j.paid.2013.09.015. Budge, S. L., Adelson, J. L., & Howard, K. A. (2013). Anxiety and depression in transgender individuals: The roles of transition status, loss, social support, and coping. Journal of Consulting and Clinical Psychology, 81, 545–557. doi:10.1037/a0031774. Chiesa, A., & Serretti, A. (2011). Mindfulness based cognitive therapy for psychiatric disorders: A systematic review and meta-analysis. Psychiatry Research, 187 (3), 441–453. doi:10.1016/j.psychres.2010.08.011. Eberth, J., & Sedlmeier, P. (2012). The effects of mindfulness meditation: A meta-analysis. Mindfulness, 3 (3), 174–189. doi:10.1007/s12671-012-0101-x. Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. Journal of Counseling Psychology, 56 (1), 97–109. doi:10.1037/a0012844. Graham, J. R., West, L. M., & Roemer, L. (2013). The experi­ ence of racism and anxiety symptoms in an AfricanAmerican sample: Moderating effects of trait mindfulness: Erratum. Mindfulness, 4 (4), 342. doi:10.1007/s12671­ 012-0152-z. Herek, G. M. (2007). Confronting sexual stigma and prejudice: Theory and practice. Journal of Social Issues, 63 (4), 905– 925. doi:10.1111/j.1540-4560.2007.00544.x. Herek, G. M., & Berrill, K. (eds.). (1992). Hate crimes: Con­ fronting violence against lesbians and gay men. Thousand Oaks, CA: Sage. Hill, D. B., & Willoughby, B. B. (2005). The development and validation of the Genderism and Transphobia Scale. Sex Roles, 53 (7–8), 531–544. doi:10.1007/s11199-005-71 40-x. Hinton, D. E., Ojserkis, R. A., Jalal, B., Peou, S., & Hofmann, S. G. (2013). Loving-kindness in the treatment of trauma­ tized refugees and minority groups: A typology of mind­ fulness and the Nodal Network Model of affect and affect regulation. Journal of Clinical Psychology, 69 (8), 817–828. doi:10.1002/jclp.22017. Hofmann, S. G., Sawyer, A. T., Witt, A. A., & Oh, D. (2010). The effect of mindfulness-based therapy on anxiety and

depression: A meta-analytic review. Journal of Consulting and Clinical Psychology, 78, 169–183. doi:10.1037/a0018 555. Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulness and meditation in everyday life. New York: Hyperion. Klainin-Yobas, P., Cho, M. A. A., & Creedy, D. (2012). Efficacy of mindfulness-based interventions on depressive symp­ toms among people with mental disorders: A meta-anal­ ysis. International Journal of Nursing Studies, 49, 109–121. doi:10.1016/j.ijnurstu.2011.08.014. Kornfield, J. (2008). The wise heart: A guide to the universal teachings of Buddhist psychology. New York: Bantam Books. Leary, M. R., Tate, E. B., Adams, C. E., Batts Allen, A., & Hancock, J. (2007). Self-compassion and reactions to unpleasant self-relevant events: The implications of treat­ ing oneself kindly. Journal of Personality and Social Psy­ chology, 92 (5), 887–904. doi:10.1037/0022-3514. 92.5.887. Levitt, H. M., Ovrebo, E., Anderson-Cleveland, M. B., Leone, C., Jeong, J. Y., Arm, J. R., . . . & Horne, S. G. (2009). Bal­ ancing dangers: GLBT experience in a time of anti-GLBT legislation. Journal of Counseling Psychology, 56 (1), 67–81. Liao, K. Y., Kashubeck-West, S., Weng, C., & Deitz, C. (2015). Testing a mediation framework for the link between per­ ceived discrimination and psychological distress among sexual minority individuals. Journal of Counseling Psychol­ ogy, 62 (2), 226–241. doi:10.1037/cou0000064. Longoria, V. (2014). Contemplating culture: Exploring the use of mindfulness therapies with diverse groups. New Mexico State University, ProQuest Dissertations Pub­ lishing, 3582299. Lyons, A. (2016). Mindfulness attenuates the impact of dis­ crimination on the mental health of middle-aged and older gay men. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 227–235. doi:10.1037/sgd0000164. Moradi, B., Van den Berg, J. J., & Epting, F. R. (2009). Threat and guilt aspects of internalized anti-lesbian and gay prej­ udice: An application of personal construct theory. Journal of Counseling Psychology, 56 (1), 119–131. doi:10.1037/ a0014571. Neff, K. D. (2003). Development and validation of a scale to measure self-compassion. Self and Identity, 2, 223–250. doi:10.1080/15298860390209035. Neff, K. D., & Germer, C. K. (2013). A pilot study and random­

ized controlled trial of the mindful self-compassion pro­ gram. Journal of Clinical Psychology, 69 (1), 28–44. doi:10. 1002/jclp.21923. Reisner, S. L., Gamarel, K. E., Nemoto, T., & Operario, D. (2014). Dyadic effects of gender minority stressors in sub­ stance use behaviors among transgender women and their non-transgender male partners. Psychology of Sexual Orientation and Gender Diversity, 1, 63–71. doi:10.10 37/0000013. Shapiro, S. L., & Carlson, L. (2009). The art and science of mindfulness: Integrating mindfulness into psychology and the helping professions. Washington, DC: American Psy­ chological Association. Shonin, E., Van Gordon, W., & Griffiths, M. D. (2014). The emerging role of Buddhism in clinical psychology: Toward effective integration. Psychology of Religion and Spiritual­ ity, 6 (2), 123–137. doi:10.1037/a0035859. Shonin, E., Van Gordon, W., Slade, K., & Griffiths, M. D. (2013). Mindfulness and other Buddhist-derived interventions in correctional settings: A systematic review. Aggression and Violent Behavior, 18, 365–372. doi:10.1016/j.avb. 2013.01.002. Siegel, D. (2010). Mindsight: The new science of personal trans­ formation. New York: Bantam. Smith, N. G., & Ingram, K. M. (2004). Workplace heterosexism and adjustment among lesbian, gay, and bisexual individ­ uals: The role of unsupportive social interactions. Journal of Counseling Psychology, 51 (1), 57–67. doi:1037/0022 0167.51.1.57. Szymanski, D. M., & Sung, M. R. (2010). Minority stress and psychological distress among Asian American sexual minority persons. Counseling Psychologist, 38 (6), 848– 872. doi:10.1177/0011000010366167. Toomey, R. B., & Anhalt, K. (2016). Mindfulness as a coping strategy for bias-based school victimization among Lati­ na/o sexual minority youth. Psychology of Sexual Orien­ tation and Gender Diversity, 3 (4), 432–441. doi:10.1037/ sgd0000192. Walls, N. E. (2008). Toward a multidimensional understand­ ing of heterosexism: The changing nature of prejudice. Journal of Homosexuality, 55 (1), 20–70. doi:10.1080/009 18360802129287. Zessin, U., Dickhäuser, O., & Garbade, S. (2015). The relation­ ship between self-compassion and well-being: A meta­ analysis. Applied Psychology: Health and Well-Being, 7 (3), 340–364. doi:10.1111/aphw.12051.

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LOVINGKINDNESS MEDITATION FOR HETEROSEXIST AND TRANSPHOBIC EXPERIENCES (ENGLISH)

“May we feel worthiness even when others devalue us.”

Allow yourself to recall, in some detail, a situation in which you were devalued by another, not because of something you did or didn’t do, but because of your sexual orientation or gender identity. Were there other aspects of your identity that you were also aware of (religion, ethnicity, etc.)? Check in with your body right now and focus your awareness on your physical sensations. Perhaps there is a feeling of resistance, of not wanting to go to such a place. Try just breathing into that feeling. Notice if any emotions, thoughts, or other physical sensations emerge.

What other comforting wishes do you want to send to this larger group? Notice how it feels to say these phrases for the LGBT community as compared to just yourself.

• Say to yourself: “This is a moment of difficulty, of

suffering.” Notice how your body responds to this acknowledgment. “There are others who are like me who have had similar experiences.” “I am not alone in having this experience.”

• Then place your hand over your heart, and feel the warmth of your hand comforting your heart. How does your body respond? Breathe in the following phrases:

“May I find some sense of safety in this moment.”

“May I feel strong in this moment.”

“May I feel worthiness even as I am devalued by

others.” “May I find some breathing space when I feel con­ strained by inequality so that I can respond creatively.” What other comforting wishes do you have for yourself in this situation? Repeat these phrases and notice how your being responds to each one.

• Now bring to mind another LGBT individual you know who has also experienced heterosexism, and picture the two of you standing together. And sur­ rounding you, try picturing all the many LGBT individuals who have faced discrimination.

“May we feel safe when we have such challenging experiences.” “May we feel strong in the face of adversity.” 88

“May we find some space to respond creatively when we feel constrained.”

• Bring your awareness back to your breath right now and check in with how your body is feeling at this moment. Which sensations have shifted? Which sensations have remained? Are there additional thoughts or feelings you are experiencing now?

MEDITACIÓN DE LA BONDAD PARA EXPERIENCIAS DE HETEROSEXISMO O TRANSFOBIA (ESPAÑOL)

Permítase recordar, con algún detalle, esta situación donde fue usted desvalorado/a por otra persona, no por algo que usted hizo o que no hizo sino por su orient­ ación sexual o su identidad de género. ¿Habían otros aspectos de su ser o de su identidad (religión, etnici­ dad, etc.) de los que también estaba usted consciente? Tome una observación de su cuerpo en este momento y traiga su atención a cualquier sensación que note. Tal vez hay una sensación de resistencia, de no querer ir a tal lugar. Trate simplemente de respirar hacia esa sensación. Sigua observando, viendo a ver si surgen emociones, pensamientos u otras sensaciones físicas.

• Dígase a sí mismo:

“ Este es un momento de dificultad, de sufrimiento.” Fíjese cómo responde su cuerpo a este recono­ cimiento. “Hay otras personas que son como yo que han tenido experiencias similares.” “No estoy solo/a en tener esta experiencia.”

• Ahora ponga su mano sobre su corazón, y sienta el

calor de su mano consolando a su corazón. ¿Cómo responde su cuerpo? Respire hacia adentro las siguientes frases:

“ Que pueda yo encontrar algún sentido de seguri­ dad en este momento.” “ Que pueda sentirme fuerte en este momento.” “Que pueda sentir que soy digno/a aun al ser des­ valorado por otros.”

“Que pueda yo encontrar un espacio para respirar cuando me sienta restringido/a por la injusticia para así poder responder creativamente.” ¿Qué otros deseos consoladores tiene para usted mismo/a en esta situación? Repita estas frases de nuevo y fíjese en cómo responde su ser a cada una de ellas. •Ahora, traiga a la mente una imagen de otra per­ sona LGBT quien usted conoce que también ha experimentado heterosexismo e imagínese que están los dos parados juntos. Y rodeándolos, trate de imaginar a todas las personas LGBT quienes han experimentado discriminación. “Que podamos sentirnos seguros cuando tengamos estas experiencias desafiantes.” “Que podamos sentirnos fuertes al frente de la adversidad.” “Que podamos sentirnos valorados y dignos aun cuando otros nos desvaloran.” “Que podamos encontrar un espacio para responder creativamente cuando nos sentimos restringidos/ as.” ¿Qué otros deseos consoladores le gustaría mandarle a este grupo más grande? Fíjese en cómo se siente el decir estas frases a todo el grupo en comparación con deseárselas a usted solo/a. • Ahora dirija de nuevo su atención a su respiración y tome una observación de cómo se siente su cuerpo en este momento. ¿Qué sensaciones han cambiado? ¿Cuáles han permanecido? ¿Hay otros pensamientos o sentimientos que está experi­ mentando ahora? Adapted from Germer, C., & Neff, K. (2017), Self-compassion break (San Diego: Center for Mindful Self-Compassion), https://=chrisgermer.com/wp-content/uploads/2017/02/ MSC-Self-Compassion-Break.pdf.

REFLECTIVE DIALOGUE USING SIFT (SIEGEL, 2010)

After completing the lovingkindness, self-compassion exercise, you will want to help the client move from having the internal experience to processing this expe­

rience through a reflective dialogue. This relational experience allows for another level of processing and possible healing. Allow a few moments of silence to occur between you and the client as the client shifts from the internal world to the relational space (use this as a time to take a few breaths and check into your own internal experience in the moment). You can spend a moment letting clients know that you will ask them to reflect on four aspects of their experience. It is very common for clients to have some difficulty identifying certain aspects of their experience, as they often move more quickly to their thoughts. It is important to ask clients to pause before expressing their thoughts until the other aspects of their experi­ ence have been explored. You can provide the ratio­ nale that many of our initial reactions to oppression are experienced in the nonverbal and nonconceptual part of the brain (the amygdala), so we need to listen to those reactions first. Then use some of the follow­ ing questions to prompt the client (we recommend that you ask only one or two questions for each level). 1. What were the physical Sensations you were aware of? Where in your body did you feel them? Describe the sensation (e.g., tightness, constric­ tion, warmth, shakiness). What are you feeling in your body right now? 2. Describe any visual Images, pictures or symbols you noticed. Were there other situations that popped into your awareness? Are any other images arising now? 3. What emotions did you feel at different moments? What might the physical sensations or images tell you about your Feelings? Did any feeling shift over time (including shifting from one bodily sensation to another) or change in intensity? Did you have any reactions to your feelings (feelings about your feelings)? Did any feeling surprise you? What are you feeling now? 4. What Thoughts did you have? Did you have any reactions to your thoughts (feelings about your thoughts)? Did any thoughts surprise you? As we are talking about it now, are there any insights (new ideas) you have about the oppressive experience?

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11 FROM STRESS TO STRENGTH: A GROUP INTERVENTION FOR PROCESSING MINORITY STRESS EXPERIENCES WITH TRANSGENDER AND GENDER-NONCONFORMING INDIVIDUALS Caroline Carter and Diane Sobel

Suggested Use: Group activity Objective

This two-part activity is designed to help transgender and gender-nonconforming (TGNC) clients learn about the harmful effects of minority stress on psycho­ logical functioning and overall mental health. Spe­ cifically, it teaches TGNC clients to use the minority stress model to identify the ways in which minority stress is present in their lives and its effects on them. Rationale for Use

This activity aims to help clients practice identifying their personal resilience within minority stress expe­ riences, including ways they are positively navigating and coping with minority stress. This activity also encourages TGNC community members to connect with one another by providing a space for them to receive validation from others about their experiences of distress, recognize and acknowledge their own and others’ signs of resilience, and increase their own abil­ ity to cope by further identifying ways to navigate specific minority stress experiences together. A nat­ ural outcome of this activity is increased in-group identification within the TGNC community, an ele­ ment that increases resiliency in the face of minority stress experiences. There is more and more documentation that TGNC individuals commonly experience gender-based

stigmatization, discrimination, and victimization (Beemyn & Rankin, 2011; Bradford et al., 2007; Clements-Nolle, Marx, & Katz, 2006; Paul, 2015). It has also been well documented that TGNC individuals demonstrate high prevalence rates of many mental health concerns, including clinical depression, anxiety, and substance abuse (Bockting et al., 2013; ClementsNolle et al., 2006). Suicidal ideation and suicide rates are also much higher among TGNC individuals than among the general population (Clements-Nolle et al., 2006; Moscicki, 1995; Weissman et al., 1999). Fur­ thermore, there is a need for increased understanding and research on higher rates of stress experienced among those who hold additional marginalized iden­ tities intersecting with a TGNC identity. The initial research on intersectionality among TGNC individ­ uals has been on those who hold an intersecting ethnic identity (Bazargan & Galvan, 2012; Kattari, Walls, Whitfield, & Langenderfer-Magruder, 2016; Whitfield, Langenderfer-Magruder, Walls, & Clark, 2014). This research has found that unlike individuals with a sin­ gular minority identity, TGNC individuals holding an additional intersecting racial or ethnic identity must navigate multiple and interacting marginaliza­ tions and thus undergo increased discriminatory experiences and stress. In recent years, theorists have built on Meyer’s (2003) minority stress model (Hatzenbuehler, 2009), and researchers and theorists have proposed extend-

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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ing Meyer’s minority stress model to include the experiences of TGNC individuals. These theorists and researchers shed light on the distinct stress experienced by the TGNC community owing to cultural transphobia (Bockting et al., 2013; Breslow et al., 2015; Hendricks & Testa, 2012; Levitt & Ippolito, 2014; Rood et al., 2016). The minority stress model was originally developed to understand the relation­ ship between the high incidence of mental health disorders among lesbian, gay, and bisexual (LGB) individuals and the high rates of discrimination, prejudice, and victimization that were due to LGB individuals’ minority status. We are using Hatzen­ buehler’s (2009) expansion of Meyer’s (2003) min­ ority stress model, additionally following Breslow and colleagues (2015), who have applied Hatzen­ buehler’s theory to TGNC individuals. This model suggests that stressful events experienced by TGNC minorities (external stressors) can be internalized (internal stressors), in such a way that the internal­ ization of them can lead to psychopathology (psy­ chological distress). External stressors, also known as distal stressors (Breslow et al., 2015; Meyer, 2003), are the initial envi­ ronmental events one experiences because of minority status membership, including direct and indirect experiences of discrimination and prejudice. Internal stressors, also known as proximal stressors (Breslow et al., 2015; Meyer, 2003), result from the “emotional and cognitive appraisals” or the meaning making of discriminatory events (Breslow et al., 2015, p. 254). Two key proximal stressors identified by Meyer (2003) are expectation or anticipation of stressful events and the internalization of negative attitudes and preju­ dices from society (Hendricks & Testa, 2012; Meyer, 2003). Anticipation of discriminatory events can lead to anxiety and vigilance, whereas internalization can result in internalized transphobia for TGNC individ­ uals, which is then directed at the self. Finally, psy­ chological distress is the result of external and internal stressors (Breslow et al., 2015). This distress can include depression, anxiety, trauma, and panic. Following this distress, individuals may turn to forms of coping in an attempt to reduce the distress (e.g., negative coping—increased substance use, self-harm, or sui­

cidality—and positive coping—reaching out for support, journaling). Several recent studies have suggested not only that TGNC individuals are negatively affected by discrimination and victimization, but also that resil­ ience can develop in response to these events (Bock­ ting et al., 2013; Breslow et al., 2015; Hendricks & Testa, 2012; Riggle, Rostosky, McCants, & PascaleHague, 2011). Resilience can be understood as the internal emotional and cognitive resources one has when one finds oneself in stressful situations (Harvey, 2007). Current research shows a number of resiliency factors that can be developed as a result of minority stress. These include taking strength from resisting discrimination, finding safe and accepting places and connection within a supportive community, being able to define one’s own gender identity, seeing gender diversity as a natural part of the world, embracing one’s self-worth, building awareness of oppression and identifying it when it occurs, and cultivating hope for the future (Scourfield, Roen, & McDermott, 2008; Singh, Hays, & Watson, 2011). The proposed activity involves several steps designed to build resiliency in TGNC clients. Psychoeducation is provided about the minority stress model in order to normalize the participants’ experiences. Peer support and pride in one’s transgender identity are cultivated by encouraging members of the group to connect with one another through sharing experi­ ences of discrimination and prejudice, expectations of rejection, internalized transphobia, and the psychologi­ cal distress that results. Individual resilience further increases through interventions, which invite mem­ bers to share successful ways of managing minority stress and to brainstorm new ways to manage minority stress experiences together. These self-disclosures instinctively draw on the social support of other members, which increases participants’ sense of belonging and inhibits feelings of thwarted belongingness and felt burdensomeness. Thwarted belongingness and felt burdensomeness often are the key drivers of social isolation, which can leave TGNC people at much higher risk of suicidal ideation and suicidality (Hendricks & Testa, 2012; Joiner, 2010). Expressions of strength and pride in one’s

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own and in one another’s ability to navigate stressful situations can both foster connection and lead to the development of pride in one’s minority identity, which has been shown to buffer the negative effects of minority stress on mental health in other minority groups (Kessler, Price, & Wortman, 1985; Meyer, 1995). The ethical guidelines for both counselors and psychologists require that these professionals provide culturally competent services to all clients (American Counseling Association [ACA], 2014; APA, 2017). APA’s “Ethical Principles of Psychologists and Code of Conduct,” for example, requires that psychologists have respect for the “Rights and Dignity” of all people (APA, 2017). Principle E states that “psychologists are aware of and respect cultural, individual, and role dif­ ferences, including those based on . . . gender identity, . . . and consider these factors when working with members of such groups” (APA, 2017). Therefore, psy­ chologists and counselors are to consider the effects of the experiences of TGNC people, including stigma and minority stress, when providing services to them. Furthermore, therapists’ involvement in assist­ ing clients to process incidents of stigma and minority stress experiences aligns with the APA’s “Guidelines for Psychological Practice with Transgender and Gen­ der Nonconforming People” (dickey et al., 2015). These guidelines give further guidance on ethical practice with TGNC clients. Guideline 10 states, “Psychologists strive to understand how mental health concerns may or may not be related to a TGNC person’s gender identity and the psychologi­ cal effects of minority stress” (dickey et al., 2015, p. 845). These guidelines additionally highlight the benefits of therapists’ facilitating peer support, which can allow TGNC individuals to provide support to one another. Guideline 11 states, “Psychologists rec­ ognize that TGNC people are more likely to experi­ ence positive life outcomes when they receive social support or trans-affirmative care” (dickey et al., 2015, p. 846). Instructions

This activity has been developed for application in a group setting. Groups should consist of gender-diverse individuals (i.e., transgender, gender-nonconforming, nonbinary, and genderfluid individuals). Leaders can 92

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use the specific prompt provided with the minority stress group exercise template at the end of the chap­ ter, which provides psychoeducation on minority stress for the group and will then prepare the group for application of the theory in the exercise. Leaders may find it beneficial to provide group members with a copy of the prompt so that they can follow along. Brief Vignette

Sarah is a trans-feminine Latina college student who identifies as female and uses she/her pronouns. She came out to her family during the summer. In this scenario (see the chart on p. 93), many of the members in the group identified with Sarah’s experience, and all of them previously had had simi­ lar experiences with one or more of their family members. Many of them shared their common expe­ riences and had thoughts (i.e., internal stressors) sim­ ilar to those that Sarah described. These included try­ ing to become invisible, remaining silent, and feeling bad about themselves. Group participants also shared experiences of wanting to escape these situations. Sharing similar feelings and experiences allowed the group’s participants to feel connected and understood by one another. As a result, the conversation was able to shift into a stance of empathic support for Sarah, who was in the situation currently. Prompting members to talk about other ways that they had responded to similar situations led to brainstorming ideas of other responses they had had in the past or that they might have in the future. These ideas included those listed in the accompany­ ing chart, as well as ideas like moving to another city and never being in touch with any family again. Group leaders validated ideas, but they also helped group members see additional choices they were not currently recognizing, but which they were empow­ ered to make (for example, instead of moving, telling family members they will not engage with them until they respect their identity). Group leaders invited members to discuss their additional intersecting identities and how these affect their experiences as TGNC people. In this situation, leaders validated the unique cultural tensions shared by Sarah as a trans Latina woman. Leaders modeled respectfulness of Sarah’s cultural identity for other members who were

FROM STRESS TO STRENGTH CHART: SARAH

External Stressor

1. Minority Stress Experience

Internal Stressor

Psychological Distress

Identify what happened. (This can be a direct or indirect experience.)

Identify what you told Identify your mood, yourself afterward. feelings, or behaviors that (For example, identify followed. internalized transphobia or anticipatory stress.)

I went home for the holiday break and was continually misgendered by grandparents after telling them my correct name and pronouns.

1. I will never be affirmed in my true gender. 2. Others will continue to never see me as female.

Depression, sadness, anger, hopelessness, shame, wanting to selfharm

3. If I speak up to my grandparents again, it will be seen as disrespectful in my culture. 3. I hate myself. 4. I am not normal.

Identify the ways you were resilient during or following this experience. Identifying Resilience

1. The best I could do was remain silent.

My personal strengths that Additional ways other the group notices. members have coped with similar experiences.

1. I am internally clear that my grandparents’ behavior was wrong, 2. I allowed myself to leave disrespectful, and the situation and go unkind. home early. 2. I am aware of my 3. I reached out to a friend feelings and have had who accepts me and the courage to share genders me correctly. them with the group.

1. Decide not to interact with those who do not respect who I am and do not make an honest effort to gender me correctly. 2. Set boundaries about whom I choose to spend time with. 3. Excuse myself from going to family gatherings that include unaccepting family members.

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struggling to see that it would be difficult for Sarah to implement certain suggestions (for example, com­ pletely cutting off ties to family because of the impor­ tance of family in Latina culture). Following the group discussion about Sarah’s experience, some par­ ticipants shared their contact information with her, inviting her to ask them for support should she find herself in a similar situation again. Suggestions for Follow-up

Following the discussion of the specific responses to the items in the chart, the leaders may invite the group members to reflect on what it was like to talk about these experiences with one another. The fol­ lowing questions can help facilitate this discussion: 1. What is it like to talk about these experiences with one another? 2. What is it like to hear that others have had some of the same experiences? 3. What is it like to hear suggestions from others? 4. What is it like to make suggestions to others? 5. What is it like to hear others talk about the posi­ tives in what others are doing to navigate very dif­ ficult circumstances? Contraindications for Use

Participants should be invited to share only what they would like to share with the group about their expe­ riences. Research has shown not only that members of the TGNC community have experienced rejection and discrimination from those within the cisgender community, but also that they have been surprised to have experiences of invalidation and rejection from those within the LGB community (Levitt & Ippolito, 2014). This can result in TGNC members being under­ standably reticent to come out and be vulnerable within a larger LGBTQ group, regardless of their antic­ ipated shared group membership with the other par­ ticipants in the group (Levitt & Ippolito, 2014). Addi­ tionally, some group participants will encourage others to get involved in the community faster than all the participants may be ready to. When this occurs, facilitators need to give permission to members to par­ ticipate, come out, or join with other members in community activities at a rate that is comfortable for them (Breslow et al., 2015). 94

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Professional Readings and Resources Erickson-Schroth, L. (2014). Trans bodies, trans selves: A resource for the transgender community. New York: Oxford University Press. Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York: Haworth Clinical Practice Press. Makadon, H. J., & American College of Physicians. (2008). The Fenway guide to lesbian, gay, bisexual, and transgender health. Philadelphia: American College of Physicians. Meyer, I. H., & Northridge, M. E. (eds.). (2007). The health of sexual minorities: Public health perspectives on lesbian, gay, bisexual, and transgender populations. New York: Springer. Stryker, S., & Whittle, S. (2006). The transgender studies reader. New York: Routledge.

Resources for Clients Gender Spectrum. https://www.genderspectrum.org/. An

organization based in Oakland, CA, that provides educa­ tion, training, and support to help create a gender-sensi­ tive and inclusive environment for all children and teens. Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Mock, J. (2014). Redefining realness: My path to womanhood, identity, love & so much more. New York: Atria. Transgender Law Center. http://transgenderlawcenter.org/. The Transgender Law Center works to change law, policy, and attitudes so that all people can live safely, authentically, and free from discrimination regardless of their gender identity or expression. Trevor Project. http://www.thetrevorproject.org/. The Trevor Project is the leading national organization providing cri­ sis intervention and suicide prevention services to lesbian, gay, bisexual, transgender, and questioning (LGBTQ) young people ages thirteen to twenty-four. Williams Institute. http://williamsinstitute.law.ucla.edu/mis sion/#sthash.0oS5ZjZ5.dpuf. An independent think tank at the University of California Los Angeles focused on providing rigorous, independent research on sexual ori­ entation and gender-identity law and public policy.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/. Bazargan, M., & Galvan, F. (2012). Perceived discrimination and depression among low-income Latina male-to-female transgender women. BMC Public Health, 12 (1), 1. Beemyn, G., & Rankin, S. (2011). The lives of transgender peo­ ple. New York: Columbia University Press. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Ham­

ilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103 (5), 943–951. doi:10.2105/AJPH.2013.301241. Bradford, J., Xavier, J., Hendricks, M., Rives, M. E., & Honnold, J. A. (2007). The health, health-related needs, and lifecourse experiences of transgender Virginians. Virginia Transgender Health Initiative Study Statewide Survey Report. www.vdh.virginia.gov/content/uploads/sites/ 10/2016/01/THISFINALREPORTVol1.pdf. Breslow, A. S., Brewster, M. E., Velez, B. L., Wong, S., Geiger, E., & Soderstrom, B. (2015). Resilience and collective action: Exploring buffers against minority stress for transgender individuals. Psychology of Sexual Orientation and Gender Diversity, 2 (3), 253–265. doi:10.1037/sgd0000117. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53–69. doi:10.1300/J082v51n03_04. dickey, l. m., et al. (2015). Guidelines for psychological prac­ tice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. Harvey, M. R. (2007). Towards an ecological understanding of resilience in trauma survivors: Implications for theory, research, and practice. In M. R. Harvey & P. TummalaNarra (eds.), Sources and expressions of resiliency in trauma survivors: Ecological theory, multicultural practice, 9–35. Binghamton, NY: Haworth. doi:10.1300/J146vl4n01_02. Hatzenbuehler, M. L. (2009). How does sexual minority stigma “get under the skin”? A psychological mediation frame­ work. Psychological Bulletin, 135 (5), 707. doi:10.1037/ a0016441.

Hendricks, M. L., & Testa, R. T. (2012). A conceptual frame­ work for clinical work with transgender and gender nonconforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 5 (43), 460–467. doi:10.1037/a0029597.

Herman, J. L. (2013, June). Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender people’s lives. Journal of Public Management and Social Policy, 65–80. Retrieved from http://williams institute.law.ucla.edu/research/ ransgender-issues/ herman-jpmss-june-2013/. Jew, C. L., Green, K. E., & Kroger, J. (1999). Development and validation of a measure of resiliency. Measurement and Evaluation in Counseling and Development, 32, 75–90. Joiner, T. (2010). Myths about suicide. Cambridge: Harvard University Press. Kattari, S. K., Walls, N. E., Whitfield, D. L., & LangenderferMagruder, L. (2016). Racial and ethnic differences in experiences of discrimination in accessing social services among transgender/gender-nonconforming people. J ournal of Ethnic & Cultural Diversity in Social Work, 1–19. doi:10.1080/15313204.2016.1242102.

Kessler, R. C., Price, R. H., & Wortman, C. B. (1985). Social factors in psychopathology: Stress, social support, and coping processes. Annual Review of Psychology, 36, 531–572. doi:10.1146/annurev.ps.36.020185.002531. Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: Navigating minority stressors and developing authentic self-presentation. Psychology of Women Quarterly, 38 (1), 46–64. doi:10.1177/0361684313501644. Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal of Health and Social Behavior, 36, 38–56. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. doi:10.1037/0033-2909.129.5.674. Moscicki, E. K. (1995). Epidemiology of suicide. Internatio­ nal Psychogeriatrics, 7, 137–148.

Paul, J. C. (2015, January). School-related victimization across subgroups of transgender individuals: Implica­ tions for psychological wellbeing and educational attain­ ment. In Society for Social Work and Research, Society for Social Work and Research 19th Annual Conference: The Social and Behavioral Importance of Increased Longevity. https://sswr.confex.com/sswr/2015/webpro gram/Paper22543.html. Riggle, E .D., Rostosky, S. S., McCants, L. E., & PascaleHague, D. (2011). The positive aspects of a transgender self-identification. Psychology and Sexuality, 2, 147–158. doi:10.1080/19419899.2010.534490. Rood, B. A., Reisner, S. L., Surace, F. I., Puckett, J. A., Maroney, M. R., & Pantalone, D. W. (2016). Expecting rejection: Understanding the minority stress experiences of transgender and gender-nonconforming individuals. Transgender Health, 1 (1), 151–164. doi:10.1089/trgh.2016.

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Scourfield, J., Roen, K., & McDermott, L. (2008). Lesbian, gay,

bisexual and transgender young people’s experiences of distress: Resilience, ambivalence, and self-destructive behaviour. Health and Social Care in the Community, 16 (3), 329–336. doi:10.1111/j.1365-2524.2008. 00769. Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling and Devel­ opment: JCD, 89 (1), 20. doi:10.1002/j.1556-6678. 2011. tb00057.x.

Weissman, M. M., Bland, R. C., Canino, G. J., Greenwald, S., Hwu, H.-G., Joyce, P. R., Karam, E. G., & Lee, C.-K. (1999). Prevalence of suicide ideation and suicide attempts in nine countries. Psychological Medicine, 29 (1), 9–17.

Whitfield, D. L., Langenderfer-Magruder, L., Walls, N. E., & Clark, B. (2014). Queer is the new black? Not so much: Racial disparities in anti-LGBTQ discrimination. Journal of Gay and Lesbian Social Services, 26 (4), 426– 440. doi:10.1080/10538720.2014.955556. From Stress to Strength: A Group Intervention

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PART 1: GROUP PSYCHOEDUCATION ON MINORIT Y STRESS Leader prompt: Today we are going to talk about the term minority stress and its role in the TGNC community. We believe that many of you in the room have experienced or are experienc­ ing minority stress as a result of your gender identity or gender expression. Our hope is that this exercise will provide you with an understanding of minority stress, while also providing the opportunity to discuss your experiences with your peers, thereby offering some relief of its burden. Minority stress can be understood as the very high levels of stress experienced by members of the TGNC community. These elevated levels of stress come from distinct and increasing amounts of prejudice and discrimination experienced by your community. Minority stress is composed of 3 parts: 1. External stressors: These are experiences of prejudice, violence/victimization, or discrimina­ tion that one directly experiences. Example: Someone refuses to serve you or treats you unfairly because of your TGNC status or presentation. External stressors can also come from indirect experiences. Example: You witness friends being harassed at a party because of their TGNC status, or you learn about a recent hate crime involving a TGNC person in an online news story. 2. Internal stressors: These can be understood as the meaning you make of the external stress­ ors. Another way of thinking of internal stressors is as negative mental filters. These filters are shaped by your thoughts and feelings about yourself and the world. When you experience the external stressor, it can go through a negative mental filter, which results in your drawing con­ clusions about yourself and the world. An example of a specific internal stressor is internalized transphobia, or the personalization of negative messages conveyed in your environment about TGNC people. Another example of an internal stressor is stigma awareness or anticipatory stress. This is the expectation or anticipation of future experiences of prejudice and/or discrimi­ nation that results in a current experience of fear, anger, vigilance, and increased stress. Antici­ patory stress can also result in the hiding of one’s identity, which can add to one’s distress. Example: Internalized transphobia: Because you read news blogs, which use demonizing words about transgender individuals (e.g., “predator,” “mentally ill”), you may tell yourself, “Others think I’m disgusting. Maybe they’re right” or “Who am I fooling? I just have a mental illness.” Example: Anticipatory stress: Because you read about an anti-transgender law passing in a nearby state, you worry: “The world will never be accepting of me.” “I will never be safe.” “I’m sure other states will pass a similar law.” “My friend lives in this neighboring state. Maybe he has friends or family who agree with this law.” “If I visit my friend I may be unsafe. I could be victimized.”

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3. Psychological distress: These are the effects, including symptoms, negative feelings moods, and behaviors, that arise as a result of the external and internal stressors. Psychological distress can often be followed by negative or positive forms of coping (ways of managing or attempt­ ing to reduce the distress). Examples: Psychological distress can include anxiety, depression, racing thoughts, worry, social isolation, increased substance use, loneliness, hopelessness, decreased motivation, suicidality, somatic symptoms (for example, stomach ache or loss of appetite). This distress may then be coped with in negative ways: substance use, self-harming, avoidance, isolation. Individuals may also use positive coping: reaching out to a friend or loved one, journaling, exercising, taking social action, and so on. PART 2: GROUP ACTIVIT Y A. Individual preparation: Identifying minority stress experiences a. Hand out a chart to all the members. b. Prompt: Everyone will work individually for five to ten minutes. Think about examples of your own personal experiences of minority stress and write them in your chart. c. Prompt: Write examples of how you have navigated some of these experiences in the chart. B. Group sharing: Building resilience a. Ask participants to share examples of external stressors (discriminatory or prejudicial events) and how they navigated them. Invite participants to join with one another in listening to the stories. b. Invite participants to share strengths that they hear in one another’s stories of how they navigated these difficult external events. c. Invite participants to brainstorm other ways they might navigate the others’ experiences of minority stress. Invite participants to reflect on the experience of talking about these experiences together using the follow-up questions.

Caroline Carter and Diane Sobel

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FROM STRESS TO STRENGTH CHART

External Stressor

Internal Stressor

Psychological Distress

Identify what happened. (This can be a direct or indirect experience.)

Identify what you told yourself afterward. (For example, identify internalized transphobia or anticipatory stress.)

Identify your mood, feelings, or behaviors that followed.

Identify the ways you were resilient during or following this experience.

My personal strengths that Additional ways other the group notices. members have coped with similar experiences.

External Stressor

Internal Stressor

Psychological Distress

Identify what happened.

Identify what you told yourself afterward.

Identify your mood, feelings, or behaviors that followed.

Identify the ways you were resilient during or following this experience.

My personal strengths that Additional ways other the group notices. members have coped with similar experiences.

1. Minority Stress Experience

Identifying Resilience

2. Minority Stress Experience

Identifying Resilience

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12 EXPLORING MULTIPLE MARGINALIZED IDENTITIES IN LGBT CLIENTS OF COLOR Vanessa Dabel Suggested Use: Activity Objective

The activity included in this chapter will help LGBT clients of color explore their intersecting minority identities and process experiences of oppression and marginalization in a clinical setting. Rationale for Use

As of 2016, about 7.3 percent of individuals aged eigh­ teen to thirty-six in the United States identified as a member of the lesbian, gay, bisexual, and transgender (LGBT) community (Gates, 2017). Also noteworthy is that higher rates of racial minorities than white individuals in the United States reported being LGBT in 2016: about 3.6 percent of whites, 4.9 percent of Asians, 5.4 percent of Hispanics, 4.6 percent of blacks, and 6.3 percent of “Other” minorities identified as LGBT (Gates, 2017). Further, about 40 percent of the overall U.S. LGBT population identified as members of racial and ethnic minorities in 2016 (Gates, 2017). These findings suggest the importance of understand­ ing the experiences of adults who hold multiple mar­ ginalized identities, specifically pertaining to their sex­ ual, gender, and racial or ethnic statuses. Researchers have found that racial, gender, and sexual minority individuals often experience oppres­ sion, marginalization, and microaggressions because of their minority statuses (Balsam et al., 2011; Gattis & Larson, 2017; Nadal et al., 2016; Sutter & Perrin, 2016). Microaggressions refer to seemingly subtle and unintentional assaults toward minority individuals. These assaults may be verbal or nonverbal and expe­ rienced as discriminatory (Balsam et al., 2011; Nadal,

2011; Nadal et al., 2016; Sue et al., 2007). Microag­ gressions may lead to distress for the person toward whom they are directed and negatively affect mental health and sense of self (Balsam et al., 2011; Gattis & Larson, 2017; Nadal, 2011; Sue et al., 2007). Respond­ ing to issues of racism, sexism, heterosexism, and overall oppression can have deleterious effects on LGBT individuals of color, leading them to experience issues such as depression, anxiety, substance abuse, and trauma, among other negative outcomes (Cochran et al., 2007; Díaz et al., 2001; Gattis & Larson, 2017; Hughes, Johnson, & Matthews, 2008; Meyer, Dietrich, & Schwartz, 2008; Sutter & Perrin, 2016; Zamboni & Crawford, 2007). LGBT individuals of color may feel ostracized and unaccepted by their heterosexual counterparts in their racial or ethnic community, while also experi­ encing racism and heterosexism in other settings (Fields et al., 2015; Malebranche, Fields, Bryant, & Harper, 2009; Nadal & Corpus, 2013; Sutter & Perrin, 2016). This is especially the case for gender-noncon­ forming individuals of color, who are often the target of violence, maltreatment, and victimization owing to their sexual identity and gender expression (Huffaker & Kwon, 2016; Singh & McKleroy, 2011). Addi­ tionally, the intersection of various identities can bring up feelings of inner turmoil for LGBT individuals of color, especially in the face of oppression. For these individuals, there may be an ongoing internal battle of attributing more value or higher priority to one par­ ticular identity, depending on which issues arise at a given moment (Nadal & Corpus, 2013; Santos & VanDaalen, 2016). Lesbian women of color, for example, may have to negotiate their various identities daily

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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when navigating family dynamics and issues in the workplace, and in instances of activism for social causes (e.g., racial inequality, women’s rights, LGBT rights). When working with LGBT clients of color in therapy, mental health professionals should consider possible within-group and cultural differences. For instance, information presented in this chapter high­ lights mainly the experiences of individuals in the United States, though some studies have also focused on non-U.S. cultures and societies (Dunn et al., 2014; Gates, 2011). It is also important for therapists to be mindful of the various sociocultural identities that can affect a client’s experiences, such as immigrant status, disability, class, and religion or spirituality (Nadal, 2008). The activity presented in this chapter contains open-ended questions specifically to allow clients to explore their individual cultural experiences with the therapist. Therapists must also consider the daily stress that LGBT individuals of color may experience given their multiple minority identities. Therefore, the activ­ ity provided here is based on the multicultural model of the stress process proposed by Slavin, Rainer, McCreary, and Gowda (1991) and adapted from Lazarus and Folkman’s (1984) stress model. This model highlights the cognitive and behavioral processes that minorities may experience following events of discrim­ ination and oppression. These individuals appraise the situation to determine level of danger, apply a relevant cultural frame to understand what they are experiencing, assess whether they can and should respond (considering aspects of their cultural identity and beliefs about systemic oppression), choose to cope through problem-focused or emotion-focused efforts, and as a result may experience a range of out­ comes (for example, somatic changes, changes in behavior or sense of self; Balsam et al., 2011; Gattis & Larson, 2017; Nadal et al., 2016; Sutter & Perrin, 2016). Individuals with multiple minority identities may constantly cycle through this process of evaluat­ ing experiences of oppression, and different aspects of their identity can be affected at different times (Nadal & Corpus, 2013; Santos & VanDaalen, 2016). Though there is no current research using the model proposed by Slavin and colleagues (1991), several researchers have emphasized the importance of under­

standing the influence of minority stress on individ­ uals with multiple minority identities, particularly LGBT people of color (Balsam et al., 2011; Gattis & Larson, 2017; Nadal et al., 2016; Sutter & Perrin, 2016). Therefore, use of the activity in this chapter can help LGBT clients of color better understand their internal processes and responses to these chal­ lenging experiences. The American Psychological Association (APA) has outlined specific guidelines for therapeutic work with lesbian, gay, and bisexual (LGB) individuals (APA, 2012), transgender and gender-nonconforming (TGNC) individuals (APA, 2015), and racial or ethnic minorities (APA, 1993). In the case of treating TGNC individuals, guideline 3 states, “Psychologists seek to understand how gender identity intersects with the other cultural identities of TGNC people” (APA, 2015). Similarly, guideline 11 for working with LGB clients states, “Psychologists strive to recognize the challenges related to multiple and often conflicting norms, values, and beliefs faced by lesbian, gay, and bisexual mem­ bers of racial and ethnic minority groups” (APA, 2012). These guidelines encourage practicing clinicians to acknowledge the role of multiple minority identities on the psychological and socioemotional functioning of clients (APA, 2012, 2015). Clinicians treating LGBT clients of color should be familiar with the guide­ lines so that they might better support these clients. Before completing this activity with clients, thera­ pists are encouraged to seek consultation and addi­ tional training if necessary to ensure delivery of cultur­ ally competent and appropriate services (APA, 1993, 2b, 2c). Professionals treating these clients must also understand the influence of their own intersecting identities and biases on their work with their clients (APA, 1993, 3a). This can be done through self-explo­ ration and using methods such as the ADDRESSING framework (Hays, 2001). This framework allows ther­ apists to examine their own cultural identities, power, and privilege across various categories, including age, disability, religion, ethnicity, social class, sexual orien­ tation, indigenous background, national origin, and gender (Hays, 2001). When considering use of the ADDRESSING framework in therapy with clients, therapists should consider their own level of comfort with self-disclosure regarding different aspects of their Exploring Multiple Marginalized Identities 101

identity and the potential effect of their disclosure on the therapeutic alliance (Hanson, 2005). Instructions

The activity presented in this chapter contains ques­ tions that can help generate discussion between ther­ apists and their clients regarding experiences with marginalization and oppression. This activity can be completed in about thirty minutes with clients in an individual or group therapy setting. By completing this exercise, clients will be able to process experiences of oppression and marginalization and explore ways that they negotiate their multiple minority identities on a daily basis. The goal is to help clients address and acknowledge these painful experiences so that they may ultimately experience healing and growth. To introduce this activity to clients, therapists may begin by saying, “I will be asking you some ques­ tions about your experience with marginalization and oppression. While I know that these questions may bring up difficult and painful experiences, my hope is that they may also lead to healing.” In addition, therapists can orient clients to ideas about oppres­ sion, marginalization, and microaggressions, though they must be sure that they themselves are familiar with these terms before discussing them with clients. Then therapists can assess clients’ understanding of these terms and offer psychoeducation if necessary. Therapists may then invite clients to reflect on their own experiences with these concepts and share aspects of these experiences in the therapy setting. After introducing the activity and relevant con­ cepts, therapists can focus on helping clients explore significant events in their journey (e.g., the comingout process) and ideas about the client’s own sexual, gender, racial or ethnic, and other social identities (e.g., socioeconomic status, religious or spiritual beliefs, nationality). Therapists can then discuss how the cli­ ents’ intersecting identities might influence their views about being LGBT (e.g., explore neighborhood demo­ graphics, stigma in their racial or ethnic community, family dynamics, religious or spiritual and sociocul­ tural experiences, possible internalized racism and homophobia). The following vignette provides an example of how a therapist might use the activity with a client. 102 Dabel

Brief Vignette

Joel is a twenty-year-old black, gay, cisgender male and a junior in college (a sociology major). He comes to the counseling center because of his concerns regarding academic stress and anxiety. He reports feeling worried about the upcoming midterms and is experiencing symptoms such as racing heartbeat, shortness of breath, and sweaty palms. He states that these symptoms have persisted for the past two weeks and he has not had much relief despite efforts to “relax.” Joel reports that he would like to learn strate­ gies for anxiety management and improved concen­ tration when studying for exams. At intake, Joel also reports that he came out to his family a couple of weeks before and has received mixed reactions. He decided that he wanted to come out to them before going home for Thanksgiving break next month, as a close friend on campus encour­ aged him to do so. His mother and father both have expressed anger and disappointment, indicating that he has “betrayed” his family and Christian upbringing. Joel has received support from his eighteen-year-old sister, while his twenty-three-year-old brother has been supportive though not completely understanding of his experience. Joel is worried about how things will go when he returns home for break. He indicates that he wants to come up with a plan for navigating his relationship with his parents, and he is wondering whether to disclose his sexuality to friends back home. Before completing the activity, the therapist spends time reflecting on her own social identities and biases that could affect her work with Joel. She and Joel both then openly share aspects of their various identities. After doing so, the therapist notices the Joel appears more relaxed, and he reports feeling more comfortable during the session. She then asks the following questions: • If you feel comfortable doing so, tell me more about your experience. Specifically, tell me about a time when you felt marginalized, discriminated against, or attacked because of who you are. • How did this experience make you feel? • How did you respond? Was that how you hoped you would respond? If not, how would you want to respond in the future?

• How do you feel that this experience has influ­ enced the way you see others, yourself, and the world? • Have you found any strategies helpful in coping with this experience? If so, what are those strategies? • What other coping strategies can you use to deal with the stress of these hurtful experiences? (Ther­ apists and client can collaboratively explore addi­ tional coping strategies.) Joel recalls feeling ostracized by his parents after com­ ing out, and he discusses his experiences with hetero­ sexism on campus. Joel also indicates undergoing psychological and psychosomatic acute trauma responses after the experiences with his family and friends, including feeling “frozen” and that his heart was “racing so fast” days after these events. Joel and the therapist collaboratively explore additional cop­ ing strategies, such as mindfulness practices, guided meditation, journaling, and continuing to process experiences in session. Joel expresses some motiva­ tion to begin implementing some of these practices, including bringing in a journal entry to his next therapy session. Suggestions for Follow-up

When following up, therapists can help clients reflect on ways to incorporate their various intersecting iden­ tities into their own sense of self. They can also help clients strengthen existing coping strategies and iden­ tify new adaptive strategies to cope with their expe­ riences. Therapists can also take time to process with clients what it was like to complete the activity and reflect on any insights gained from doing so. Contraindications for Use

When helping LGBT clients of color process experi­ ences of marginalization through this activity, thera­ pists must note that inquiries made regarding these experiences may lead clients to become retraumatized and retriggered. Therefore, therapists’ attunement to clients’ responses and body language is essential (Hanson, 2005; Levitt, Pomerville, & Surace, 2016). Clients who exhibit great discomfort or anxiety, for example, may not be ready to engage in the activity. It is also

important that therapists focus on establishing solid therapeutic rapport and fostering a sense of relative safety before asking potentially triggering questions. Professional Readings and Resources Davidson, M. M., & Hauser, C. T. (2015). Multicultural coun­ seling meets potentially harmful therapy: The complexity of bridging two discourses. Counseling Psychologist, 43 (3), 370–379. doi:10.1177/001100001456714. Ferguson, A. D., Carr, G., & Snitman, A. (2014). Intersections of race-ethnicity, gender, and sexual minority communi­ ties. In M. L. Miville & A. D. Ferguson (eds.), Handbook of race- ethnicity and gender in psychology, 45–63. New York: Springer. Hendricks, M. L., & Testa, R. J. (2012). A conceptual frame­ work for clinical work with transgender and gender non­ conforming clients: An adaptation of the minority stress model. Professional Psychology: Research and Practice, 43, 460–467. doi:10.1037/a0029597. Miville, M. L., & Ferguson, A. D. (eds.). (2014). Handbook of race-ethnicity and gender in psychology. New York: Springer. Wendt, D. C., Gone, J. P., & Nagata, D. K. (2015). Potentially harmful therapy and multicultural counseling: Bridging two disciplinary discourses. Counseling Psychologist, 43 (3), 334–358. doi:10.1177/0011000014548280.

Resources for Clients APA Division 44, Society for the Psychological Study of Lesbian, Gay, Bisexual, and Transgender Issues. (2018). https:// www.apa.org/about/division/div44.aspx. APA Office on Sexual Orientation and Gender Diversity (2018). Programs and services. https://www.apa.org/pi/lgbt/. Audre Lorde Project. (n.d.). http://alp.org. Chin, S. (2009). The other side of paradise: A memoir. New York: Simon and Schuster. Consortium of Higher Education LGBT Resource Professionals. (2017). https://www.lgbtcampus.org/. Human Rights Campaign. (2017). https://www.hrc.org. National LGBTQ Task Force. (2018). www.thetaskforce.org. Trans People of Color Coalition. (2013). https://www.glaad. org/tags/trans-people-color-coalition.

References American Psychological Association (APA). (1993). Guidelines for providers of psychological services to ethnic, linguistic, and culturally diverse populations. American Psychologist, 48, 45–48. American Psychological Association (APA). (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender Exploring Multiple Marginalized Identities 103

nonconforming people. American Psychologist, 70, 832– 864. doi:10.1037//a0039906. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity and Ethnic Minority Psychology, 17 (2), 163–174. doi:10.1037/a0023244. Cochran, S. D., Mays, V. M., Alegria, M., Ortega, A. N., & Takeuchi, D. (2007). Mental health and substance use dis­ orders among Latina/o and Asian American lesbian, gay, and bisexual adults. Journal of Counseling and Clinical Psychology, 75, 785–794. doi:10.1037/0022-006X.75. 5.785. Díaz, R. M., Ayala, E. B., Bein, E., Henne, J., & Marin, B. V. (2001). The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: Findings from 3 US cities. American Journal of Public Health, 91 (6), 927–932. Dunn, T. L., Gonzalez, C. A., Costa, A. B., Nardi, H. C., & Iantaffi, A. (2014). Does the minority stress model gen­ eralize to a non-U.S. sample? An examination of minority stress and resilience on depressive symptomatology among sexual minority men in two urban areas of Brazil. Psychology of Sexual Orientation and Gender Diversity, 1 (2), 117–131. doi:10.1037/sgd0000032. Fields, E. L., Bogart, L. M., Smith, K. C., Malebranche, D. J., Ellen, J., & Schuster, M. A. (2015). “I always felt I had to prove my manhood”: Homosexuality, masculinity, gender role strain, and HIV risk among young black men who have sex with men. American Journal of Public Health, 105 (1), 122–131. doi:10.2105/AJPH.2013.301866. Gates, G. J. (2011). How many people are lesbian, gay, bisex­ ual, and transgender? Williams Institute, 1–8. http://wil liamsinstitute.law.ucla.edu/wp-content/uploads/Gates­ How-Many-People-LGBT-Apr-2011.pdf. Gates, G. J. (2017). In U.S., more adults identifying as LGBT. Washington, DC: Gallup. http://www.gallup.com/poll/ 201731/lgbt-identification-rises.aspx. Gattis, M. N., & Larson, A. (2017). Perceived microaggressions and mental health in a sample of black youths experi­ encing homelessness. Social Work Research, 41, 7–17. doi:10.1093/swr/svw030. Hanson, J. (2005). Should your lips be zipped? How therapist self-disclosure and non-disclosure affects clients. Coun­ selling and Psychotherapy Research, 5 (2), 96–104. doi:10. 1080/17441690500226658. Hays, P. A. (2001). Addressing cultural complexities in practice: A framework for clinicians and counselors. Washington, DC: American Psychological Association. Huffaker, L., & Kwon, P. (2016). A comprehensive approach to sexual and transgender prejudice. Journal of Gay and Lesbian Social Services, 28, 195–213. doi:10.1080/105387 20.2016.1191405.

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Hughes, T. L., Johnson, T. P., & Matthews, A. K. (2008). Sexual orientation and smoking: Results from a multisite wom­ en’s health study. Substance Use and Misuse, 43, 1218–1239. doi:10.1080/10826080801914170. Lazarus, R., & Folkman, S. (1984), Stress, appraisal, and coping. New York: Springer. Levitt, H. M., Pomerville, A., & Surace, F. I. (2016). A qualita­ tive meta-analysis examining clients’ experiences of psy­ chotherapy: A new agenda. Psychological Bulletin, 142, 801–830. doi:10.1037/bul0000057. Malebranche, D. J., Fields, E. L., Bryant, L. O., & Harper, S. R. (2009). Masculine socialization and sexual risk behaviors among black men who have sex with men: A qualitative exploration. Men and Masculinities, 12, 90–112. doi:10. 1177/1097184X07309504. Meyer, I., Dietrich, J., & Schwartz, S. (2008, June). Lifetime prevalence of mental disorders and suicide attempts in divers lesbian, gay, and bisexual populations. American Journal of Public Health, 98 (6), 1004–1006. Nadal, K. L. (2008). Preventing racial, ethnic, gender, sexual minority, disability, and religious microaggressions: Rec­ ommendations for promoting positive mental health. Prevention in Counseling Psychology: Theory, Research, Practice, and Training, 2, 22–27. Nadal, K. L. (2011). The Racial and Ethnic Microaggressions Scale (REMS): Construction, reliability, and validity. Jour­ nal of Counseling Psychology, 58 (4), 470. doi:10.1037/ a0025193. Nadal, K. L., & Corpus, M. J. (2013). “Tomboys” and “bak­ las”: Experiences of lesbian and gay Filipino Americans. Asian American Journal of Psychology, 4 (3), 166–175. doi:10.1037/a0030168. Nadal, K. L., Whitman, C. N., Davis, L. S., Erazo, T., & Davidoff, K. C. (2016). Microaggressions toward lesbian, gay, bisex­ ual, transgender, queer, and genderqueer people: A review of the literature. Journal of Sex Research, 53, 488–508. doi :10.1080/00224499.2016.1142495. Santos, C. E., & VanDaalen, R. A. (2016). The associations of sexual and ethnic-racial identity commitment, conflicts in allegiances, and mental health among lesbian, gay, and bisexual racial and ethnic minority adults. Journal of Coun­ seling Psychology, 63, 668–676. doi:10.1037/cou0000170. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender people of color who have survived traumatic life events. Traumatology, 17, 34–44. doi:10.1177/1534765610369261. Slavin, L. A., Rainer, K. L., McCreary, M. L., & Gowda, K. K. (1991). Toward a multicultural model of the stress process. Journal of Counseling and Development, 70 (1), 156–163. doi:10.1002/j.1556-6676.1991.tb01578.x. Sue, D. W., Capodilupo, C. M., Torino, G. C., Bucceri, J. M., Holder, A. M. B., Nadal, K. L., & Esquilin, M. (2007). Racial microaggressions in everyday life: Implications

for clinical practice. American Psychologist, 62, 271–286. doi:10.1037/0003-066X.62.4.271. Sutter, M., & Perrin, P. B. (2016). Discrimination, mental health, and suicidal ideation among LGBTQ people of color. Journal of Counseling Psychology, 63, 98–105. doi:10. 1037/cou0000126.

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Exploring Multiple Marginalized Identities 105

ACTIVIT Y The following guided questions will help clients process and cope with their experiences of marginalization and oppression. Please discuss the activity, along with related concepts, with clients before asking these questions, as they may be triggering. • If you feel comfortable doing so, tell me more about your experience. Specifically, tell me about a time when you felt marginalized, discriminated against, or attacked because of who you are.

• How did this experience make you feel?

• How did you respond? Was that how you hoped you would respond? If not, how would you want to respond in the future?

• How do you feel that this experience has influenced the way you see others, yourself, and the world?

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• Have you found any strategies helpful in coping with this experience? If so, what are those strategies?

• What other coping strategies can you use to deal with the stress of these hurtful experiences? (Therapists and clients can collaboratively explore additional coping strategies.)

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13 SOMOS LATINX: EXPLORING CULTURAL VALUES OF SEXUALLY AND GENDER-DIVERSE LATINX CLIENTS Zully A. Rivera Ramos, Amanda Lawson-Ross, and Carlos Hernández Suggested Use: Handout Objective

The objective of this handout is to support sexually and gender-diverse Latinx clients in exploring the influence of traditional cultural values (Edwards & Cardemil, 2015; Marin & Marin, 1991) on their sexual, gender, and Latinx identities. Doing so may facilitate their process of integrating and affirming these intersecting identities. Clients may be able to identify, process, and communicate their experi­ ences at personal, interpersonal, structural, and cultural levels. Rationale for Use

Historically, underrepresented sexually and genderdiverse individuals have suffered from marginaliza­ tion and oppression, which is further complicated by their intersection with other marginalized identities, such as Latinx (González & Espín, 1996; Manalansan, 1996; Rivera-Ramos, Oswald, & Buki, 2015). We use the term Latinx as a gender-inclusive way of referring to people of Latin American descent (Padilla, 2016). The use of Latino marginalizes women, transgender, and genderqueer individuals. By replacing the use of “o/a” at the end of “Latin” with an “x,” we acknowl­ edge the intersectionality of sexual, gender, and Latinx identities (Padilla, 2016). In the United States, under­ represented sexually and gender-diverse Latinx indi­ viduals probably experience heterosexism or cisgen­ derism (or both) within their Latinx community and racism within the primarily white underrepresented sexually and gender-diverse community, which may lead them to have to choose between these commu­

nities (González & Espín, 1996; Manalansan, 1996; Rivera-Ramos et al., 2015). Individuals who self-identify with their Latinx community have unique challenges in how they expe­ rience and internalize oppression (Manalansan, 1996; Muñoz-Laboy et al., 2009; Rivera-Ramos et al., 2015; Velez, Moradi, & DeBlaere, 2014; Zea, Reisen, & Poppen, 1999). The Pulse massacre is a tragic example of the complexity of these challenges. Pulse is a night­ club located in Orlando, Florida, serving primarily underrepresented sexually and gender-diverse individ­ uals. One June 12, 2016, a large mass shooting occurred at Pulse during Latinx night (Vazquez, 2016). Many Latinx families learned about their children’s sexually and gender-diverse identities in the aftermath of the shooting. Much of the media coverage was focused on the sexually and gender-diverse identities of the victims or the attacker’s Muslim identity without not­ ing the intersectionality of Latinx, sexual, and gender identities. This chapter attempts to address the com­ plexity of these intersecting experiences to promote culturally responsive interventions. Liberation psychology is a culturally appropriate theoretical orientation in working with underrepre­ sented sexually and gender-diverse Latinx individuals, as it was developed by Ignacio Martín-Baró (1983a, 1983b), a social psychologist from El Salvador who served and advocated for socially marginalized groups. He suggested that it is critical to examine the oftenpathologized subjective experiences of marginalized groups who have had few opportunities to tell their story from their perspective because of the dominant discourse established by oppressive social structures. This theory facilitates giving voice to those often

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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silenced by oppression and marginalization and advo­ cates for a social justice approach addressing systemic, cultural, and sociopolitical factors influencing individ­ ual experiences (Chávez, Torres Fernandez, HipólitoDelgado, & Torres Rivera, 2016; Martín-Baró, 1983a, 1983b). The theory includes three main processes: consci­ entization, empowerment, and problematization (Chávez et al., 2016). Conscientization entails assisting clients in becoming aware of the structural factors influencing their distress (Chávez et al., 2016). With underrepresented sexually and gender-diverse Latinx clients, this involves becoming aware of the effects of oppression that are due to their race or ethnicity, sex­ ual orientation, gender identity, social class, and doc­ umentation status, among others. Through promoting empowerment we instill hope and support, recognize clients’ strength and resiliency, and identify support­ ive resources that have helped them survive in the midst of systemic oppression. We can support clients by normalizing their experiences and recognizing that they can reclaim and redefine Latinx cultural values. This leads to the process of problematization, where we facilitate an understanding of how the interaction of personal, interpersonal, structural, and cultural factors have perpetuated the cycle of oppression in which they live (Chávez et al., 2016). Problematization entails questioning how these cultural values affect the integration of their marginalized identities. Liberation psychology aligns itself with affirmative practices because it goes beyond the individual and focuses on sociocultural factors. This theory can be easily integrated with multicultural and feminist the­ ories (Crethar, Torres-Rivera, & Nash, 2008; Funder­ burk & Fukuyama, 2001; Gonzalez, Biever, & Gardner, 1994; Negy & McKinney, 2006) because they also focus on social justice advocacy and structural inequalities, as well as power dynamics between the client-counselor relationship and the influence of cultural values on individuals’ psychological well-being. Multiculturalism assumes that people construct the meaning of their world through their cultural and sociohistorical experi­ ences, and there are thus multiple perspectives that should be equally valued (Funderburk & Fukuyama, 2001). Feminist counseling has been found to enhance resiliency and emotional well-being among under­

represented sexually and gender-diverse individuals and families (Negy & McKinney, 2006). Latinx sexu­ ally and gender-diverse individuals often have to navi­ gate hostile sociopolitical and familial environments (Manalansan, 1996; Muñoz-Laboy et al., 2009; RiveraRamos et al., 2015; Velez et al., 2014; Zea et al., 1999). Thus, it is critical to address resiliency in dealing with oppression and negative biases. Through integrating these theories with the hand­ out in this chapter, clients may explore their Latinx cultural values in relation to their sexual orientation and gender identity. The assumption is that clients are experts on their own lives and counselors are col­ laborators. This is key as we support clients’ develop­ ment of autonomy and sense of control in order to facilitate taking action to change the oppressive struc­ tural system affecting their distress. Ethical codes for counselors (ACA, 2014, F.11.c) and psychologists (APA, 2017, 2.01b) encourage the development of awareness, knowledge, and skills in serving culturally diverse individuals in regard to eth­ nicity, gender identity, race, sexual orientation, and other cultural identities. Understanding the influence of these identities is critical for providing services and making appropriate referrals (ACA, 2014, A.11.b). Awareness about our role as service providers, as well as our limitations, is critical as we engage in social justice–oriented work (ACA, 2014, A.4.b). To be con­ sistent with ACA and APA ethics codes, it is also important to be aware of the biases that we hold and how these affect our understanding of cultural values that may be salient for underrepresented sexually and gender-diverse Latinx clients (ACA, 2014, C.5; APA, 2017, 3.01, 3.03). Instructions

After rapport-building and information-gathering sessions are completed, the handout may be intro­ duced. Give the handout to clients to be completed in session or at home and process it in session. Read the instructions on the sheet and explain the exam­ ple to facilitate understanding. The aim is to identify cultural values that may be affecting clients both negatively and positively, as a way to support them in integrating and affirming their intersecting gender, sexual, and Latinx identities. Somos Latinx: Exploring Cultural Values 109

Brief Vignette

Alex (pronouns: they, them, theirs) is a twenty-year­ old college junior majoring in engineering. They came to the counseling center to explore feelings of depression and sadness related to school and family. On the intake form, they indicated “questioning” on sexual orientation and “other” on gender identity. They self-identified as multiracial and of Cuban, Mexican, and Puerto Rican descent and disclosed having fam­ ily members of mixed documentation status. Alex appeared nervous and was tearful. They are from a “traditional loving and chaotic” working-class family where both of their parents and their older brother (twenty-two) contribute financially. Alex has a younger sister (seventeen). The family is Catholic and attends church regularly. Alex completed the first two years at a junior college close to home, and it has been difficult for them to adjust to a primarily European American, white university. Alex expressed feeling homesick and not really connecting with other students on cam­ pus. They feel they have no time to socialize because of the amount of work required in their major. They started questioning their sexual and gender identities in high school, and it has continued in col­ lege. They reported having gone to a sexually and gender-diverse student club meeting once, but left shortly after arriving because they did not feel they belonged and felt nervous and scared someone might recognize them. They had not spoken to anyone about this at the beginning of counseling and expressed feeling sad and disgusted; they also mentioned pray­ ing to God to help them “change.” Alex expressed struggling with their family’s cultural values and how their family may react; Alex worried that they may have to choose between being themselves and adhering to their Latinx culture’s norms, values, and expectations. Alex completed the handout at home. During the following session, we processed the results, and they had marked that respeto had a moderate and positive effect on their Latinx identity, while it had a greater and negative influence on their sexual and gender identities (i.e., conscientization). This suggested that the effect of this value is conflicted and potentially contributing to their distress. Helping Alex recog­ nize their strength and resiliency in navigating the value of respeto instilled hope and empowerment in 110 Rivera Ramos, Lawson-Ross, & Hernández

their decision to uphold their parents’ wishes not to come out to others in the family, while seeking sup­ port and affirmation in exploring their sexual ori­ entation and gender identity (i.e., empowerment). This led to the question of how respeto is affecting the integration of their Latinx, sexual, and gender identities, as well as understanding their concerns within a larger sociocultural context (i.e., prob­ lematization). Thus, the counseling process pro­ moted an understanding of their intra- and inter­ personal challenges, in conjunction with the psychosocial and sociopolitical implications related to Alex’s distress. In the following sessions, we con­ tinued to deepen exploration of respeto and other salient cultural values. We also addressed how their views of the cultural values compared to their fami­ ly’s views. This counseling process helped Alex depathologize their concerns, feel more connected to their intersecting identities, accept certain aspects of their culture, and improve their relationships. Suggestions for Follow-up

Processing the responses on the handout may take several sessions. Refer to the list of follow-up questions for further exploration. It is important to challenge irrational thinking and myths, reconstruct positive and affirming characteristics, and empower clients as you support them in integrating and valuing their sexual, gender, and Latinx identities. Contraindications for Use

This handout is based on our experience working with sexually and gender-diverse Latinx college students at predominantly white institutions. Given the variety of resources available at institutions of higher educa­ tion, working with community members (e.g., mar­ ried with children or elderly) may present additional challenges related to language barriers, documenta­ tion status, and finances. The handout may work with other age ranges and may need to be adapted for the client’s developmental stage. The handout may not be useful with elementary- and middle-school children because they may not have a clear understanding of Latinx cultural values and how these may intersect with sexual orientation and gender identity. It may be

also contraindicated for use with individuals who reject or do not identify with their Latinx culture and related values. Professional Readings and Resources Edwards, L. M., & Cardemil, E. V. (2015). Clinical approaches to assessing cultural values among Latinos. In K. F. Geisinger (ed.), Psychological testing of Hispanics: Clinical and intellectual issues, 215–236. Washington, DC: Ameri­ can Psychological Association. doi:10.1037/14668-012. Estrada, F., Rigali-Oiler, M., Arciniega, G. M., & Tracey, T. J. G. (2011). Machismo and Mexican American men: An empirical understanding using a gay sample. Journal of Counseling Psychology, 58 (3), 358–367. doi:10.1037/ a0023122. Hames-García, M., & Martínez, E. J. (2011). Gay Latino studies: A critical reader. Durham, NC: Duke University Press. Muñoz-Laboy, M., Leau, C. J., Sriram, V., Weinstein, H. J., del Aquila, E. V., & Parker, R. (2009). Bisexual desire and familism: Latino/a bisexual young men and women in New York City. Culture, Health, and Sexuality, 11, 331–344. doi:10.1080/13691050802710634. Rivera-Ramos, Z. A., Oswald, R. F., & Buki, L. P. (2015). A Latina/o campus community’s readiness to address les­ bian, gay, and bisexual concerns. Journal of Diversity in Higher Education, 8 (2), 88. doi:10.1037/a0038563. Sager, J. B., Schlimmer, E. A., & Hellmann, J. A. (2001). Latin American lesbian, gay, and bisexual clients: Implications for counseling. Journal of Humanistic Counseling, Educa­ tion, and Development, 40 (1), 21–34. doi:10.1002/j.21 64-490X.2001.tb00099.x. Velez, B. L., Moradi, B., & DeBlaere, C. (2014). Multiple oppres­ sions and the mental health of sexual minority Latina/o individuals. Counseling Psychologist, 43 (1), 7–38. doi:10. 1177/0011000014542836. Zea, M. C., Reisen, C. A., & Poppen, P. J. (1999). Psychological well-being among Latino lesbians and gay men. Cultural Diversity and Ethnic Minority Psychology, 5, 371–379. doi:10.1037/1099-9809.5.4.371.

Resources for Clients: Print and Online American Psychological Association (APA). (2011). Respues­ tas a sus preguntas sobre las personas trans, la identidad de género y la expresión de género. https://www.apa.org/ topics/lgbt/brochure-personas-trans.pdf. American Psychological Association (APA). (2012). Respues­ tas a sus preguntas para una mejor comprensión de la ori­ entación sexual y la homosexualidad. https://www.apa. org/topics/lgbt/answers-questions-so-spanish.pdf. Asociación de Psicología de Puerto Rico, Comité de Asuntos de la Comunidad LGBT. (2014). Estándares para el tra­ bajo e intervención en comunidades lesbianas, gay, bisex­

uales e identidades trans. http://docs.wixstatic.com/ ugd/0522af_89334b8cc3904582841b58dcce2ca374.pdf. DeColores Queer Orange County. (n.d.). https://dcqoc.wee bly.com/. De la Torre, M., Castuera, I., & Meléndez Rivera, L. (n.d.). A la familia: Una conversación sobre nuestras familias, la biblia, la orientación sexual y la identidad de género. http://www.thetaskforce.org/static_html/downloads/ release_materials/tf_a_la_familia.pdf. Familia: Trans Queer Liberation Movement. (n.d.). http:// familiatqlm.org/. Familia es familia. (2017). http://familiaesfamilia.org/. Harrison-Quintana, J., Pérez, D., & Grant, J. (2012). Injustice at every turn: A look at Latino/a respondents in the National Transgender Discrimination Survey. www. transequality.org/sites/default/files/docs/resources/ntds_ latino_english_2.pdf. Human Rights Campaign. (2013). Guía de recursos para salir del closet: Para personas lesbianas, gais, bisexuals y trans­ géneros. http://assets.hrc.org//files/assets/resources/ GuiaParaSalirDelCloset_2013_final.pdf. Latino Outreach and Understanding Division: LOUD. (n.d.). http://somosloud.org/. PFLAG San Juan, PR. (n.d.). https://www.facebook.com/ PFLAG.SanJuan.PR. Somos Orlando. (n.d.). http://somosorlando.info/. [email protected] Coalition. (n.d.). https://www.translatinacoali tion.org/. University of Washington Q Center. (2008). Guide to Latin American LGBT communities. http://depts.washington. edu/qcenter/sites/default/files/downloads/Latin%20 Am%20LGBT%20Guide.pdf. Vásquez-Rivera, M., Martínez-Taboas, A., Francia-Martínez, M., & Toro-Alfonso, J. (2016). LGBT 101: Una mirada introductoria al colectivo. San Juan, PR: Publicaciones Puertorriqueñas.

Resources for Clients: Films Barbosa, P., & Lenoir, G. (directors). (2001). De colores (doc­ umentary). Oakland, CA: Eyebite Productions & Woman Vision Productions. Barrón, E. (producer), & Tovar Velarde, S. (director). (2014). Cuatro lunas. Mexico City: Atko Films, Los Gueros, Kinomada, Color Space, & Skyflak Studio. Castro-Bojorquez, M. (producer & director), & Alfaro, J. (direc­ tor). (2011). Tres gotas de agua (documentary). Oakland, CA: Somos Familia. Castro-Bojorquez, M. (producer & director), Alfaro, J. Cruz, K., & Salinas, L. (producers). (2015). El canto del colibrí (documentary). San Francisco: Somos Familia & Bayview Hunters Point Center for Arts and Technology. Gutiérrez A. T., & Tabío, J. C. (directors). (1993). Fresa y choc-

Somos Latinx: Exploring Cultural Values 111

olate. Havana: Instituto Cubano del Arte e Industrias Cinematográficos. McCray, J. (producer & director). (2007). Tal como somos (documentary). Chicago: Juneteenth Productions & University of Illinois at Chicago.

References American Counseling Association (ACA). (2014). ACA code of ethics. https://www.counseling.org/resources/aca-code­ of-ethics.pdf. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/. Anastasia, E. A., & Bridges, A. J. (2015). Understanding ser­ vice utilization disparities and depression in Latinos: The role of fatalismo. Journal of Immigrant and Minority Health, 17, 1758–1764. doi:10.1007/s10903-015-0196-y. Arciniega, G. M., Anderson, T. C., Tovar-Blank, Z. G., & Tracey, T. J. G. (2008). Toward a fuller conception of machismo: Development of a traditional machismo and caballerismo scale. Journal of Counseling Psychology, 55 (1), 19–33. doi:10.1037/0022-0167.55.1.19. Bryant-Davis, T., & Comas-Díaz, L. (2016). Womanist and mujerista psychologies: Voices of fire, acts of courage. Wash­ ington, DC: American Psychological Association. Chávez, T. A., Torres Fernandez, I., Hipólito-Delgado, C. P., & Torres Rivera, E. (2016). Unifying liberation psychol­ ogy and humanistic values to promote social justice in counseling. Journal of Humanistic Counseling, 55 (3), 166–182. doi:10.1002/johc.12032. Crethar, H. C., Torres-Rivera, E., & Nash, S. (2008). In search of common threads: Linking multicultural, feminist, and social justice counseling paradigms. Journal of Counseling and Development, 86, 269–278. doi:10.1002/j.1556-6678. 2008.tb00509.x. Edwards, L. M., & Cardemil, E. V. (2015). Clinical approaches to assessing cultural values among Latinos. In K. F. Geisinger (ed.), Psychological testing of Hispanics: Clini­ cal and intellectual issues, 215–236. Washington, DC: American Psychological Association. doi:10.1037/14668 -012. Funderburk, J. R., & Fukuyama, M. A. (2001). Feminism, multiculturalism, and spirituality: Convergent and divergent forces in psychotherapy. Women & Therapy, 24 (3–4), 1–18. doi:10.1300/J015v24n03_01. González, F. J., & Espín, O. M. (1996). Latino men, Latina women, and homosexuality. In R. P. Cabaj & T. S. Stein (eds.), Textbook of homosexuality and mental health, 583–602. Washington, DC: American Psychiatric Press. Gonzalez, R. C., Biever, J. L., & Gardner, G. T. (1994). The multicultural perspective in therapy: A social construc­ tionist approach. Psychotherapy, 31, 515–524. doi:10.1037/0033-3204.31.3.515.

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Manalansan, M. F., IV. (1996). Double minorities: Latino, Black, and Asian men who have sex with men. In R. C. Sav­ in-Williams & K. M. Cohen (eds.), The lives of lesbians, gays, and bisexuals, 393–415. Orlando, FL: Harcourt Brace. Marin, G., & Marin, B. V. (1991). Research with Hispanics. Newbury Park, CA: Sage. Martín-Baró, I. (1983a). Las estructuras sociales y su impacto psicológico. In Martín-Baró, Acción e ideología, 71–109. San Salvador: UCA Editores. Martín-Baró, I. (1983b). La interacción personal contexto y percepción. In Martín-Baró, Acción e ideología, 183–240. San Salvador: UCA Editores. Muñoz-Laboy, M., Leau, C. J., Sriram, V., Weinstein, H. J., del Aquila, E. V., & Parker, R. (2009). Bisexual desire and familism: Latino/a bisexual young men and women in New York City. Culture, Health and Sexuality, 11, 331– 344. doi:10.1080/13691050802710634. Negy, C., & McKinney, C. (2006). Application of feminist therapy: Promoting resiliency among lesbian and gay families. Journal of Feminist Family Therapy, 18, 67–83. doi:10.1300/J08v18n01_03. Ojeda, L., Pina-Watson, B., & Gonzalez, G. (2016). The role of social class, ethnocultural adaptation, and masculinity ideology on Mexican American college men’s well-being. Psychology of Men and Masculinity, 17 (4), 373–379. doi:10.1037/men0000023. Padilla, Y. (2016, April 18). What does “Latinx” mean? A look at the term that’s challenging gender norms. Complex. https://www.complex.com/life/2016/04/latinx/. Piña-Watson, B., & Abraído-Lanza, A. (2016). The intersection of fatalismo and pessimism on depressive symptoms and suicidality of Mexican descent adolescents: An attribution perspective. Cultural Diversity and Ethnic Minority Psy­ chology, 23 (1), 93–101. doi:10.1037/cdp0000115. Piña-Watson, B., Ojeda, L., Castellon, N., & Dornhecker, M. (2013). Familismo, ethnic identity, and bicultural stress as predictors of Mexican American adolescents’ positive psychological functioning. Journal of Latina/o Psychology, 1 (4), 204–217. doi:10.1037/lat0000006. Rivera-Ramos, Z. A., Oswald, R. F., & Buki, L. P. (2015). A Latina/o campus community’s readiness to address lesbian, gay, and bisexual concerns. Journal of Diversity in Higher Education, 8 (2), 88–103. doi:10.1037/a0038563. Stevens, E. P. (1973). Marianismo: The other face of machismo in Latin America. In A. Pescatello (ed.), Female and male in Latin America: Essays, 89–100. Pittsburgh: University of Pittsburgh Press. Tropp, L., Erkut, S., García Coll, C., Alarcón, O., & Vazquez García, H. (1999). Psychological acculturation: Develop­ ment of a new measure for Puerto Ricans on the U.S. mainland. Educational Psychological Measurement, 59 (2), 351–367. doi:10.1177/00131649921969794.

Vasquez, R. (2016, June 19). The Point podcast episode 1: Covering the Pulse shooting. The Point @ WUFT Podcast. https://www.wuft.org/news/2016/06/19/the-point­ podcast-episode-1-covering-the-pulse-shooting/. Velez, B. L., Moradi, B., & DeBlaere, C. (2014). Multiple oppressions and the mental health of sexual minority

Latina/o individuals. Counseling Psychologist, 43 (1), 7–38. doi:10.1177/0011000014542836. Zea, M. C., Reisen, C. A., & Poppen, P. J. (1999). Psychologi­ cal well-being among Latino lesbians and gay men. Cul­ tural Diversity and Ethnic Minority Psychology, 5, 371–379. doi:10.1037/1099-9809.5.4.371

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FOLLOW-UP QUESTIONS The questions below can be used as a follow-up to the cultural values activity over several sessions. Make sure to process clients’ reactions to the activity. The goal is for clients to reflect on the effects of the intersections of their Latinx, gender, and sexual identities. 1. How does your gender, and what this means for you, affect your Latinx and sexual identities?

2. How was your coming-out process, given your multiple oppressed identities?

3. How does your family’s documentation status influence your experiences as a sexually or genderdiverse Latinx individual?

4. Which sociopolitical events, such as the Pulse massacre, have affected your experiences as a sexually or gender-diverse Latinx individual?

5. If you speak Spanish or Portuguese with your family, how does language relate to your comingout process?

6. Who are people within your Latinx family and community who can act as potential allies in your coming-out process and who may help you cope with the fear of rejection?

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7. What have you heard about sexually or gender-diverse individuals within your Latinx family and community?

8. What biases do you have in relation to sexual orientation or gender identity?

9. How have you navigated your Latinx, gender, and sexual identities?

10. What other intersecting identities have affected you?

11. What do you need to feel truly integrated as a sexually or gender-diverse Latinx individual?

12. How does your experience as a sexually or gender-diverse Latinx individual within the Latinx community compare to your experience within the European American white dominant society?

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14 BUILDING RESILIENCE WITH CLIENTS WHO FACE MULTIPLE FORMS OF OPPRESSION Kristin N. Bertsch

Suggested Uses: Activity, homework Objective

This activity is designed for clients who face multiple intersecting minority identities (e.g., race, sexual ori­ entation, and gender). Clients will be encouraged to explore the multiple identities they hold and how experiences of oppression affect them in their every­ day life. Additionally, clients will be invited to assess their individual strengths and values and be guided in how to use these strengths and values to partici­ pate in collective action that is meaningful to them to build resilience against incidents of discrimina­ tion. For the purposes of this exercise, collective action has been defined as an individual of a particu­ lar group “acting as a representative of the group” and participating in action that “is directed at improving the condition of the entire group” (Wright, Taylor, & Moghaddam, 1990, p. 995). Rationale for Use

An increasing amount of research conducted with pop­ ulations with multiple marginalized identities (e.g., race, sexual orientation, and gender) suggests that experiences of discrimination are related to negative mental health concerns (DeBlaere et al., 2014, Ghab­ rial, 2017). Specifically, individuals who identify with these intersecting marginalized identities have unique experiences apart from those of their white sexualminoritized counterparts and their heterosexual eth­ nic-minoritized counterparts. For instance, in a quali­ tative study with eleven lesbian, gay, bisexual, trans, and queer people of color (LGBTQ-POC), Ghabrial (2017) sought to examine how respondents described

the relationships between their identities and com­ munities, to explore how underresearched microag­ gressions may affect LGBT-POC, and to learn more about how multiple marginalization and discrimina­ tion affect stress and health in the LGBTQ-POC community. Four common themes emerged. Some respondents reported feeling disconnected from their racial or ethnic community because of their sexual orientation and/or disconnected from the mainstream LGBTQ community owing to their racial or ethnic identity. In terms of identity relationships, some par­ ticipants felt they had to conceal their sexual orien­ tation because of their racial identity, often referring to cultural expectations as one of the reasons, whereas other participants felt that a sexual-minority and racialized identity was a source of pride. In terms of coming out, some participants concealed their sexual identity because of cultural homophobia, threat to safety, and stress, noting the importance of awareness of one’s basic needs and safety. Stress and anxiety, the last theme, were centered on negative psychological and physical symptoms (e.g., hair loss) that result from having these multiple minoritized identities. For all these reasons, it is important that therapists hold a unique, nuanced understanding of the variety of chal­ lenges faced by this population and use culturally appropriate interventions. Although research has been conducted to assess therapist competencies when working with sexualminority populations, fewer studies have examined the efficacy of affirmative psychotherapy practices when working with these populations (Berke, Maples-Keller, & Richards, 2016). However, scholars agree that there are a few central behaviors that are critical to affirmative

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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counseling. For instance, important LGBQ-affirmative behaviors include building a strong therapeutic alli­ ance, advocacy skills (e.g., knowledge of community resources for LGBQ individuals), therapist knowledge of LGBQ-nuanced concerns, self-awareness of atti­ tudes toward one’s own and others’ sexual-identity development, and assessment of underlying concerns of LGBQ clients (Dillon, Worthington, Soth-McNett, & Schwartz, 2008). Additionally, affirmative counsel­ ors work from a nonpathological framework when conceptualizing an LGBQ person’s presenting concerns (APA, 2012). It is important that affirmative interven­ tions match the client’s developmental level, culture, stage of identity, and level of self-acceptance. Affir­ mative therapists are also aware that this population is resilient and knowledgeable about interventions that will build on that resilience to help thwart the negative effects of discriminatory experiences. The minority stress framework posits that grouplevel coping strategies may build further resilience and thus lessen the negative mental health conse­ quences associated with oppression for sexual-minor­ ity persons (Meyer, 2003; Szymanski & Owens, 2009). DeBlaere and colleagues (2014) investigated the protective power of collective action for sexual-minority women of color in the context of multiple discrimi­ nation experiences (e.g., racism, sexism, and hetero­ sexism) and psychological distress. Several findings were telling in the experiences of sexual-minority women of color. Experiences of racism, sexism, and heterosexism were each positively and significantly related to psychological distress. When examined together, only heterosexism accounted for significant and unique variance in psychological distress with this sample of sexual-minority women of color. These findings suggest that participants in this sample may have developed coping strategies related to gender and race because of the visibility of these identities. Because sexual identity is often invisible, women in this sample may have been more likely to encounter heterosexual discrimination as a result of having developed fewer coping strategies for discrimination that was based on this identity. It is evident that hav­ ing multiple marginalized identities is complex and important to explore. In accordance with affirmative counseling practices, the ability to integrate ways to

explore collective-action interventions in the therapy room requires a strong therapeutic alliance, a deep understanding of the client’s presenting concerns, and accurate perception of the client’s development level. Finally, the American Psychological Association provides “Guidelines for Psychological Practice with LGB Clients” (APA, 2012). These codes can be helpful in guiding and informing work with clients. In particu­ lar, guideline 1 states, “Psychologists strive to under­ stand the effects of stigma (i.e., prejudice, discrimina­ tion, and violence) and its various contextual manifest­ ations in the lives of lesbian, gay, and bisexual people” (APA, 2012, p. 12). In terms of application, APA notes that a safe therapeutic relationship is of primary importance. Additionally, this guideline also under­ scores the importance of understanding “the different combinations of contextual factors related to gender, race, ethnicity, cultural background, social class, reli­ gious background, disability, geographic region, and other sources of identity that can result in dramatically different stigmatizing pressures and coping styles” (APA, 2012, pp. 12–13). Along with increasing a cli­ ent’s sense of safety and decreasing stress, APA urges psychologists to assist clients in developing social resources and to empower clients to confront social stigma and discrimination when appropriate. APA distinguishes between clients who are more comfortable with their sexual orientation and those who are not as comfortable when referring clients to social resources. For those who are more comfort­ able, referring to local support groups or other com­ munity resources may be appropriate. For those who are less comfortable with their sexual orientation, online discussion groups or community groups may better meet the client’s level of identity development. Taken together, APA recognizes the importance of building social networks and community as a way to protect against the negative psychological effects of discrimination. Therefore, psychologists who are knowledgeable about a range of collective-action activi­ ties that are aimed at decreasing isolation and build­ ing resilience are also adhering to APA guidelines and recommendations. The “Guidelines for Psychological Practice with LGB Clients” (APA, 2012) pay particular attention to cli­ ents with multiple minoritized identities. For instance, Building Resilience with Clients Who Face Oppression 125

guideline 11 states, “Psychologists strive to recognize the challenges related to multiple and often conflicting norms, values, and beliefs faced by lesbian, gay, and bi­ sexual members of racial and ethnic minority groups” (APA, 2012, p. 20). APA encourages psychologists to work with clients in identifying protective factors and coping skills that may have developed as a result of their multiple minoritized identities. Additionally, psy­ chologists should be aware of additional protective factors that have been demonstrated to be helpful in decreasing the amount of psychological distress (e.g., collective action; DeBlaere et al., 2014). These pro­ tective factors can help clients build on their already existing coping strategies to strengthen resilience against stigma and discrimination that are based on their sexual, racial, and ethnic identities. Instructions

This exercise would best be used after the therapist has a conceptual understanding of the client’s sexualidentity development level and presenting concerns and has created a strong therapeutic relationship. This activity may range over a number of sessions depending on the clients and where they are in terms of readiness to take action steps. In terms of intro­ ducing the activity, it is important for the therapist to use everyday language to communicate psychoedu­ cation about the potential benefit of participating in collective action to thwart the negative psychological consequences of discriminatory experiences. First, it is important to use the Identity Prompts Worksheet to explore aspects of identity that are salient to the client. The prompts provided (which are not exhaustive) are important for therapists to use whether or not they engage further in the activity, as doing so gives them a nuanced understanding of their clients’ particular identities. The identity exploration may take place in the beginning sessions (e.g., session three or four, depending on the nature of the therapeutic alli­ ance) and may take an entire session or multiple ses­ sions, depending on the client and the content dis­ closed. As therapists learn more about their clients, their level of knowledge will inform the types of collec­ tive-action activities that may be suggested. It is important to emphasize that collective action can take different forms and can be shaped in ways 126 Bertsch

that align with an individual’s strengths, values, inter­ ests, and time constraints. It can be particularly help­ ful to explain to clients that participating in collec­ tive action can help people feel empowered by “doing something.” To assist clients in exploring and identi­ fying which type of collective action may align most with their strengths and interests, therapists may use the Homework Assignment (on page 130) for sug­ gested exploration questions that clients can think about and answer between sessions. Clients can com­ plete the assignment at home as they reflect on their answers, or they can complete it in session, depending on the wishes of the clients or therapists. In the explanation of the Homework Assignment, therapists should invite clients to think more in depth about their values and strengths and which collectiveaction activity may be the best fit. Additionally, depend­ ing on the clients’ preferences and strengths, thera­ pists may benefit from spending time between sessions finding local community organizations that support LGBQ persons of color and also researching upcom­ ing events. In the following session, therapists should invite clients to discuss their progress or lack thereof and process the experience of doing the homework— or what prevented them from exploring their inter­ ests. In this session, therapists may present the Collec­ tive-Action Activity sheet and work with clients to determine if one or more of the activities listed seem like an appropriate fit. Therapists should note to the clients that the list is not exhaustive and that clients are welcome to try other activities that are not listed. Brief Vignette

Kia identified as a twenty-one-year-old African Amer­ ican, cisgender, queer woman in her senior year at a four-year university. She said she had come out to her parents about a year before, and her mother continues to imply that “this is just a phase,” and her father “does not acknowledge that part of my life.” Kia said that before she came out, she had a close relationship with her parents and would go home often for family and church events, as she was always active in her family, church, and black community (the three often inter­ sected). After coming out, Kia reported visiting home less frequently and feeling like an outsider in her fam­ ily and in church. Kia noted that she has a girlfriend,

but her mother refers to Kia’s girlfriend as “her friend” and her father does not acknowledge her girlfriend “at all.” Kia said she has limited social support other than that from her girlfriend and often felt that she “didn’t fit in anywhere.” Kia reported that she knew of spaces on campus that might be “safe” and identified the women’s center, the LGBT center, and the Black Cultural Center, but she also acknowledged feeling that she could talk about only one identity that cor­ responded with that particular center, and when she attempted to talk about the intersection of her minori­ tized identities, the room often fell silent. It became clear that Kia began to internalize these reactions, as she perceived them to be invalidating and silencing. The therapist worked to create a strong thera­ peutic rapport that allowed Kia to share all her iden­ tities. It was during session three that Kia and her therapist were able to explore Kia’s multiple identities in greater depth. Simultaneously, the therapist nor­ malized Kia’s experience. For example, the therapist commended and highlighted the coping skills Kia had developed as a way of dealing with feelings of rejection from her community (e.g., writing poetry) and empathized with the challenges she faced (e.g., isolation). Approximately five sessions into therapy, the therapist provided psychoeducation on collective action and how it may be helpful to find community with people with similar identities and experiences. The therapist explained that collective action can take many forms. Kia was invited to take home the Home­ work Assignment and either write in or reflect on activities that she found meaningful or fun (or both). In session six and after some discussion of Kia’s inter­ ests and strengths, the therapist presented Kia with the Collective-Action Activity sheet, which provides a number of examples of what collective action could look like. Working with Kia, the therapist identified several activities that could be beneficial. After some discussion, Kia decided to join the Queer Students Group, where she’d heard that there were other black and brown members. Additionally, Kia started read­ ing memoirs of black lesbians, which helped her feel empowered, validated, and less isolated in her expe­ riences. After a few months of therapy, she had formed a network of people on whom she could rely for sup­ port, and she did not feel the need to censor any of

her identities in these spaces. At the end of therapy, Kia still struggled with integration of her identities in terms of her family but felt more at ease with herself and her ability to cope with negative experiences. Suggestions for Follow-up

After the exercise has been completed, it is important for therapists to continually follow up in sessions on how collective-action activities are going between session meetings. Over time, clients may begin to see positive effects in collective-action engagement (e.g., stronger ability to cope with external experiences of discrimination, less isolation, increased social con­ nection). However, if the collective-action activities are not helpful, it is important that therapists be aware of this so they can work with clients to find out what may be hindering the benefits (e.g., lack of Internet access or transportation to meetings, conflict with work schedule) and to strategize other collective-action activities that may be easier to access or more reward­ ing. In addition, exploration of if and how clients’ involvement in collective-action activities changes their ability to cope over time with experiences of oppression is important. Contraindications for Use

The exercise may not be useful for those clients who are not developmentally ready to take action and are in the beginning stages of identity exploration. There­ fore, it is important to assess clients’ stage of identity development and their readiness for being involved with collective action. For instance, clients who are closeted and do not feel physically or emotionally safe to come out may not want to join a group in which they would feel pressure to out themselves. Further, clients who are questioning their sexual identity and would like more time to explore this in individual sessions may not want to engage in this type of collec­ tive action. In the cases of early stages of exploration or physical and safety concerns with coming out, it is recommended that therapists share resources (e.g., online resources, books) that clients can read on their own, as this activity would also be considered collective action. The clients’ presentation may shift over the course of therapy, in which case this exercise’s appro­ priateness can be reevaluated. Building Resilience with Clients Who Face Oppression 127

Professional Readings and Resources Bowleg, L., Craig, M. L., & Burkholder, G. (2004). Rising and surviving: A conceptual model of active coping among black lesbians. Cultural Diversity and Ethnic Minority Psychology, 10, 229–240. doi:10.1037/1099-9809.10.3.229. DeBlaere, C., & Bertsch, K. N. (2013). Perceived sexist events and psychological distress of sexual minority women of color: The moderating role of womanism. Psychology of Women Quarterly, 37, 167–178. doi:10.1177/03616843124 70436. Friedman, C., & Leaper, C. (2010). Sexual-minority college women’s experiences with discrimination: Relations with identity and collective action. Psychology of Women Quarterly, 34, 152–164. doi:10.1111/j.1471-6402.2010. 01558.x.

Resource for Clients Grant, S. J. (2016, November 11). A guide to QTPoC organi­ zations in the U.S. Huffington Post. https://www.huffing tonpost.com/entry/a-guide-to-queer-qtpoc-organizations­ in-the-us_us_5824b64ee4b0e89dd9ee7e8f.

References American Psychological Association (APA). (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. doi:10.1037/ a0024659. Berke, D. S., Maples-Keller, J. L., & Richards, P. (2016). LGBTQ perceptions of psychotherapy: A consensual qualitative analysis. Professional Psychology: Research and Practice, 47, 373–382. doi:10.1037/pro0000099.

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DeBlaere, C., Brewster, M. E., Bertsch, K., DeCarlo, A., Kegel, K., & Presseau, C. (2014). The protective power of collec­ tive action for sexual minority women of color: An inves­ tigation of multiple discrimination experiences and psy­ chological distress. Psychology of Women Quarterly, 38, 20–32. doi:10.1177/03616843-13493252. Dillon, F. R., Worthington, R. L., Soth-McNett, A. M., & Schwartz, S. J. (2008). Gender and sexual identity–based predictors of lesbian, gay, and bisexual affirmative coun­ seling self-efficacy. Professional Psychology: Research and Practice, 39, 353–360. doi:10.1037/0735-7028.39.3.353. Ghabrial, M. A. (2017). “Trying to figure out where we belong”: Narratives of racialized sexual minorities on community, identity, discrimination, and health. Sex Research Social Policy, 14, 42–55. doi:10.1007/s13178-016-0229-x. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129, 674–697. doi:10.1037/0033-2909.129.5.674. Szymanski, D. M., & Owens, G. P. (2009). Group-level coping as a moderator between heterosexism and sexism and psychological distress in sexual minority women. Psychol­ ogy of Women Quarterly, 33, 197–205. doi:10.1111/j.1471 -6402.2009.01489.x. Wright S. C., Taylor D. M., & Moghaddam, F. M. (1990). Responding to membership in a disadvantaged group: From acceptance to collective protest. Journal of Person­ ality and Social Psychology, 58, 994–1003. doi:10.1037/ 0022-3514.58.6.994.

IDENT IT Y P RO M P T S

WO RKS H EET

1. What identities feel most salient to you?

2. When did you first discover these identities?

3. What were your first messages about race, gender, and sexual orientation?

4. Was there anyone in particular who helped you in this process?

5. Who were your role models in helping you realize your multiple identities?

6. What types of messages in the media, family, and/or religion did you receive about your identities?

Examples: What did you hear about racial or ethnic minorities in the sexual minority community? What did you hear about sexual minorities in your racial or ethnic community? Which ideas about gender did you hear, and where did you hear them (racial or ethnic community, family, religious affiliation)?

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HOMEWORK ASSIGNMENT

1. What are your hobbies?

2. What do you like to do in your free time?

3. What are some of your skills (e.g., public speaking, writing)?

4. Do you like to work and play independently, or do you prefer working and playing in groups?

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COLLECTIVE-ACTION ACTIVITIES (Not an exhaustive list)

1. Join a listerv, discussion group, or Facebook group to read and share experiences of oppression and gain support. 2. Volunteer to call or write to local politicians on behalf of the client’s group(s). 3. Attend a local rally. 4. Attend a local poetry- or book-reading event that showcases the identities salient to the client. 5. Research different meet-up groups in the area (meetup.org); this can be helpful in finding others who are also looking for community. 6. Attend a Pride parade. (Caveat: because of the parades’ history of excluding voices of color, this activity may not be appropriate, as the mainstream LGBT community does not resonate with many individuals. If someone is interested in attending a Pride parade, it may be important to provide some psychoeducation and also be aware of your own community’s efforts, or lack thereof, to include communities of color in their Pride events.) 7. Read literature related to a client’s particular identities. 8. Attend conferences or local presentations. 9. Join a local support group (in person or online).

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15 BUILDING A STRONGER ADVOCACY ROLE FOR OLDER LGBT+ ADULTS IN NURSING HOME SETTINGS Angela Schubert Suggested Use: Activity Objective

The objectives of this activity are to (a) help LGBT+ clients examine their own assumptions and biases related to their minority status(es) and other social identities; (b) challenge internalized prejudice through curious intentionality and empathy; (c) explore the pros and cons of coming out in the nursing home; (d) educate older LGBT+ clients of their rights in the nursing home; and (e) assist LGBT+ clients to effec­ tively communicate and advocate for themselves and their personal needs when choosing a nursing home. Rationale for Use

Research suggests that residential experiences of older LGBT+ adults are often overwhelmingly negative (Stein, Beckerman, & Sherman, 2010). Although the federal 1987 Nursing Home Reform Act (2002; Resi­ dent Rights, 42 C.F.R. §483.10) explicitly requires nursing homes to protect and promote the lives of each resident, countless anecdotal claims of discrim­ ination, isolation, and abuse are reported by residents in nursing home facilities (Hovey, 2009; Pope, Wier­ zalis, Barret, & Rankins, 2007; Schubert, 2015; Stein, Beckerman, & Sherman, 2010). Older LGBT+ adults often face aging alone or with a different version of “family” and, therefore, may be afraid to approach the nursing home staff regarding personal needs related to their sexual orientation, sexual expression, gender identity, and/or gender expression (Hovey, 2009; Schubert, 2015; Stein, Beckerman, & Sherman, 2010). Relentless homophobic attitudes continue to discour­

age the LGBT+ older adult population from coming out in the nursing home (Hunter, 2007), and this response is further complicated when LGBT+ older adults negatively internalize their own sexual orien­ tation and/or gender. Counselors have a unique opportunity to support their older clients through the process of coming out in the nursing home. Because of the possibly sensitive and complex nature of the presenting issues, counselors would benefit from a the­ ory that offers an affirming, exploratory approach to a client’s social identities. An understanding of how those identities affect the experience of coming out is essential for client growth and counselor advocacy (Singh & Moss, 2016). Relational cultural theory (RCT) is an ideal approach for the very reason that it is founded in the context of mutual understanding, empathy, and radi­ cal respect (Comstock et al., 2008). Using a contextual approach, RCT emphasizes connectedness, emotional well-being, and improving the “adverse impact of various forms of cultural oppression, marginalization, and social injustice” (Comstock et al., 2008, p. 280). These specific activities are inspired by RCT, the aim being to transform a client’s perspective from a place of self-exploration and reflection to a state of con­ nection, action, and advocacy (Singh & Moss, 2016). As clients explore their comfort and safety in address­ ing their sexual orientation and gender identity to themselves and, later, to the nursing home facility, cli­ ents may become better at advocating for themselves and their basic human needs. The use of intersectionality theory in practice cre­ ates the opportunity to discuss the relationship among

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aging, sexuality, and gender (Krekula, 2007). Lesbians and gay men of different age cohorts have experienced varying levels of exposure to social changes that have, in turn, influenced personal awareness of and attitudes about sexual orientation. This activity engages the client and counselor in a dialogue about what it means to be an older adult who identifies as LGBT+, and how sexual and gender identification are influenced by the client’s age and other intersecting identities. As a result, affirming and empowering the client’s inter­ secting identities, including nontraditional gender and sexual identities, can decrease possible shame, fear, isolation, and secrecy (Hall, Barden, & Conley, 2014). Affirmative practice includes addressing and explor­ ing several American Counseling Association (ACA) (2014) and American Psychological Association (APA) (2012) codes and guidelines related to client’s rights and readiness to explore topics related to stigma surrounding contextual factors regarding intersecting identities. Most important, it is therapeutically effi­ cacious and ethically competent to understand that the multilayered process is not the same for all LGBT+ individuals, and therapists therefore require a thor­ ough exploration of what it means to come out for each LGBT+ client (Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC], 2009, A.18, A.19). Ethically competent clinicians are charged with respecting the client’s rights (ACA, 2014, B.1.a; ALG­ BTIC, 2009, A.13) and helping identify any personal safety concerns related to disclosing orientation and gender identity to the nursing home. To strengthen ethically affirming therapeutic practice, the ACA established the ALGBTIC Competencies Taskforce (ALGBTIC, 2009) to identify, examine, and approach the intersecting identities of clinicians and clients in order to better understand power, privilege, and ther­ apeutic development. In these guidelines, contextual factors related to intersecting identities associated with LGBT+ individuals include important and crit­ ically unique reasons to refrain from sharing their orientation with others, or not, across the life span (ALGBTIC, 2009, A.13, A.14). Individuals who identify as LGBT+ experience oppression both systemically and interpersonally as a result of heterosexism (Singh & Moss, 2016), discrim­

ination (Mereish & Poteat, 2015), sexism (Singh & Moss, 2016), ageism (Schubert, 2015), internalized heterosexism (Kashubeck-West, Szymanski, & Meyer, 2008), transphobia (Ward, Sutherland, & Rivers, 2012), and racism (Balsam et al., 2011; Szymanski & Gupta, 2009). Such layered experiences of oppression mag­ nify stigma and increase risk of mental health issues for LGBT+ individuals (Mereish & Poteat, 2015; Singh & Moss, 2016). To challenge the negative conversa­ tions presented to and/or internalized by the LGBT+ older adult, the RCT approach emphasizes relation­ ships and contextual factors associated with the inter­ secting identities and experiences of the person (Hall, Barden, & Conley, 2014). The APA guidelines address the ways in which cli­ nicians may assist LGB needs from the client’s per­ spective. These guidelines include the obligation of ethically competent clinicians to identify and examine the effect of contextual factors or intersecting identi­ ties that may increase social stigma when LGB individ­ uals come out (APA, 2012). Similarly, as part of the therapeutic process, the ACA ALGBTIC Competencies Taskforce advises clinicians to incorporate comingout identity models of development as a means to val­ idate the multicontextual identity of clients, and to assist the client with the development of an integrated sense of self as a result (ALGBTIC, 2009, A.16, A.17). Instructions

In this activity, the counselor and client engage in a collaborative four-step intervention consisting of (a) a reflection of lived social identities (see “Examining Intersectionality: A Self-Reflection Survey,” on page 138); (b) an exploration of perceived beliefs and knowledge of nursing homes (see the same survey); (c) an identification of any personal safety concerns related to coming out to the nursing home; and (d) an engagement in self-advocacy through experiential role-playing with the counselor (see “Nursing Home Affirming Policies and Practices Questionnaire,” on page 139). One way to protect LGBT+ older adults from negative experiences is to educate them (and their families) on specific questions to ask when select­ ing a nursing home. Clients may use this question­ naire to inquire about specific policies and practices at potential nursing homes. Clients are tasked with Building a Stronger Advocacy Role for Older LGBT+ Adults 133

identifying their own fears or hesitations regarding the nursing home experience. More specifically, with the assistance of counselors, clients will write out their perceived beliefs and knowledge of nursing homes and identify any personal safety concerns related to coming out to the nursing home. Simply put, the counselor helps clients make a list of pros and cons of relocating to a nursing home. Once the list is made, clients are asked to identify their rights as a nursing home resident with the counselor. The counselor can assist them with identifying a local ombudsman to assist in answering questions related to nursing home resident rights. Note that this process requires counselors to first identify and explore their own individual prejudices and biases regarding sexual orientation, gender, abil­ ities, and ageism, and to understand the ways in which minority social identities are oppressed and discrimi­ nated against in society (Corey & Corey, 2016). By consciously addressing personal prejudices in a pro­ active way, clinicians are better able to assist their LGBT+ clients in examining their own assumptions and biases related to their minority status(es) and other social identities (Bigner & Wetchler, 2012).

man living under someone else’s roof. He discloses his coming-out story and what it meant for him to be a man who was gay, biracial, alone, and in need of others’ help. He explores his own internalized hetero­ sexism, his disconnect with others in previous social circles, and his fears of coming out to staff at the nursing home; he also reveals his trepidation about disclosing at all. With much chagrin, he comes to the conclusion that he does not desire to spend his life hiding anymore. During the next session, Bernard is able to witness his own strength in response to the reflective ques­ tioning. He addresses his need to feel connected to others. He then explores what he needs in order to feel connected to others at the nursing home. He recog­ nizes he has some concerns for his personal safety and seeks advice on how to select an LGBT+-affirming nursing home. The counselor then explores Bernard’s comfort by role-playing the interview between him and a hypothetical nursing home. Bernard has diffi­ culty at first with the questioning and wonders how he would handle the conversation. After several roleplays, Bernard identifies his own adaptation of the questions and requests the counselor be present during the call.

Brief Vignette

Bernard is a seventy-five-year-old biracial, cisgender male of African American and Puerto Rican descent. Bernard recently fell at his apartment. His partner of twenty years, Rodrigo, passed away last year and Bernard has lived alone ever since. Bernard sought counseling eight months after Rodrigo died to address his grief and loneliness. The hospital staff wanted him to temporarily relocate to a nursing home because of his need to use a wheelchair, but Bernard refused. Since leaving the hospital, it has become more diffi­ cult for him to move around his apartment. It is not wheelchair accessible, and the amount of energy he uses to move from one room to another exhausts him. Still, he is able to use not-for-profit rural bus trans­ portation to attend counseling sessions. Bernard anx­ iously addresses the possibility of relocating to an assisted-living facility permanently. Using “Examining Intersectionality: A Self-Reflection Survey” (p. 138), Bernard spends the rest of the time in session exam­ ining his own fears of what it means to be a gay, biracial 134 Schubert

Suggestions for Follow-up

The reflective process of exploring interpersonal rela­ tionships, connectedness, and disconnectedness can be quite challenging for both the client and the coun­ selor. Clients may initially experience some discom­ fort and hesitation as they examine the social systems they navigate. According to McCauley (2013), the most effective RCT approach requires a conscious effort to address the originating system of resistance. This process involves naming the problem by thera­ peutically shifting the conversation from verbalizing grievances to making a conscious choice to move toward a system that promotes relational values (McCauley, 2013). The process by which a system of resistance is identified may be strengthened through continued reflective questioning related to connection. It would be beneficial to follow up with clients to explore to what degree their conceptualization of con­ nection and disconnection has changed. As a result of identifying a system of resilience, the client may

identify a supportive community that can assist in resisting oppressive forces and disconnection. Contraindications for Use

RCT emphasizes the importance of establishing ther­ apeutic rapport as a means to cultivate a deeper under­ standing of the client’s connection to self and others (McCauley, 2013). One way to establish rapport is to engage clients in discourse regarding their worldview through culturally relevant questioning. Bernard communicated several identities but identified his role as a man as his primary identification. This identifi­ cation influenced his conceptualization of his other identities, including his second identification as a gay man. Clients may not consider sexual orientation as the central issue with regard to their needs in the nurs­ ing home. A thorough conversation is therefore nec­ essary between client and clinician before engaging in advocacy. More important, careful inspection of the client’s social identities will assist the clinician in understand­ ing how such identities may affect the experience of coming out in the nursing home. RCT’s contextual nature offers this very opportunity. For example, con­ sider Bernard’s racial and ethnic identities—African American and Puerto Rican descent. Both African American and Latino communities tend to hold strong views toward family, religion, and heritage (Lemelle, 2010). As a result, minority sexual orientation within these communities may be considered a sin (Lemelle, 2010), and disclosure of LGBT+ orientation can be viewed as an act against the family and the heritage (Trahan & Goodrich, 2015). Regardless of the known homophobia and heterosexism in both communi­ ties, individuals who identify as LGBT+ may choose silence about their sexual orientation for the sake of their families and their heritage (Lemelle, 2010; Tra­ han & Goodrich, 2015). Although Bernard did not specifically address his biracial identity as a primary identity, his racial and ethnic heritage must be taken into consideration. Another intersectional layer may include gener­ ational differences in attitude toward coming out and age. Internalized ageism is psychologically inter­ twined with one’s sense of self-worth and core iden­ tity as a human (Schubert, 2015): “Lesbians and gay

men of different age cohorts have experienced varying levels of exposure to these social changes that have, in turn, influenced personal awareness of and attitudes about sexual orientation” (Parks, Hughes, & Matthews, 2004, p. 243). Although humans are sexual beings, society often dismisses the sexual desires and needs of the older adult population, and older adults are not exempt from thinking of aging sexuality in this way. As a result, older LGBT+ adults may not give their sexual orientation or their identity as a sexual being high priority and may dismiss their own feelings and desires altogether. Counselors would benefit from exploring whether publicly addressing the sexual orientation of their clients is a concern. Counselors might need to first work with clients to explore their internalized ageism before clients consider coming out to a nursing home. Professional Readings and Resources Brick, P., Lunquist, J., Sandak, A., & Planned Parenthood of Greater Northern New Jersey. (2009). Older, wiser, sexually smarter: 30 sex ed lessons for adults only. Morristown, NJ: Planned Parenthood of Greater Northern New Jersey. Day-Vines, N. L., Wood, S. M., Grothaus, T., Craigen, L., Hol­ man, A., & Dotson-Blake, K. (2007). Broaching the sub­ jects of race, ethnicity, and culture during the counseling process. Journal of Counseling and Development, 85 (4), 401–409. doi:10.1002/j.1556-6678.2007.tb00608.x. Fox, R. C. (2007). Gay grows up: An interpretive study on aging metaphors and queer identity. Journal of Homosexuality, 52 (3–4), 33–61. Frank, D. A., & Cannon, E. P. (2010). Queer theory as pedagogy in counselor education: A framework for diversity training. Journal of LGBT Issues in Counseling, 4 (1), 18–31. Hall, K. G., Barden, S., & Conley, A. (2014). A relational-cul­ tural framework: Emphasizing relational dynamics and multicultural skill development. Professional Counselor, 4 (1), 71–83. Hill, R. J. (2004). Activism as practice: Some queer consider­ ations. New Directions for Adult and Continuing Educa­ tion, 102, 85–94. Misawa, M. (2010). Queer race pedagogy for educators in higher education: Dealing with power dynamics and positionality of LGBTQ students of color. International Journal of Critical Pedagogy, 3 (1), 26–35. Stone, C. B. (2003). Counselors as advocates for gay, lesbian, and bisexual youth: A call for equity and action. Journal of Multicultural Counseling and Development, 31 (2), 43–155.

Resources for Clients

Building a Stronger Advocacy Role for Older LGBT+ Adults 135

Adult Protective Services (APS). To locate APS services in your area, visit www.napsa-now.org/get-help/help-in-your­ area/. Lambda Legal Help Desk. Discrimination against a nursing home resident who identifies as LGBT+ is illegal. Contact for information and lawyer referrals: 1-866-542-8336 or https://www.lambdalegal.org. Long-term care ombudsman (LTCO). For information about the ombudsman program and to locate your LTCO pro­ gram, visit https://www.ltcombudsman.org/about/about­ ombudsman. National Resource Center on LGBT Aging. Locate a variety of resources related to long-term care services at www. lgbtagingcenter.org/resources/resources.cfm?s=15.

References American Counseling Association (ACA). (2014). ACA Code of Ethics. Alexandria, VA: Author. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for counseling with transgender clients. Alexandria, VA: Author. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2012). ALGBTIC competen­ cies for counseling with lesbian, gay, bisexual, transgender, queer, questioning, intersex, and ally individuals. https:// www.counseling.org/docs/ethics/algbtic-2012-07.pdf? sfvrsn=2. Balsam, K. F., Molina, Y., Beadnell, B., Simoni, J., & Walters, K. (2011). Measuring multiple minority stress: The LGBT People of Color Microaggressions Scale. Cultural Diversity and Ethnic Minority Psychology, 17 (2), 163–174. doi:10. 1037/a0023244. Bigner, J. J., & Wetchler, J. L. (2012). Handbook of LGBT- affir­ mative couple and family therapy. New York: Routledge. Comstock, D. L., Hammer, T. R., Strentzch, J., Cannon, K., Parsons, J., & Salazar, G., II. (2008). Relational-cultural theory: A framework for bridging relational, multicultural, and social justice competencies. Journal of Counseling & Development, 86 (3), 279–287. Corey, M. S., & Corey, G. (2016). Becoming a helper. Belmont, CA: Brooks/Cole, Cengage Learning. Grzanka, P. R., & Miles, J. R. (2016). The problem with the phrase “intersecting identities”: LGBT affirmative therapy, intersectionality, and neoliberalism. Sexuality Research and Social Policy, 13 (4), 371–389. doi:10.1007/s13178­ 016-0240-2.

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Hall, K. G., Barden, S., & Conley, A. (2014). A relational-cul­ tural framework: Emphasizing relational dynamics and multicultural skill development. Professional Counselor, 4 (1), 71–83. Hovey, J. E. (2009). Nursing wounds: Why LGBT elders need protection from discrimination and abuse based on sex­ ual orientation and gender identity. Elder Law Journal, 17 (1), 95. Hunter, S. (2007). Coming out and disclosure: LGBT persons across the lifespan. Binghamton, NY: Haworth Press. Kashubeck-West, S., Szymanski, D., & Meyer, J. (2008). Inter­ nalized heterosexism: Clinical implications and training considerations. Counseling Psychologist, 36 (4), 615–630. doi:10.1177/0011000007309634. Krekula, C. (2007). The intersection of age and gender: Rework­ ing gender theory and social gerontology. Current Sociol­ ogy, 55 (2), 155–171. doi: 0.1177/0011392107073299. Lemelle, A. J. (2010). Black masculinity and sexual politics. New York: Routledge. McCauley, M. (2013, March). Relational-cultural theory: Fostering healthy coexistence through a relational lens. In G. Burgess & H. Burgess (eds.), Beyond intractability. Boulder: Conflict Information Consortium, University of Colorado, Boulder. https://www.beyondintractability. org/essay/relational-cultural-theory. Mereish, E. H., & Poteat, V. P. (2015). A relational model of sexual minority mental and physical health: The negative effects of shame on relationships, loneliness, and health. Journal of Counseling Psychology, 62 (3), 425–437. doi: 10.1037/cou0000088. Montagu, A. (1986). Touching: The human significance of the skin, 3rd edition. New York: Harper & Row. Muzacz, A. K., & Akinsulure-Smith, A. M. (2013). Older adults and sexuality: Implications for counseling ethnic and sexual minority clients. Journal of Mental Health Counseling, 35 (1), 1–14. doi:10.17744/mehc.35.1.534385 v3r0876235. Parks, C. A., Hughes, T. L., & Matthews, A. K. (2004). Race/ ethnicity and sexual orientation: Intersecting identities. Cultural Diversity and Ethnic Minority Psychology, 10, 241–254. Pope, M., Wierzalis, E. A., Barret, B., & Rankins, M. (2007). Sexual and intimacy issues for aging gay men. Adultspan Journal, 6 (2), 68–82. doi:10.1002/j.2161-0029.2007. tb00033.x. Resident Rights. (1987). Nursing Home Reform Act of 1987, 42 C.F.R. §483.10, Omnibus Budget Reconciliation Act. Schubert, A. M. (2015). Attitudes toward aging sexual expres­ sion in nursing homes: An exploration of the older adult resident phenomenon. PhD diss., University of Missouri– Saint Louis.

Singh, A. A., & Moss, L. (2016). Using relational-cultural theory in LGBTQQ counseling: Addressing heterosexism and enhancing relational competencies. Journal of Coun­ seling and Development, 94 (4), 398–404. doi:10.1002/ jcad.12098. Stein, G. L., Beckerman, N. L., & Sherman, P. A. (2010). Les­ bian and gay elders and long-term care: Identifying the unique psychosocial perspectives and challenges. Jour­ nal of Gerontological Social Work, 53 (5), 421–435. doi:10 .1080/01634372.2010.496478. Szymanski, D. M., & Gupta, A. (2009). Examining the rela­ tionship between multiple internalized oppressions and

African American lesbian, gay, bisexual, and questioning persons’ self-esteem and psychological distress: Correction. Journal of Counseling Psychology, 56 (2), 300. doi:10.103 7/a0015407. Trahan, D. P., Jr., & Goodrich, K. M. (2015, March). You think you know me, but you have no idea. Family Journal, 23 (2), 147–157. doi:10.1177/1066480715573423. Ward, R., Sutherland, M., & Rivers, I. (2012). Lesbian, gay, bisexual, and transgender ageing: Biographical approaches for inclusive care and support. London: Jessica Kingsley.

Building a Stronger Advocacy Role for Older LGBT+ Adults 137

E XAM INING INT ERS ECT IO NA L IT Y:

A SEL F-REF L ECT IO N S URVEY

Neurologically, humans are wired to connect in meaningful ways, and social structures can either foster healthy relational development and growth or oppress socialized relationships and identities. To better understand when and how your problems occurred within the social framework, identify the source of your pain. 1. Describe your coming-out process across your life span.

2. How was your coming-out process received by others?

3. How did you experience your coming-out process?

4. What is your understanding of what it means to be a man or a woman? To be a man or woman of color?

5. What is your understanding of what it means to be a man or woman and in need of others’ support?

6. What has been your experience asking others for support?

7. What does connection mean to you in relation to your desire to connect with others and for those to connect with you?

8. Describe your social relationships. What has allowed you to remain connected with them? If not, what has gotten in the way of staying connected?

9. What are your concerns regarding the nursing home and nursing home staff?

10. How important is it to disclose your sexual orientation and/or gender expression to the nursing home?

11. What do you feel you need in order to feel safe at the nursing home?

138

Angela Schubert

N U RSIN G HO M E A F F IRM ING P O L ICIES A ND

P RACT ICES Q UES T IO NNA IRE

1. Which policies are in place to honor and protect privacy of the residents?

2. Does your nursing home explicitly address nondiscrimination policies related to LGBT+ identity and gender expression?

3. How are staff members trained to address nontraditional gender identities and LGBT+ orientations?

4. Are any staff currently employed openly LGBT+?

5. Does the nursing home currently care for LGBT+ residents?

6. Are residents expected to seek out assistance related to privacy for intimacy issues related to gender expression?

7. Is there an LGBT+ resident advocate on staff?

8. Which policies are in place to honor same-sex couples and gender-variant partners?

9. Are there any community events held to celebrate LGBT+ persons or issues?

10. Are same-sex couples allowed to live in the same room?

11. Does the nursing home support nonbiological families in its policies?

12. Are same-sex partners honored as medical powers of attorney?

13. How is gender and sexual inclusivity marketed in this nursing home?

Angela Schubert

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16 A TOOLKIT FOR COLLABORATIVE SAFETY AND TREATMENT PLANNING WITH TRANSGENDER YOUTH OF COLOR Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz Suggested Use: Collaborative activity Objective

The objective is to create an Inclusive Safety Plan of Care (ISPOC) for transgender youth of color. This tool­ kit was developed to assist clients and therapists in cocreating a plan to bring together concerns, ideas, strengths, and members of support to help transgen­ der youth of color meet their basic needs and achieve their goals. Note that this activity can be generalized for use with clients who hold a variety of marginalized identities. Rationale for Use

Transgender (including transsexual, gender-variant, genderqueer, genderfluid, agender, Two-Spirit, and gender-nonconforming) youth of color face stigma related both to race or ethnicity and gender identity. The rejection, harassment, and violence they experi­ ence are significantly more severe than those experi­ enced by their lesbian, gay, and bisexual counterparts (Norton & Herek, 2013). Surviving racial or ethnic discrimination requires strong connections to family and ethnic community. However, transgender youth of color seldom receive the support of their larger com­ munity regarding their transgender identity (Ryan, 2009). Unlike racial stereotypes that a family or ethnic community positively reframes, many communities reject a child’s gender nonconformity, unwittingly reinforcing negative cultural perceptions regarding gender identity (Ryan, Russell, Huebner, & Diaz,

2010). Stigma places these young people at greater risk for homelessness, substance use, violence, suicidal ideation, and risky sexual behaviors at a rate twentyfive times higher than that for the general population (Grant et al., 2011). Transgender youth face safety challenges where gender-conforming (or congruent) youth frequently do not; contexts such as home, school, communities, foster care, and juvenile justice systems are often the backdrop for bullying and victimization. Disrespect for their identity or punishment for iden­ tity expression can result in denial of public restrooms, exclusion from activities, disproportionate discipline, and ongoing marginalization. Additional consequences of harassment and discrimination include depres­ sion, substance abuse, suicide, and being the victim of hate crimes (Ryan et al., 2010). Thus, safety is a critical element in treatment planning with this population. An unfortunate result in the clinical environment is that youth’s identities, rather than their presenting problems or safety concerns, become the focus of intervention (Lev, 2004). Additional barriers to safety for transgender youth of color include the sex-segregated nature of many residential services (homeless shelters, substance abuse treatment centers, group homes) and a dearth of pro­ viders of gender-affirming medical services, as well as inconsistent insurance coverage for such services (Lyons et al., 2015). In the face of institutional dis­ crimination and systemic oppression, family support may serve as a protective factor against the multitude of threats to safety and well-being (Bockting, 2014;

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Grant et al., 2011). This ISPOC facilitates practitioners’ and family members’ support for the safety and wellbeing of transgender clients without pathologizing their identities. Although there is minimal material regarding eth­ ical and affirming clinical practice with transgender youth, a small body of work has begun to emerge (Bernal & Coolhart, 2012). If a youth has disclosed a gender identity to family members, and family has been mildly to moderately rejecting, use of the Family Acceptance Project model may be appropriate (Ryan, Huebner, Diaz, & Sanchez, 2009; Ryan et al., 2010; Snapp et al., 2015). The Family Acceptance Project is congruent with the ISPOC framework in that it pro­ vides an opportunity for dialogue and psychoeducation with parents or other caretakers regarding rejecting parental behaviors (blaming, shaming, excluding, name-calling) and accepting parental behaviors (requiring respect, supporting, advocating, expressing affection), the latter being positively correlated with healthy outcomes, higher self-esteem, closer family relationships, and better overall health. This model is also appropriate for use with foster parents, an impor­ tant consideration given that LGBTQ youth of color are nearly twice as likely to be placed in foster care (Ryan, 2013). By acknowledging legitimate health challenges facing the transgender community, the ISPOC will affirm transgender mental and medical health care (e.g., hormone therapies, gender-confirmation surgery, safe and trans-positive general medical services) through the entire life span, not just during the initial assessment process or during transition. Using this plan affirms mental and medical health care by asking specific questions about current mental health status and medical care (i.e., both past and present history). The plan serves as a guide to support therapists, col­ laborating professionals, family members, and other involved persons to inquire about needs rather than making assumptions. As clinicians, it is our ethical responsibility to engage in practices that promote and demonstrate respect for differences, supporting the expansion of cultural knowledge and resources safe­ guarding the rights of and confirming equity for trans individuals (Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC],

2009). In addition, the ISPOC can be used to under­ stand the biological, familial, social, cultural, socio­ economic, and psychological factors that influence the course of development of transgender identities to expand choice and opportunity. Ethically speak­ ing, clinicians must be equipped to provide their clients with education and resources on gender experiences, gender expression, and sexuality (ALGBTIC, 2009). In using the ISPOC, clinicians must identify the gen­ der-normative assumptions present in current life­ span development theories and address these biases in assessment and counseling practices. It is ethically incumbent on the clinician when completing the ISPOC to understand how stigma and pressures to be gender conforming may affect personality develop­ ment even in the face of the resiliency and strengths of transgender individuals (ALGBTIC, 2009). Further, understanding how these factors influence decision making in regard to employment, housing, and health care is essential when constructing the ISPOC. Cli­ nicians must also understand how psychological dis­ orders manifest themselves in transgender clients. The ISPOC is designed to motivate clinicians to recognize the influence of other contextual factors and social determinants of health (race, education, ethnicity, religion and spirituality, socioeconomic sta­ tus, sexual orientation, role in the family, peer group, geographical region, and so on) that may be of impor­ tance to clinical treatment. Clinicians should be informed on the various ways of living consistently with one’s gender identity, which may or may not include physical or social gender transition, and how these options may affect transgender individuals throughout their treatment; these matters should be discussed when developing the ISPOC (Bernal & Coolhart, 2012). Ethically, clinicians must be aware of the sociopolitical influences that affect the lives of transgender individuals, and that stereotyping, dis­ crimination, and marginalization may shape the client’s treatment processes, self-esteem, self-concept, and willingness to access the resources identified on the ISPOC (Bernal & Coolhart, 2012). Finally, when clinicians are collaborating with clients in developing their ISPOC, they must be pro­ active in identifying additional barriers and challenges faced by transgender individuals (e.g., ethnic identity Treatment Planning with Transgender Youth of Color 141

and/or sexuality; anxiety and depression; suicidal ideation and behavior; nonsuicidal self-injury; sub­ stance abuse; academic failure; homelessness; inter­ nalized transphobia; STD/HIV infection; addiction). According to a survey conducted by Haas, Rodgers, and Herman (2014), suicide attempts are 50 percent higher among those who openly disclose they are transgender or gender nonconforming. In particular, 65 percent of the transgender population with a men­ tal health condition that substantially affects a major life activity reported attempting suicide. The research clearly reflects the fact that multiple marginalized identities increase risk for transgender youth. Transgender youth of color experience higher rates of homelessness, sexual violence, substance use or abuse, and mental health challenges than their white transgender youth counterparts (Bockting, 2014). Instructions

The therapist will collaborate with the client to create an ISPOC. It is recommended that the therapist sit with the client when creating this plan in a session. The therapist and client should work together over an average of four to six sessions to cocreate the plan. The duration of each session should be fifty to seventyfive minutes. The therapist should begin the session by discussing expectations and the purpose of the plan (i.e., to meet the client’s individual needs, to promote safety, and to support ongoing well-being). It is impor­ tant for both the therapist and the client to know that this plan is a working document that is meant to evolve and change over time to continue meeting the client’s needs. It is recommended that the therapist reassess the client every three months (or sooner, as needed) to ensure that the plan is relevant and up-to­ date. In addition, the therapist should consider the following points to guide the planning session: • Use language that is inclusive and nonpejorative with regard to sexual orientation and gender identity. • Focus on the client’s strengths, irrespective of gen­ der identity. • Address the needs of the whole person (i.e., inter­ secting identities). • Ask the client how they self-identify and use these terms and pronouns. 142 Ashley, Lipscomb, & Mountz

• The therapist and client should identify safer places, peers, and allies of support for times of need (e.g., shelters). • Assess youth disclosure to family and level of fam­ ily acceptance, engaging family where indicated and appropriate. • The therapist and client should identify kinship net­ works, mentors, sources of support, and permanency resources (those that promote long-term support) outside family of origin, where appropriate. • The therapist and client should identify safety pro­ tocols if the client is in the process of transitioning, referring to appropriate medical services where indicated (e.g., youth-serving clinics that provide gender-affirming treatments). • The therapist should work with the client regarding health insurance options for pursuing gender-affirm­ ing treatment (depending on jurisdiction, public insurance may or may not cover treatment). • The therapist should employ a harm-reduction approach to engaging youth in terms of current substance use and/or use of street hormones and participation in a street economy related to pro­ curing gender-affirming treatment (e.g., sex work). • The therapist should acknowledge, validate, and affirm the client’s intersectional values, attitudes, and beliefs. • The therapist and client should work together to identify triggers for suicidal ideation and risk factors. Brief Vignette

Shay is a seventeen-year-old African American transgender youth. She self-identifies as queer and uses the pronouns she, her, and hers. Shay shared with her therapist during the assessment that “things have hap­ pened” to her in her life. She also noted that when she turns eighteen she is going to another country to have a procedure done. Shay is currently homeless and is staying on the streets. She was kicked out of her devoutly Christian mother’s home when she was found wearing women’s clothing. Shay occasionally stays with her grandmother, who says, “I don’t agree with that spirit or why you choose to wear women’s clothing, but I love you and will pray for you. I just

want you to be safe.” When asked if she would be interested in staying in a shelter she replies, “Hell no! They’re all fucked up in the shelter and I don’t have time for their bullshit!” She tells her therapist, “I just want to be independent, have my own things, and not have everyone telling me how they want me to be all the time.” The therapist replies by validating Shay’s feelings of frustration and disappointment with past experi­ ences residing in a shelter. The therapist also affirms and praises Shay for wanting to be independent and self-sufficient. In addition, the therapist invites Shay to work in collaboration on a plan that would assist her in working toward her goals. The therapist says, “I would like to work with you on developing a plan that will increase your independence, based on your goals. You have shared with me some challenges you’ve experi­ enced based on your gender identity, so I would like to identify trans-affirming resources, services, and sup­ port to assist you with meeting your needs. Please keep in mind that this plan is a working document that can be changed or modified at any time to accommodate your day-to-day and future needs as they change. You are the one guiding this plan, and if something does not sound right or work for you, it can be changed. As your therapist, I am here to provide support, to offer assistance in locating trans-affirming resources, and to ensure that you are safe. What do you think about working with me to create this plan to help you reach your goals?” Shay appeares hesitant but agrees to work with her therapist to cocreate the plan. Once completed, the plan illuminates many of Shay’s strengths as well as multiple challenges that she may face in moving toward independence. Further, the plan provides a framework for Shay and her ther­ apist to collaboratively identify resources and services to mitigate some of the barriers she faces. The pro­ cess of completing the plan has allowed Shay and her therapist to engage in authentic dialogue about cul­ turally relevant concerns, which supports the therapeu­ tic relationship. Additionally, Shay’s senses of empow­ erment, motivation, and agency have increased. Suggestions for Follow-up

It is the therapist’s responsibility to continue to follow up and check in with the client regarding the appli­

cability of the current ISPOC. The therapist should continue to assess and collaborate on an ongoing basis with the client to ensure the plan is up-to-date in addressing the client’s needs. Contraindications for Use

The ISPOC is advisable for transgender youth of color, as well as many other populations; there are minimal contraindications for use. The most effective use of the ISPOC requires clients to be vulnerable in disclos­ ing their needs and desires; thus, a therapeutic rap­ port is critical. Practitioners should anticipate guarded presentations initially and be prepared to pace them­ selves in fully completing the document. In cases in which clients present with acute psychosis, severe depression, mania, traumatic brain injury, or eating disorders, consultation with a psychiatrist and/or med­ ical doctor should be included in the plan. In addi­ tion, if the therapist does not have any awareness of local resources before starting this plan, constructing this plan may be of less benefit to the client and family. Professional Readings and Resources Conron, K., Wilson, J., Cahill, S., Flaherty, J., Tamanaha, M., & Bradford, J. (2015, November). Our health matters: Mental health, risk, and resilience among LGBTQ youth of color who live, work, or play in Boston. Fenway Insti­ tute, Boston. https://fenwayhealth.org/wp-content/ uploads/our-health-matters.pdf. Dank, M., Yu, L., Yahner, J., Pelletier, E., Mora, M., & Conner, B. M. (2015, September). Locked in: Interactions with the criminal justice and child welfare systems for LGBTQ youth, YMSM, and YWSW who engage in survival sex. Urban Institute, Research Report. www.urban.org/sites/ default/files/publication/71446/2000424-Locked-In-In teractions-with-the-Criminal-Justice-and-Child-WelfareSystems-for-LGBTQ-Youth-YMSM-and-YWSW-Who­ Engage-in-Survival-Sex.pdf. Klein, A., & Golub, S. A. (2016). Family rejection as a predic­ tor of suicide attempts and substance misuse among transgender and gender nonconforming adults. LGBT Health, 3 (3), 193–199. Ryan, C. (2009). Helping families with lesbian, gay, bisexual and transgender (LGBT) children. San Francisco: Marian Wright Edelman Institute, Family Acceptance Project, San Francisco State University. http://nccc.georgetown. edu/documents/LGBT_Brief.pdf. Ryan, C., Russell, S. T., Huebner, D., & Diaz, R. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23 (4), 205–213. Treatment Planning with Transgender Youth of Color 143

Substance Abuse and Mental Health Services Administration. (2014). A practitioner’s resource guide: Helping families to support their LGBT children. HHS Publication No. PEP14­ LGBTKIDS. Rockville, MD: Substance Abuse and Mental Health Services Administration. Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., & Russell, S. T. (2010). Gender-nonconforming lesbian, gay, bisexual, and transgender youth: School victimization and youth adult psychosocial adjustment. Developmental Psychology, 46 (6), 1580–1589.

Resources for Clients Beemyn, G. (2014). Transgender history. In L. Erickson Schroth (ed.), Trans bodies, trans selves. New York: Oxford Uni­ versity Press. Fierce. Building the leadership & power of LGBTQ youth of color. http://fiercenyc.org/. Ryan, C., et al. (2009). Family Acceptance Project publica­ tions. http://familyproject.sfsu.edu/publications. Simmons, H., & White, F. (2014), Our many selves. In L. Erickson Schroth (ed.), Trans bodies, trans selves. New York: Oxford University Press. Trans bodies. A resource guide for the transgender commu­ nity. http://transbodies.com/. Trans lifeline: (877) 565-8860 Transsexual Road Map. Transsexual & transgender road map. http://www.tsroadmap.com/index.html. World Professional Association for Transgender Health. Standards of care. https://www.wpath.org/publications/ soc.

References Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for counseling with transgender clients. Alexandria, VA: Author. Bernal, A. T., & Coolhart, D. (2012). Treatment and ethical considerations with transgender children and youth in family therapy. Journal of Family Psychotherapy, 23 (4), 287–303. Bockting, W. (2014). The impact of stigma on transgender iden­ tity development and mental health. In B. P. C. Kruekels, T. D. Steensma, & A. L. C. de Vries (eds.), Gender dys­ phoria and disorders of sex development, 319–330. New York: Springer.

144 Ashley, Lipscomb, & Mountz

Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey, executive summary. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force. Haas, A., Rodgers, P., & Herman, J. (2014). Suicide attempts among transgender and gender non-conforming adults: Findings of the National Transgender Discrimination Survey. American Foundation for Suicide Prevention and Williams Institute, UCLA School of Law. https:// williamsinstitute.law.ucla.edu/wp-content/uploads/AFSP­ Williams-Suicide-Report-Final.pdf. Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. New York: Haworth Clinical Practice Press. Lyons, T., Shannon, K., Pierre, L., Small, W., Krüsi, A., & Kerr, T. (2015). A qualitative study of transgender individuals’ experiences in residential addiction treatment settings: Stigma and inclusivity. Substance Abuse Treatment, Pre­ vention, and Policy, 10, 17. http://doi.org/10.1186/s13011­ 015-0015-4. Norton, A. T., & Herek, G. M. (2013). Heterosexuals’ attitudes toward transgender people: Findings from a national probability sample of U.S. adults. Sex Roles: A Journal of Research, 68 (11), 738–753. Ryan, C. (2009). Helping families with lesbian, gay, bisexual, and transgender (LGBT) children. San Francisco: Marian Wright Edelman Institute, Family Acceptance Project, San Francisco State University. http://nccc.georgetown. edu/documents/LGBT_Brief.pdf. Ryan, C. (2013). Generating a revolution in prevention, well­ ness, and care for LGBT children and youth. Temple Polit­ ical and Civil Rights Law Review, 23, 331. Ryan, C., Huebner, D., Diaz, R. M., & Sanchez, J. (2009). Fam­ ily rejection as a predictor of negative health outcomes in white and Latino lesbian, gay, and bisexual young adults. Pediatrics, 123 (1), 346–352. Ryan, C., Russell, S. T., Huebner, D., & Diaz, R. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23 (4), 205–213. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low-cost strategies for positive adjustment. Family Rela­ tions, 64 (3), 420–430.

INCLUSIVE SAFET Y PL AN OF CARE (ISPOC) Name of client: Pronouns used: Additional previously used names: Date of birth: Date of plan: Phase of treatment Assessment Treatment planning/middle phase Termination Crisis Other Permanency plan/long-term goal (written in client’s own words):

Team members involved in developing, creating, building, and supporting this plan: Name

Relationship

Phone number

Available 24/7?

1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

145

Client strengths and needs (considering trauma)—check as many as apply: Safety Suicide

Homicide

Abuse (child or elder)

Substance use/abuse

Domestic violence

Grave disability

Notes: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Family School/education Work/vocational Social Sex work Money Emotional Behavioral Mentorship

Health/medical Cultural Fun/recreational Spiritual Legal Street hormones/ hormones Housing Mental health Insurance

Notes: ______________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________ Family strengths and needs—check as many as apply: Safety

Family

School/educational

Work/vocational

Social

Sex work

Money

Emotional

Behavioral

Mentorship

Health/medical

Cultural

Fun/recreational

Spiritual

Legal

Street hormones/ hormones

Housing

Mental health

Insurance

Notes: _____________________________________________________________________________________________ _____________________________________________________________________________________________ _____________________________________________________________________________________________

146

Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

SHORT- AND LONG-TERM RESOURCES

1.

2.

3.

4.

5.

6.

Name

Phone Number Location Hours Service

COURT/LEGAL CONSIDERATIONS

Need

Strengths

Strategy(ies)

Person Responsible

Cost/Resource

Other

1.

2.

3.

4.

5.

Plan Progress: The team will revisit this plan two weeks after its creation. Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

147

INCLUSIVE SAFET Y PL AN AGREEMENT We, the Inclusive Safety Plan members, agree to the planning, implementation, and success of this plan. Together we will work with (client name)____________________________ to meet (pronoun)_____________ goals and vision.

Vision statement:

Name

Signature

Date Signed

Copy Received? n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No n Yes n No

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Wendy Ashley, Allen Eugene Lipscomb, and Sarah Mountz

17 HEALING FROM HETEROSEXISM: AN EMPIRICALLY BASED EXERCISE FOR PROCESSING HETEROSEXIST EXPERIENCES Kathleen M. Collins, Meredith R. Maroney, Tangela S. Roberts, Brianna M. Wadler, and Heidi M. Levitt Suggested Use: Homework Objective

This activity entails an expressive writing exercise intended to help clients process experiences of hetero­ sexism that they have had. Objectives of the exercise include permitting clients (1) to focus on these expe­ riences in order to more fully process their effects or regulate emotions connected to them; (2) to develop insights about themselves, interpersonal dynamics, or societal systems that contributed to heterosexist events; and (3) to develop strategies for coping with these events, relationships, or systems. This exercise is appropriate for lesbian, gay, bisexual, queer-identi­ fied, and other nonheterosexual (LGBQ) clients as well as transgender clients who identify as LGBQ. Rationale for Use

Heterosexism refers to the pervasive attitude in West­ ern culture concerning the superiority of heterosexual orientations, relationships, and behaviors, and the resulting systemic oppression of all nonheterosexual identities (Herek, 2004). Heterosexism is a nuanced concept that can be understood in relation to, and is often used interchangeably with, related terms such as homophobia, homonegativity, and heteronormativ­ ity (Russell & Bohan, 2007). However, heterosexism does not imply only an aversion to homosexuality; it also describes how society tacitly and repeatedly com­ municates the message that heterosexual orientations

and behaviors are superior to any nonheterosexual orientations and behaviors. Heterosexism is perpetuated through both indi­ vidual factors, such as attitudes and behaviors, and systemic factors, such as policies and actions that dis­ criminate against nonheterosexuals (Meyer, 2003). These factors create stressors for LGBTQ people that range from distal, such as stressful events and hypervigilance stemming from expectation of such events, to proximal, including internalization of heterosexist attitudes that cause individual psychological distress (Herek, 2017; Meyer, 2003). Heterosexism is trans­ mitted not only through overt acts of discrimination, such as acts of violence or the lack of equal civil rights; subtle microaggressive acts and comments that endorse heterosexism can be just as harmful because of their insidious nature (Nadal et al., 2011). Because these communications are often implicit and routine, the stress caused by them may accumulate slowly without prompting the same self-protective responses that other stressors might (e.g., Herek, 2004; Russell & Bohan, 2007). Expressive writing is an intervention aimed at helping people cope with difficult emotions or situa­ tions through personal disclosure. In this interven­ tion, people typically write about their thoughts and feelings regarding traumatic or challenging experi­ ences. The original paradigm (Pennebaker & Beall, 1986) has been used with various populations and methodological adaptations. A meta-analysis of 146

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

150

expressive writing studies, examining how these exer­ cises influence traumatic experiences, found that they demonstrate positive effects (Frattaroli, 2006), with an average effect size of r = .075. Completing at least three sessions that last at least fifteen minutes each was found to yield larger effect sizes in psychological health, physical health, and subjective effect, as well as a positive overall effect size (r = .08), compared to adaptations with shorter or fewer writing sessions. These documented psychological benefits are especially promising considering the low-cost (inexpensive, lowrisk) nature of engaging in expressive writing. Expressive writing exercises have been used to help people process a variety of psychological issues, including depression (Baikie, Geerligs, & Wilhelm, 2011), trauma (Smyth, Hockemeyer, & Tulloch, 2008), and life transitions (Booker & Dunsmore, 2017). Expressive writing also has been used to address minority-specific issues and their psychological cor­ relates, including internalized racism (Kaufka, 2009), trauma-related distress in Hispanic individuals (Hirai, Skidmore, Clum, & Dolma, 2012), gay-related stress in men (Pachankis & Goldfried, 2010) and women (Lewis et al., 2005), and coping with hate speech (Crowley, 2014). These studies indicate that expressive writing appears to be effective for LGBQ clients, and they suggest that it also may be helpful for LGBQ cli­ ents who also hold other oppressed identities, although none of these studies directly focused on intersec­ tional identities. These exercises have reliably led to psychological improvement, as measured by scales assessing depres­ sion (Henry et al., 2010), anxiety (Hirai et al., 2012), positive and negative affect (Pachankis & Goldfried, 2010), self-esteem (Pennebaker, Colder, & Sharp, 1990), and avoidance behaviors (Swanbon, Boyce, & Greenberg, 2008), as well as reduced physiological measures (e.g., cortisol in response to traumatic mem­ ories; Smyth et al., 2008). Studies testing the effective­ ness of expressive writing typically use a pen-and­ paper method, but online formats are also effective in yielding positive psychological change (Baikie et al., 2011; Lange et al., 2000). The exercise being presented here is in the process of being developed as part of an empirical assessment of a set of expressive writing exercises for LGBTQ

clients. Preliminary research (Collins et al., 2017) has shown that LGBTQ individuals who completed the expressive writing exercise described in this chapter, or either of two additional online exercises, experi­ enced a reduction in negative affect, symptoms of depression, and subjective distress caused by hetero­ sexist events. The term heterosexist events in this exer­ cise includes discrimination, harassment, microag­ gressions, and violence toward LGBTQ clients because of their sexual orientations or beliefs about their sex­ ual orientations. These reductions in psychological distress were seen immediately after completing the exercise as well as at a two-month follow-up. Partici­ pants also experienced subjective benefits in addi­ tion to the empirical reductions in psychological dis­ tress; just over 90 percent of participants reported that the exercises helped them make progress in dealing with their heterosexist event. LGBTQ participants who engaged in these expres­ sive writing exercises in the context of the online study also were asked to reflect on their participation and growth. Participants identified multiple aspects of the exercises that were helpful to them (Maroney, Levitt, Roberts, & Wadler, 2016). For instance, some participants noted that the structured parts of the study—such as the guided questions, revisiting the heterosexist event on three days, and time guidelines— were helpful for them, whereas others reported that these exercises promoted internal reflection by desig­ nating a space for them to better understand their experiences by putting their thoughts and feelings into words. Other gains that participants noted included an increased awareness of their emotions, new per­ spectives and understanding of the event, and more action-oriented changes, such as bringing new reali­ zations to therapy or recognizing future goals. This exercise can be used to support therapists in providing responsive treatments tailored to LGBTQ clients. Ethically, therapists should have the compe­ tence and awareness to provide affirming care to LGBTQ clients (American Psychological Association [APA], 2010, 2012, 2015). The first of the Guidelines for Practice with Lesbian, Gay, and Bisexual Clients (APA, 2012, p. 12) specifically states, “Psychologists strive to understand the effects of stigma (i.e., preju­ dice, discrimination, and violence) and its various Healing from Heterosexism 151

contextual manifestations in the lives of gay, lesbian, and bisexual people,” which speaks to the relevance of recognizing heterosexism and openness to process­ ing heterosexist experiences in therapy. Therapists who are not as familiar with the influence of heterosexism on LGBTQ clients will wish to consider seeking out additional education on how best to serve LGBTQ clients (APA, 2010, standard 2; APA, 2012, guideline 20; see the Professional Readings and Resources later in this chapter). Referring clients to the following exercise can support them in further processing het­ erosexist experiences. By inviting them to discuss their experience in writing, therapists can allow clients a space to reflect and develop their thoughts about these experiences and then continue processing them in therapy. Instructions

Not all LGBTQ clients have experienced heterosexist events that they want to process. Clients may come to therapy for a variety of reasons and have varying issues they would like to discuss; however, LGBTQ clients often use therapy to discuss events that have happened in their lives that are, or were, driven by heterosexist sentiments (Russell & Bohan, 2007). Cli­ ents may be upset about these events, may be unsure if an event was heterosexist, or may feel uncertain how deeply it has affected them. In any of these cases, this activity can be offered to clients as a homework exercise to enable them to further process that expe­ rience. However, clients may or may not wish to engage in this exercise or may wish to discuss the event with their therapist in order to decide. The following pointers can help during these conversations. This exercise can be introduced by explaining that it involves twenty minutes of writing per day for three days with the aim of further processing and healing from heterosexism. The exercise was created as part of a research study to develop treatments for distress caused by heterosexism, which has permitted the assessment of its effectiveness, and the exercise has been found to be helpful to the vast majority of the people who have completed it so far (just over 90 per­ cent; Collins et al., 2017). Clients who engage in this homework exercise between sessions can develop insights about the events or about how they would like 152 Collins, Maroney, Roberts, Wadler, & Levitt

to respond to those events that they can bring into session to discuss further. They can complete the exer­ cise on paper or can visit the link to the online study to complete either the same exercise or one of two others. Clients who opt to complete the exercise online will be randomly sorted into one of the three writing exercises about heterosexism, so those who want to be sure to complete the exercise included in this chap­ ter are encouraged to complete the exercise on paper. Identifying a heterosexist event. The heterosexist event might have occurred recently or a long time ago. It might be a onetime event or a long-standing or continuing event. The central feature of the event is that it is something that is still troubling to the client and that the client wishes to resolve, develop insight into, or learn to cope with better. Some clients are very clear on when they have experienced heterosex­ ist events, but others may be unsure if an event was driven by heterosexist sentiments or not. They may not be familiar with terms like heterosexism, homopho­ bia, and biphobia. Labeling an experience by saying that it sounds like a heterosexist event, and hearing the therapist define those words, however, can be very empowering. Recognizing that an event or experi­ ence is characterized by heterosexist dynamics allows clients to externalize responsibility or blame that they may be internalizing. This appropriate externalization can help alleviate distress or shift problematic inter­ personal dynamics. Even if an event is recognized as heterosexist, time to process it can help lead to new options and possibilities for how to respond to that event in a healthier manner. 1) Introducing the exercise. Once the client and ther­ apist identify a heterosexist experience that is trou­ bling for the client, the homework exercise can be suggested to the client toward the end of the ses­ sion. The suggestion might sound like this: “I have a homework exercise that you might find benefi­ cial. It can help you process this experience more and make progress in how you are thinking about it. The writing exercise takes about twenty minutes, which you should try to do three days in a row to help you process your heterosexist experience. You can do this exercise on a handout that I can give you, or you can do this or another exercise focused on heterosexist events that is included in an online

research study. You can read about the online ver­ sion at the link on the handout, if you’d like to learn more. If you’d like to try this, it is completely up to you which version you select. The important point is that most of the people who have com­ pleted these exercises have found them to be help­ ful, and so I am curious to see if it would be help­ ful for you. If you would like to talk about your experience doing the exercises, I’d be glad to hear about how they went in our next session.” (See the instructions for follow-up on page 154 for more details on leading a discussion after this exercise.) 2) Additional information about the exercises. The following information is provided in case clients decide to engage in the online version and discuss it in session. Suggestions are made to help thera­ pists consider which version might be appropriate to recommend, and distinctions between the for­ mats are noted. Clients may prefer to engage in the written exercise if they are less comfortable with computers or cannot access them. Clients may pre­ fer to engage in the online study if they would ben­ efit from emailed reminders each day to complete the writing exercise. Additionally, it can empower clients to make a contribution to LGBTQ research and the development of interventions that not only may help them but can also assist other people who have had heterosexist events. There are two main differences between the exercise in this chapter and the online study. The first is that on the first day of the online study and at a one month follow-up, clients complete ques­ tionnaires to assess demographics, psychological distress, and event-related distress. These questions allow researchers to see how these exercises are most helpful and continue to shape these exercises to benefit LGBTQ clients. The second difference is in the online study, after reviewing a consent form with a detailed description of the study and con­ senting, clients are randomly assigned to one of three exercises. Preliminary results suggest that they all are effective in helping the majority of clients make gains and have not suggested significant dif­ ferences among the exercises (Collins et al., 2017). The following are brief descriptions of the three different types of writing exercise in the online

format. The written exercise presented in this chap­ ter is an open-ended writing exercise modeled after a typical expressive writing exercise, in which clients are asked to write about their thoughts and emotions surrounding their heterosexist experi­ ence. A second exercise is a focused-attention exer­ cise, in which participants are prompted to describe the event and then write objective descriptions of their actions over the past twenty-four hours in order to notice how they can decide to focus their thinking. It is reflective of mindfulness-based prac­ tices that have been found effective in helping gay men deal with discrimination (Lyons, 2016). The final format is a more structured exploration that guides clients to focus on their feelings, their needs based on these feelings, and the actions they would like to take to meet those needs. It is based on principles tied to emotion-focused therapy, a therapy that has been found to be well adapted for LGBTQ populations (Greenberg, 2002; Hardtke, Armstrong, & Johnson, 2010). Clients are welcome to try a new format of exercise online or to engage in one writing exercise format multiple times; how­ ever, we encourage them to complete the first set of writing exercises and the follow-up before they try a new exercise. Some clients find that progress occurs on the third writing day. Brief Vignette

Maria is a thirty-two-year-old Mexican American, cisgender woman who identifies as a lesbian. Maria described having a conversation with her mother about her fiancée and having her mother sigh and express her wish that Maria could still back out of the wedding. The following dialogue occurred while Maria discussed this event with her therapist: T: It sounds like planning your wedding is very troubling. It is a joyful event, but also there are lots of other emotions that are more worrisome. M: Yeah. I wish this could go more smoothly. I feel really worried about upsetting my family and that I might regret doing this later. Maybe I shouldn’t be getting married and we should just live together. T: It seems to me that this heterosexist or homophobic reaction from your mother is having quite an effect Healing from Heterosexism 153

on you and really stripping a lot of the happiness from your wedding. I wonder if the ways that her feelings have affected you would be good to explore? It can be easy to internalize attitudes like this, especially from our families, and it’s sometimes hard to figure out how to respond. Do you think you would be inter­ ested in exploring your feelings and reactions about this event further?

suggest that clients continue to engage in these sets of exercises if or when they wish and can express a will­ ingness to process the event in session. If clients indicate that they are interested in dis­ cussing their experience, the following are potential prompts for talking about the homework in session:

M: Definitely!

2. How has your understanding of the event changed since last week?

T: There is an exercise that you might want to try that other LGBTQ people have found helpful. It is a writing exercise aimed at helping people process heterosexist experiences, like the one we’ve been discussing. I can give you a handout that contains the exercise instruc­ tions. You can use the handout instructions with a piece of paper or go online to the link on the handout. The links leads to a research study that has this exer­ cise and two others embedded within it and contrib­ utes to the development of interventions for LGBTQ therapy. If you would like to try this exercise, it is up to you which format you select. In both cases, the exercise guides you to engage in writing for twenty minutes a day for three consecutive days about your experience. If you do decide to complete this exercise, we can talk more about your experience next week. I’d be glad to hear what you discover. M: OK. I’ll check that out. Suggestions for Follow-up

Upon completing the homework, clients may or may not want to discuss their experience of engaging in the writing exercise. Because therapists may not know what clients will prefer (and this preference might shift), therapists will want to tentatively ask clients if they engaged in the writing exercise and if they would like to discuss their experience of doing this. For some, the process of writing extensively about a heterosexist event may bring up painful and intensely personal thoughts and emotions that they may not be ready to address in session, but for many this opportunity for support will be welcomed. Indeed, a number of partic­ ipants in the research study indicated that they would like to find a therapist to discuss their insights from the exercise or reported that they spoke with their ther­ apist about their writing. In this case, therapists can 154 Collins, Maroney, Roberts, Wadler, & Levitt

1. What was it like to sit down and write on three consecutive days?

3. Did any new emotions come forward while you wrote? 4. What did the exercise make you realize? About yourself? About others? 5. Did you discover any new ways of thinking about your relationship? 6. What, if anything, was difficult about writing? 7. What, if anything, did you find most powerful about the exercise? 8. Did you notice any new thoughts about how to get your needs met in the world? Therapists can explore clients’ responses, examining how the emotions, behaviors, and ideas that emerge relate to other patterns that have been identified in the course of therapy. Therapists who are not as familiar with leading conversations on heterosexist experiences may find that this structure aids them in facilitating exploration. At the same time, it will be important that therapists seek education on LGBTQ therapy and ethics (see APA, 2012, 2015). Therapists should take care to affirm clients’ experiences and recognize that microaggressions that can seem subtle on the surface can be distressing, especially as they reoccur in clients’ lives and reinforce negative messages with which they have had to contend across their lifetimes. Contraindications for Use

This homework exercise may not work for everybody. Clients come to therapy for a variety of reasons, and clinical judgment should be used when assessing whether this exercise would be well received by a cli­ ent. Because of the nature of the exercise, this home­ work may not be suitable for clients who are not com­

fortable expressing themselves through writing. This exercise may not be appropriate for clients who are currently in crisis, as they might need extra support and may benefit from processing the event with their therapist in session and creating safe boundaries together rather than on their own. All clients conduct­ ing this exercise would need a safe place to engage in the exercise. Clients considering the online exercises also must have access to a computer connected to the Internet and would need to be able to write fluently in English and be over eighteen years of age. Professional Readings and Resources American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67, 10–42. doi:10. 1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832–864. doi:10.1037/a0039906. Puckett, J. A., & Levitt, H. M. (2015). Internalized stigma within sexual and gender minorities: Change strategies and clinical implications. Journal of LGBT Issues in Coun­ seling, 9, 329–349. doi:10.1080/15538605.2015.1112336. Russell, G. M., & Bohan, J. S. (2007). Liberating psychotherapy: Liberation psychology and psychotherapy with LGBT clients. Journal of Gay and Lesbian Psychotherapy, 11, 59–75. doi:10.1300/J236v11n03_04. Spengler, E. S., Miller, D. J., & Spengler, P. M. (2016). Microaggressions: Clinical errors with sexual minority clients. Psychotherapy, 53, 360. doi:10.1037/pst0000073. Szymanski, D. M., & Mikorski, R. (2016). External and inter­ nalized heterosexism, meaning in life, and psychological distress. Psychology of Sexual Orientation and Gender Diversity, 3, 265. doi:10.1037/sgd0000182.

Resources for Clients GLBT National Hotline. https://www.glbthotline.org/national hotline.html; hotline: 1-888-843-4564. Heterosexism Healing Study. http://tinyurl.com/HetHealing. LGBTQ Mental Health. (n.d.). Resources and exercises to sup­ port healing from heterosexism. https://LGBTQMental­ Health.com. Singh, A. (2018). The queer and transgender resilience work­ book: Skills for navigating sexual orientation and gender expression. Oakland, CA: New Harbinger. Trans Lifeline. www.translifeline.org; hotline: 1-877-565-8860. Trevor Project. Crisis intervention for LGBTQ+ youth. www. thetrevorproject.org; hotline: 1-866-488-7386.

References American Psychological Association (APA). (2010). Ethical principles of psychologists and code of conduct. http:// apa.org/ethics/code/index.aspx. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gen­ der nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Baikie, K. A., Geerligs, L., & Wilhelm, K. (2011). Expressive writing and positive writing for participants with mood disorders: An online randomized controlled trial. Journal of Affective Disorders, 136 (3), 310–319. doi:10.1016/j. jad.2011.11.032. Booker, J. A., & Dunsmore, J. C. (2017). Expressive writing and well-being during the transition to college: Compar­ ison of emotion-disclosing and gratitude-focused writing. Journal of Social and Clinical Psychology, 36, 580–606. doi:10.1521/jscp.2017.36.7.580. Braun, V., & Clarke, V. (2006). Using thematic analysis in psy­ chology. Qualitative Research in Psychology, 3, 77–101. doi:10.1191/1478088706qp063oa. Collins, K. M., Levitt, H. M., Maroney, M. R., Roberts, T. S., Wadler, B. M., & Minami, T. (2017, June). Healing from heterosexism through expressive writing interventions. In H. M. Levitt (chair), Psychotherapeutic responses to het­ erosexist injuries: Research toward recovery. Symposium conducted at the forty-eighth international annual meet­ ing of the Society for Psychotherapy Research, Toronto, Canada. Crowley, J. P. (2014). Expressive writing to cope with hate speech: Assessing psychobiological stress recovery and forgiveness promotion for lesbian, gay, bisexual, or queer victims of hate speech. Human Communication Research, 40, 238–261. doi:10.1111/hcre.12020. Frattaroli, J. (2006). Experimental disclosure and its modera­ tors: A meta-analysis. Psychological Bulletin, 132, 823. doi:10.1037/0033-2909.132.6.823. Greenberg, L. S. (2002). Emotion-focused therapy: Coaching clients to work through their feelings, 2nd edition. Wash­ ington, DC: American Psychological Association. Hardtke, K. K., Armstrong, M. S., & Johnson, S. (2010). Emo­ tionally focused couple therapy: A full-treatment model well-suited to the specific needs of lesbian couples. Jour­ nal of Couple & Relationship Therapy, 9 (4), 312–326. doi :10.1080/15332691.2010.515532. Henry, E. A., Schlegel, R. J., Talley, A. E., Molix, L. A., & Bet­ tencourt, B. A. (2010). The feasibility and effectiveness of expressive writing for rural and urban breast cancer sur-

Healing from Heterosexism 155

vivors. Oncology Nursing Forum, 37, 749–757. doi:10. 1188/10.ONF.749-757. Herek, G. M. (2004). Beyond “homophobia”: Thinking about sexual prejudice and stigma in the twenty-first century. Sexuality Research and Social Policy, 1, 6–24. doi:10.15 25/srsp.2004.1.2.6. Herek, G. M. (2017). Documenting hate crimes in the United States: Some considerations on data sources. Psychology of Sexual Orientation and Gender Diversity, 4, 143–151. doi:10.1037/sgd/0000227. Hirai, M., Skidmore, S. T., Clum, G. A., & Dolma, S. (2012). An investigation of the efficacy of online expressive writ­ ing for trauma-related psychological distress in Hispanic individuals. Behavior Therapy, 43, 812–824. doi:10.1016/ j.beth.2012.04.006. Kaufka (2009). The shadows within: Internalized racism and reflective writing. Reflective Practice: International and Multidisciplinary Perspectives, 10, 137–148. doi:10.10 80/14623940902786115. Lange, A., van de Ven, J. P., Schrieken, B. A., Bredeweg, B., & Emmelkamp, P. M. G. (2000) Internet-mediated, proto­ col-driven treatment of psychological dysfunction. Jour­ nal of Telemedicine and Telecare, 6 (1), 15–21. http:// journals.sagepub.com/doi/abs/10.1258/1357633001 933880. Lewis, R. J., Derlega, V. J., Clarke, E. G., Kuang, J. C., Jacobs, A. M., & McElligott, M. D. (2005). An expressive writing intervention to cope with lesbian-related stress: The mod­ erating effects of openness about sexual orientation. Psy­ chology of Women Quarterly, 29, 149–157. doi:10.1111/ j.1471-6402.2005.00177.x. Lyons, A. (2016). Mindfulness attenuates the impact of dis­ crimination on the mental health of middle-aged and older gay men. Psychology of Sexual Orientation and Gender Diversity, 3, 227–235. doi:10.1037/sgd0000164. Maroney, M. R., Levitt, H. M., Roberts, T. R., & Wadler, B. M. (2016, October). Using an online writing intervention to process experiences of heterosexism in LGBTQ individ­ uals. Presentation at the Sixteenthth Annual Diversity Challenge at Boston College, Chestnut Hill, MA. Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Concep­ tual issues and research evidence. Psychological Bulletin, 129, 674–697. doi:10.1037/0033-2909.129.5.674.

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Nadal, K. L., Issa, M. A., Leon, J., Meterko, V., Wideman, M., & Wong, Y. (2011). Sexual orientation microaggressions: “Death by a thousand cuts” for lesbian, gay, and bisexual individuals. Journal of LGBT Youth, 8, 234–259. doi:10.1 080/19361653.2011.584204. Pachankis, J. E., & Goldfried, M. R. (2010). Expressive writing for gay-related stress: Psychosocial benefits and mecha­ nisms underlying improvement. Journal of Consulting and Clinical Psychology, 78 (1), 98–110. doi:10.1037/a0017580. Pennebaker, J. W., & Beall, S. K. (1986). Confronting a trau­ matic event: Toward an understanding of inhibition and disease. Journal of Abnormal Psychology, 95, 274–281. doi:10.1037/0021-843X.95.3.274. Pennebaker, J. W., Colder, M., & Sharp, L. K. (1990). Acceler­ ating the coping process. Journal of Personality and Social Psychology, 58, 528–537. doi:10.1037/0022-3514.58.3. 528. Puckett, J. A., & Levitt, H. M. (2015). Internalized stigma within sexual and gender minorities: Change strategies and clinical implications. Journal of LGBT Issues in Counseling, 9, 329–349. doi:10.1080/15538605.2015.1112336. Remer, L. (2013). Feminist therapy. In J. Frew & M. D. Spiegler (eds.), Contemporary psychotherapies for a diverse world, 373–414. New York: Routledge. Russell, G. M., & Bohan, J. S. (2007). Liberating psychotherapy: Liberation psychology and psychotherapy with LGBT clients. Journal of Gay and Lesbian Psychotherapy, 11, 59–75. doi:10.1300/J236v11n03_04. Smyth, J. M., Hockemeyer, J. R., & Tulloch, H. (2008). Expres­ sive writing and post‐traumatic stress disorder: Effects on trauma symptoms, mood states, and cortisol reactivity. British Journal of Health Psychology, 13, 85–93. doi:10. 1348/135910707X250866. Spengler, E. S., Miller, D. J., & Spengler, P. M. (2016). Microaggressions: Clinical errors with sexual minority clients. Psychotherapy, 53, 360. doi:10.1037/pst0000073. Swanbon, T., Boyce, L., & Greenberg, M. A. (2008). Expres­ sive writing reduces avoidance and somatic complaints in a community sample with constraints on expression. British Journal of Health Psychology, 13 (1), 53–56. doi:10. 1348/135910707X251180. Szymanski, D. M., & Mikorski, R. (2016). External and inter­ nalized heterosexism, meaning in life, and psychological distress. Psychology of Sexual Orientation and Gender Diversity, 3, 265. doi:10.1037/sgd0000182.

EXPRESSIVE WRITING EXERCISE

This exercise is one of three that were found to be helpful to most clients in a research study that contributes to the development of therapy interventions to help LGBTQ people. If you prefer to participate in that study online, you can visit http://tinyurl.com/HetHealing to learn more. Please complete this exercise when you are alone in a quiet space where you can reflect without distractions. You will need a blank sheet of paper, a notebook, or something similar on which to write your thoughts. Don’t worry about spelling and grammar for this exercise—just focus on the exercise instructions. 1. First, take five minutes to write a description of the heterosexist experience that you are focusing on for this exercise. Please describe what happened, what was upsetting for you at the time, and what remains upsetting for you now. (Examples: being insulted or bullied, being harassed, being denied services.)

2. Now use the next fifteen minutes to really explore your deepest feelings and thoughts about this experience.

3. Repeat this exercise three days in a row. Even if one day doesn’t seem particularly helpful, the next day might lead you to a new place. Be curious about your experience and see what comes as you write.

Kathleen M. Collins, Meredith R. Maroney, Tangela S. Roberts, Brianna M. Wadler, and Heidi M. Levitt

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18 AT THE INTERSECTION OF THE AUTISM SPECTRUM AND SEXUAL AND GENDER DIVERSITY: CASE STUDIES FOR USE WITH CLINICIANS AND CLIENTS Eva Mendes and Meredith R. Maroney Suggested Uses: Activity, handout Objectives

We aim to provide an overview of the autism spectrum and to highlight some ways autism may present among individuals who identify as LGBTQ. This exercise is designed to facilitate a conversation between clients and clinicians regarding intersecting identities, includ­ ing those related to autism, gender identity, and sex­ ual orientation. A list of autism spectrum disorder (ASD) traits, case studies of individuals identifying with these intersecting identities, and questions for use in therapy are also included; these may be useful for counselors working with clients of LGBTQ+ and autistic identities. Rationale for Use

The current CDC figures for the prevalence of ASD in children are currently one in sixty-eight (Christensen et al., 2016). There is emerging evidence that there is greater diversity of sexual orientation and gender identity among children, adolescents, and adults on the autism spectrum than in the general population (Glidden, Bouman, Jones & Arcelus, 2016; May, Pang, & Williams, 2017; Mendes & Bush, 2015; Van Der Miesen, Hurley, & De Vries, 2016; van Schalkwyk, Klingensmith, & Volkmar, 2015). Thus, there is grow­ ing recognition in both the research and clinical com­ munities of the intersection of sexual orientation and gender diversity among individuals on the autism spectrum. There is limited clinical knowledge about

adults on the autism spectrum, especially those who are diagnosed with Asperger’s syndrome/ASD Level 1 (the high-functioning variety of ASD), and few inter­ ventions for working with their neurological differ­ ences and unique social, communication, and emo­ tional challenges (Mendes, 2015). There is even less information about and understanding of those who identify as autistic and LGBTQ+ (Bennett & Goodall, 2016). This understanding is important in promoting acceptance and sensitivity among family, friends, and providers toward those who identify as autistic (Mendes & Bush, 2015). Providers’ expertise tends to come from working either with those on the autism spectrum or with LGBTQ+ individuals, which can make it challenging for clients to seek out support from providers who are affirming of both identities. There now seems to be a very small group of pioneering men­ tal health providers who understand how to include both identities in an affirming way (Strang et al., 2018). Those who identify as LGBTQ and autistic may face unique challenges as a result of their intersecting identities, which are important to consider in the context of clinical work. For instance, individuals with autism may face invalidation of their sexual orienta­ tion or gender identity because their capacity to under­ stand their identities is considered to be dubious, or because their identity has been mislabeled as a fixa­ tion on gender identity or sexual orientation (Burke, 2016). A lack of acceptance and understanding of LGBTQ identities can have major implications for autistic clients in their gender expression, their ability

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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to make medical decisions and access care that is affirming, and their ability or willingness to seek out social and legal recognition (ASAN, NCTE, and National LGBTQ Task Force, 2016). Clients who are LGBTQ and autistic may also struggle with social isolation or finding spaces that are affirming of their multiple identities (Strang et al., 2018). Finally, autistic individuals and transgender individuals have been shown to have more difficulties related to employment and navigating their identities at work and school; these difficulties may be exacerbated for those who are both gender diverse and autistic (Budge, Tebbe, & Howard, 2010; Hendricks, 2010; Strang et al., 2018). Given the growing recognition of the prevalence of the ASD and LGBTQ+ spectrum overlap (Van Der Miesen et al., 2016), it is important that there be increased discussion of this intersection in the clinical community. Clinicians run the risk of undertreating their clients or invalidating their clients’ identities if they do not understand the diversity of sexual orien­ tation and gender identity and how it may be manifest among autistic individuals (Glidden et al., 2016). Clinicians must seek out appropriate training around areas beyond their own competence (American Psycho­ logical Association [APA], 2017), which is increas­ ingly important given that there are few who are knowl­ edgeable about sexual orientation, gender identity, and autism. Because of the lack of services available for autistic adults and the lack of consensus on evi­ dence-based treatments with this population (Murphy et al., 2016), clinicians may have to seek out educa­ tion independently to ensure that they achieve the necessary competence to serve clients (APA, 2017, standard 2). As stated in the “Guidelines for Psycho­ logical Practice with Transgender and Gender Non­ conforming [TGNC] People” (APA, 2015), providers should strive to understand the complexity of the mul­ tiple identities of TGNC individuals and how intersec­ tionality may affect gender identity and access to affirmative care. Recently released clinical guidelines on working with clients who present with co-occur­ ring gender dysphoria and autism spectrum disorder highlight the importance of treatment that addresses both gender and autism concurrently; such treatment may require a collaborative approach from profession­

als who specialize in each area (Strang et al., 2018). As stated in the American Psychological Association’s ethics code (APA, 2017, principle E), psychologists are urged to eliminate the effect of biases in their work. By exploring their own attitudes and the knowledge they may hold about clients’ diverse identities, clini­ cians are better able to assess their ability to provide affirmative treatment (APA, 2010, 2015). It is essential that counselors educate themselves on working with this population and deepen their understanding, sensi­ tivities, and strategies for working with individuals who identify on the dual spectrums of ASD and LGBTQ+. Instructions

The following case studies can be used as a tool in exploring identity with clients who are on the autism spectrum and are LGBTQ+, serving as a means of facilitating discussion about similarities to and differ­ ences from the cases provided. Clinicians may wish to bring these narratives into the therapy room when they perceive that clients are questioning their sexual orientation or gender identity, exploring or present­ ing with ASD, or experiencing challenges regarding family or couples work. This activity could be intro­ duced if the client reports being unsure of how to start a session, to normalize the experience a client is having, or for clients with more difficulty naming what is happening to them. Clinicians should introduce this activity by stating something similar to the follow­ ing: “I sometimes have my clients read something in therapy to be able to facilitate a conversation. Would you be open to that?” Clinicians can give clients the option to read independently or together. It may be useful to have the case studies and questions available for clients to refer to as a visual, should they choose. The table of traits could be brought into session inde­ pendently to initiate a conversation about the ways the client’s autistic identity may be affecting different facets of life. Clinicians may wish to talk through guided questions or refer to them after reading through the case study with clients. Materials Included

Handout A: A handout listing common ASD traits and how they may manifest themselves in clients

Intersection of Autism Spectrum and Sexual and Gender Diversity 159

Handout B: Two case studies with clients who hold intersecting LGBTQ and autistic identities Handout C: Guided questions for clinicians to use in therapy with clients who identify as autistic or ASD and diverse in gender identity or sexual orientation Brief Vignette

Lex is a twenty-five-year-old nonbinary, bisexual Asian American individual with work and family challenges. Lex’s pronouns are they, them, and their, and they were assigned female at birth. They are currently seeing a counselor because they are working as a part-time cashier at a ski-sports shop, but they are trained and educated as a musician and would like to work in their field. They also recently broke up with their girl­ friend and are wondering if they are on the autism spectrum because of their recurrent social challenges with work and relationships. In session Lex recently disclosed, “I’m also not out to my family as nonbinary and could use some help with that.” Handout A: When Lex glances at the list of ASD traits and features, they ask for a pencil and put checkmarks against most of the traits on the list. They focus on the first core area of ASD differences and features, under the heading Social. They began talking about how working with a theater group as a pianist was so chal­ lenging for them because they were unable to interpret what the music director wanted. They got so stressed out from the confusing messages and wanting to do a good job that they quit the job after just two weeks. Then they moved on to the features listed under Emo­ tional and spoke about how their girlfriend broke up with them because they couldn’t emotionally support her while she was going through a bout of depres­ sion and a fight with her father. Lex had already been researching if they were on the autism spectrum before all this happened, but their girlfriend’s telling them that she had been secretly reading books about ASD before the breakup confirmed their suspicions. They said, “Until then, I would just randomly look up ASD traits on the Internet, but wasn’t motivated to do enough to go speak to a specialist or anything. How­ ever, when Shelby broke up with me, I realized that I really needed to look into this.”

160 Mendes & Maroney

After Lex completed Handout A, the counselor examined the traits that Lex had checked. A profile of traits began to form that pointed toward major socialcommunication and emotional challenges. Employ­ ment and relationship challenges related to these traits became very apparent. After a few sessions processing Lex’s ASD traits and working through coping strate­ gies for work-related social-communication challenges, the counselor presented Lex with Handout B—Case Study 2. Reading the case study helped the counselor and Lex examine and process the challenges with Shelby, their ex-girlfriend. Suggestions for Follow-up

Clinicians may wish to check in with their clients as a way of continuing the conversation about the inter­ section of autistic and sexual orientation and gender identities. It may be helpful for clinicians to refer to the handout of common ASD traits as they appear relevant to their clients’ experiences and presentation, exploring the ways these traits manifest themselves in different situations (e.g., in the workplace, among family, in friendships and romantic relationships). Referring to the list of traits and case studies may be useful when setting goals in treatment, as well as when reflecting on client growth. Contraindications for Use

Clinicians should be aware of their own comfort level discussing autistic and LGBTQ identities. Those who are newer to working with autistic clients, or clients at the intersection of autistic and LGBTQ identities, may wish to seek out support, consultation, or addi­ tional resources. Clinicians should be aware of where clients are in understanding their identities, and they should note their clients’ reactions to the case studies. For instance, some clients may relate but may not be ready to explore, while others may explicitly state they are not interested in discussing this topic as part of treatment. Clinicians should note that there is large variability across the autism spectrum, as illustrated by a quote from Stephen Shore, an autistic advocate, professor, and author: “If you’ve met one person with Asperger’s, you’ve met one person with Asperg­ er’s” (quoted in Mendes, 2015, p. 230). Therefore, the included case studies may not resonate with all clients.

Professional Readings and Resources American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. https://www.apa.org/ practice/guidelines/transgender.pdf. Attwood, T. (2008). The complete guide to Asperger’s syn­ drome. Philadelphia: Jessica Kingsley Publishers. Burke, C. (2016, January 26). Gender dysphoria and autism with Aron Janssen MD. Ackerman Podcast. http://acker man.podbean.com/e/the-ackerman-podcast-22-gender­ dysphoria-autism-with-aron-janssen-md/. Glidden, D., Bouman, W. P., Jones, B. A., & Arcelus, J. (2016). Gender dysphoria and autism spectrum disorder: A sys­ tematic review of the literature. Sexual Medicine Reviews, 4 (1), 3–14. doi:10.1016/j.sxmr.2015.10.003. Mendes, E. A. (2015). Marriage and lasting relationships: Suc­ cessful strategies for couples and counselors. Philadelphia: Jessica Kingsley Publishers. Mendes, E., & Bush, H. H. (2015). “Labels do not describe me”: Gender identity and sexual orientation among women with Asperger’s and autism. www.evmendes.com/wpcontent/uploads/2015/04/Labels-do-not-final.pdf. Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A. L., Menvielle, E., Leibowitz, S., . . . & Pleak, R. R. (2018). Ini­ tial clinical guidelines for co-occurring autism spectrum disorder and gender dysphoria or incongruence in ado­ lescents. Journal of Clinical Child & Adolescent Psychology, 47 (1), 105–115. doi:10.1080/15374416.2016.1228462.

Resources for Clients Attwood, T. (2008). The complete guide to Asperger’s syndrome. Philadelphia: Jessica Kingsley Publishers. Decker, J. S. (2014). The invisible orientation: An introduction to asexuality. New York: Carrel Books. Mendes, E. A. (2015). Marriage and lasting relationships: Suc­ cessful strategies for couples and counselors. Philadelphia: Jessica Kingsley Publishers. Sickels, C. (2015). Untangling the knot: Queer voices on mar­ riage, relationships, and identity. Portland, OR: Ooligan Press. Tammet, D. (2007). Born on a blue day: Inside the extraordi­ nary mind of an autistic savant: A memoir. New York: Free Press. Testa, R. J., Coolhart, D., & Peta, J. (2016). The gender quest workbook: A guide for teens and young adults exploring gender identity. Oakland, CA: Instant Help Books.

References American Psychiatric Association. (2013). Diagnostic and sta­ tistical manual of mental disorders, 5th edition. Arlington, VA: American Psychiatric Publishing. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and

bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. ASAN, NCTE, and National LGBTQ Task Force. (2016, June). Joint statement on the rights of transgender and gender non-conforming autistic people. (Press release). http:// autisticadvocacy.org/wp-content/uploads/2016/06/ joint_statement_trans_autistic_GNC_people.pdf. Bennett, M., & Goodall, E. (2016). Towards an agenda for research for lesbian, gay, bisexual, transgendered and/or intersexed people with an autism spectrum diagnosis. Journal of Autism and Developmental Disorders, 46 (9), 3190–3192. Budge, S. L., Tebbe, E. N., & Howard, K. A. (2010). The work experiences of transgender individuals: Negotiating the transition and career decision-making processes. Journal of Counseling Psychology, 57 (4), 377–393. Burke, C. (2016, January 26). Gender dysphoria and autism with Aron Janssen MD. Ackerman Podcast. http:// ackerman.podbean.com/e/the-ackerman-podcast-22-gender­ dysphoria-autism-with-aron-janssen-md/. Christensen, D. L., et al. (2016). Prevalence and characteristics of autism spectrum disorder among children aged 8 years—autism and developmental disabilities monitoring network, 11 sites, United States, 2012. CDC Morbidity and Mortality Weekly Report. Surveillance Summaries, 65 (3), 1–23. doi:10.15585/mmwr.ss6503a1. De Vries, A. L., Noens, I. L., Cohen-Kettenis, P. T., van Berckelaer-Onnes, I. A., & Doreleijers, T. A. (2010). Autism spectrum disorders in gender dysphoric children and adolescents. Journal of Autism and Developmental Disor­ ders, 40 (8), 930–936. doi:10.1007/s10803-010-0935-9. Glidden, D., Bouman, W. P., Jones, B. A., & Arcelus, J. (2016). Gender dysphoria and autism spectrum disorder: A sys­ tematic review of the literature. Sexual Medicine Reviews, 4 (1), 3–14. doi:10.1016/j.sxmr.2015.10.003. Hendricks, D. (2010). Employment and adults with autism spectrum disorders: Challenges and strategies for success. Journal of Vocational Rehabilitation, 32 (2), 125–134. May, T., Pang, K. C., & Williams, K. (2017). Brief report: Sexual attraction and relationships in adolescents with autism. Journal of Autism and Developmental Disorders, 47 (6), 1–7. doi:10.1007/s10803-017-3092-6. Mendes, E. A. (2015). Marriage and lasting relationships: Suc­ cessful strategies for couples and counselors. Philadelphia: Jessica Kingsley Publishers. Mendes, E., & Bush, H. H. (2015). “Labels do not describe me”:

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Gender identity and sexual orientation among women with Asperger’s and autism. www.evmendes.com/wpcontent/uploads/2015/04/Labels-do-not-final.pdf. Murphy, C. M., Wilson, C. E., Robertson, D. M., Ecker, C., Daly, E. M., Hammond, N., . . . & McAlonan, G. M. (2016). Autism spectrum disorder in adults: Diagnosis, manage­ ment, and health services development. Neuropsychiatric Disease and Treatment, 12, 1669–1686. doi:10.2147/NDT. S65455. National Institute for Health and Care Excellence (NICE). (2012, June). Autism spectrum disorder in adults: Diag­ nosis and management. www.nice.org.uk/guidance/cg142. Shumer, D. E., Reisner, S. L., Edwards-Leeper, L., & Tishelman, A. (2015). Evaluation of Asperger syndrome in youth presenting to a gender dysphoria clinic. LGBT Health, 3 (5), 387–390. doi:10.1089/lgbt.2015.0070.

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Strang, J. F., Meagher, H., Kenworthy, L., de Vries, A. L., Men­ vielle, E., Leibowitz, S., . . . & Pleak, R. R. (2018). Initial clinical guidelines for co-occurring autism spectrum dis­ order and gender dysphoria or incongruence in adoles­ cents. Journal of Clinical Child & Adolescent Psychology, 47 (1), 105–115. doi:10.1080/15374416.2016.1228462. Van Der Miesen, A. I., Hurley, H., & De Vries, A. L. (2016). Gender dysphoria and autism spectrum disorder: A nar­ rative review. International Review of Psychiatry, 28 (1), 70–80. doi:10.3109/09540261.2015.1111199. van Schalkwyk, G. I., Klingensmith, K., & Volkmar, F. R. (2015). Gender identity and autism spectrum disorders. Yale Journal of Biology and Medicine, 88 (1), 81–83.

HANDOUT A: CORE DIFFERENCES AND TRAITS In the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), Asperger’s syndrome was collapsed under the umbrella of Autism Spectrum Disorder. This table in not intended to be diagnostic or comprehensive. Diagnosing someone on the autism spectrum is a longer and much more complicated process. This table is a summary of the common manifestation of traits for people on the ASD spectrum. Please refer to the DSM-5 (APA, 2013) for specific diagnostic criteria.

Core Areas of Differences and Features 1. Social

Traits May Be Manifest in This Way n Deficits in social reciprocity n Reduced sharing of interests n Struggling to navigate social situations n Black-and-white thinking (all or nothing) n Rigid thinking and inflexible point of view n Lack of perspective taking or theory of mind, i.e., the ability to understand another’s point of view or to understand that others have their own thoughts and feelings n Inconsistent eye contact n Trouble adjusting behavior to suit social context

2. Communication

n Verbal, nonverbal communication challenges n Inappropriate body language and expression n Echolalia (i.e., repeating odd phrases or sentences) n Lack of initiation n Trouble with back-and-forth conversation flow n Communicating to inform rather than connect n Slow processing n Tendency to focus on details or the negative n Highly logical; can make insensitive comments n Unusually loud or monotonous voice n Struggling to hear/understand tone (dismissive, angry) of voice n Taking things literally n Trouble understanding what is said n Linear thinking patterns and speech

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3. Emotional

n Challenges with emotion regulation n Escalation from zero to sixty n Extreme emotions: up or down n Even-keel emotions: never up or down n Lacking in emotional reciprocity n Anger issues n Poor emotional self-awareness n Alexithymia (no words for emotions) n Vulnerability to stress n Low emotional intelligence quotient (EIQ) n Inability to understand another’s point of view n Lack of awareness or understanding of others’ feelings

4. Physical

n Unusual physicality or repetitive motor movements n Rigid body or unusual body movements n Rocking, flapping, tapping, or shaking legs n Unusual, awkward gait n Odd hand gestures

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5. Need for Structure and Routine

n Attachment to routines, objects, or structure n Hard time changing schedules n Needing structure n Adhering to routines n Sitting in the same chair or spot n Insisting on sameness n Needing to have things neat and organized n Needing to know exactly when things start and end n Always punctual or arrives way ahead of time

6. Executive Functioning Deficits

n Trouble organizing space n Extremely messy n Hoarding n Time-management issues n Chronically late

7. Obsessive Special Interests

n Obsessive, narrow interests n Ritualized behaviors n Highly restricted, fixated interests n Intense special interest in a particular subject or subjects (interests can change over time) n Hyper- or hypo-sensitivity

8. Sensory Issues

n Hyper- or hypo- sensitivity (for example, does not feel cold or is always cold) n Needing to sleep with a weighted blanket Eva Mendes and Meredith R. Maroney

HANDOUT B: T WO CASE STUDIES Case Study 1: Kat Kat, twenty-five, an asexual, nonbinary, European American individual, comes in for counseling at her parents’ behest after her recent autism diagnosis. She is dressed in black leggings and a hooded, long-sleeved sweatshirt dress. One side of her head is shaved, the other dyed blue. Her lip and eye­ brows are pierced. She arrives looking disheveled and as though she hasn’t showered in a couple of days and mildly smelling of body odor. Kat is also thirty minutes late to the session because she took the wrong route to get to the therapist’s office. Once she arrives at the door marked with the therapist’s name, she opens it without knocking. Not even giving a chance for the therapist to invite her in, she barges in and plops herself down on the couch. Appearing to be visibly upset, she keeps her gaze fixed on the floor. After a long pause, she say looks up briefly and says, “I’m sorry, I’m just trying to gather myself. I couldn’t find your office and kept going around in circles! Why is there no sign on this building?” The therapist thinks to herself, “There is a big sign marking the building right in front, but she probably missed it in her anxiety to get here.” Kat says, “I don’t know how this works. What do I say?” “I understand that your parents wanted to you to come see me. Usually in a therapy session, cli­ ents start by telling me why they came in and what things they want to work on.” Kat seems to take the information in and ponders aloud, “Yes, I’m here because my parents want me to.” She rolls her eyes. “They keep saying that I need to see someone to work on my social skills. Do you help with that? I’m not so sure I need help with social skills. But I could use some help finding a job. I just lost my job recently because I was rude to a customer. Is that something you can help me with?” “Sure, we can definitely discuss that.” Kat abruptly changes topic and says, “Did they tell you that I recently told them that I’m asexual?” The therapist replies, “No, they didn’t. Can you tell me more about that?” “I don’t know!” Kat suddenly snaps. “Will you judge me for it? My last therapist tried to tell me that I would grow out of it! She said that people with autism develop later in life and that I might become attracted to people as I grow older. She said it was a developmental thing. She wouldn’t lis­ ten to me!” The therapist gently reassures her, “No, I won’t judge you. Or at least I’ll try not to. I’m so sorry that your last therapist was so unsupportive.” “Thank you. That’s helpful and I don’t want to write off all therapists just because of one.” Case Study 2: Sunee Sunee, thirty, is a gay, cisgender, Turkish immigrant male with ASD who entered therapy along with his partner, Enrique, a cisgender, gay, Hispanic male for couples counseling. Sunee recalls: “Enrique first mentioned that I might have ASD, but I had a hard time being con­ vinced at first. In fact, our first couples counselor also had a hard time seeing my ASD traits.” Speaking about his family of origin, and why he had not previously sought an ASD diagnosis, Sunee says, “I was born and raised in Turkey in a really quirky family of intellectuals. My parents were medical doctors, and so I always had a very out-of-the-box upbringing. In the quirky family, I wasn’t considered odd at all. I started speaking in full sentences when I was two and a half years old, for example, and was reading books on astronomy by the time I was six years old. No one told Eva Mendes and Meredith R. Maroney

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me that was weird or unusual. Also, I only wore black in my teen years, kind of like goth! Even though growing up in Turkey made it hard for me to socially isolate myself, I didn’t have any friends outside the family in the true sense of the word.” Describing his childhood and school years in the context of his autistic behaviors, Sunee explains, “My teachers and classmates probably thought I was strange not only because of the way I dressed, but how I acted in school. I challenged authority a lot, but my parents were prominent in the community, and things were somehow smoothed over for me. In hindsight, I do wish I were less protected. I might have learned more social skills that way. But I also have to say that I was too accomplished to be diagnosed with a disability. I was a published photographer and poet by the time I was ten! I might have also not thought of myself as strange or different because I was always in my own little world. “When I met Enrique, it took a while for us to find a balance that worked for us in terms of spending time together. When we were dating, it was fine, but now that we live together it has become much harder. Enrique really enjoys going out late at night to dance with our friends, and I have a really hard time with the loud music, the crowds, and don’t get why he wants to do this so often. It feels like there’s nothing I can do to fix it—it ends in a fight if I don’t go, and if I do, it always triggers a meltdown. “Most problematic about my ASD are my anger issues and meltdowns, which have become more and more frequent lately, largely before or after social situations. This has been really damag­ ing to our relationship.” Enrique adds, “It’s not like I go out every night or even every weekend. I’ll go out like once a month maybe, but the problem is that Sunee is always coding. He has his own start-up. When he’s not working, he’s composing music, so it’s really hard to get any quality time with him. Also, he smokes pot a lot to help him relax. But then he’s not in a place to really engage with me in a mean­ ingful way.”

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HAN D O U T C : Q UES T IO NS F O R EXP LO RAT IO N O F

IDENT IT IES WIT H CL IENT S

1. Did you relate to anything in Sunee’s story? In Kat’s? What resonated with you?

2. When did you first become aware of your autism and your sexual orientation or gender identity? What was that like for you?

3. How do you identify in terms of your autism? How do you identify your sexual orientation or gender identity? Have these labels shifted or changed for you?

4. How do you see yourself as someone who is autistic and LGBTQ?

5. What comes to mind, academically, culturally, socially, and in terms of your family and upbringing?

6. How have your identities affected your socioeconomic status, if at all?

7. Have you come out to a therapist before? What was that experience like?

8. What would you hope to see from mental health providers who want to support your sexual orientation, gender identity, and autism?

9. Do you see any obstacles to your ability to live authentically and feel at peace with and accepting of your identity? What are those thoughts? Can we look at them?

10. Write down things that you like about your ASD/LGBTQ identities

11. How can we help you combat the obstacles you’ve identified? What helps you feel better?

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19 CLINICAL WORK WITH LGBTQ ASYLUM SEEKERS Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne Suggested Use: Activity Objective

The purpose of this activity is to provide clinicians with an overview of the unique challenges faced by sexual and gender minority individuals who are seek­ ing asylum. In this activity, we aim to facilitate dis­ cussion about the client’s potential concerns and cur­ rent needs. To further assist clinicians, two additional questionnaires that have been beneficial in exploring sources of support and resilience for people success­ fully resettling are provided to frame the discussion (Alessi, 2016). Rationale for Use

LGBTQ individuals seeking asylum status tend to have a specific set of experiences and needs about which clinicians should be aware when working with these individuals (Hopkinson et al., 2017). People seeking asylum often have a history of trauma (Heller, 2009). This history, combined with the process of leaving their home country and pleading their asylum cases, can create high levels of additional stress that can ham­ per their successful adjustment to the new country (Portman & Weyl, 2013). As defined by the United Nations High Commis­ sioner for Refugees (UNHCR), refugees are individ­ uals who flee their countries of origin “owing to a well founded fear of being persecuted for reasons of race, religion, nationality, membership of a particu­ lar social group or political opinion” (UNHCR, 2011, p. 10). As Heller (2009) explains, fear of persecution applies to both asylum seekers and refugees. The pri­ mary difference is that refugees are granted legal sanctuary status before arriving in the new country,

whereas asylum seekers go to another country to seek sanctuary and then apply for refugee status. As a part of seeking asylum, individuals undergo immigration proceedings in the new country. Exact numbers of LGBTQ people seeking or granted asylum in the United States are hard to determine (Heller, 2009) because sexual orientation and gender identity infor­ mation is not regularly recorded as part of U.S. data collection (McGuirk, Niedzwiecki, Oke, & Volkova, 2015). Portman and Weyl (2013) estimated that fewer than five hundred people were granted asylum in the United States for sexual orientation or gender identity. In Stronger Together: Best Practice Guide for Support­ ing LGBT Asylum Seekers in the U.S., the Human Rights Campaign Foundation, the National LGBTQ Task Force, and the LGBT Freedom Asylum Network esti­ mated that approximately 5 percent of all asylum claims in the United States are for sexual orientation or gender identity (Brodie, Craig, & Amaro, 2015; McGuirk et al., 2015). Affirmative asylum claims in 2017 were approximately 139,801 (DHS-OIS, 2019); 5 percent of those claims would be about 6,990 people whose asylum claims involved sexual orientation or gender identity. Individuals request asylum through a series of steps particular to the host country, which generally include the process of explaining their personal expe­ riences through a narrative and providing evidence of persecution, which may include testimony from wit­ nesses (Berg & Millbank, 2009). In the United States, asylum seekers must request asylum status within one year of arriving (Piwowarczyk, Fernandez, & Sharma, 2017). As part of the asylum process, LGBTQ asylum seekers must demonstrate that they have experienced persecution because of their membership in a “social

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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group,” that is, a sexual or gender minority group, and that they will face persecution if they return (Berg & Millbank, 2009; Piwowarczyk et al., 2017; Reading & Rubin, 2011). The evidence provided is then judged by officials who either grant or deny asylum status. The process of sharing their personal narratives with immigration officials is extremely stressful for people seeking asylum, but particularly so for people seeking asylum on the basis of minority sexual ori­ entation or gender identity because they may never have shared these experiences with others (Reading & Rubin, 2011). In their countries of origin, LGBTQ asylum seekers may have experienced shame about their identities and feared sharing them, and they often have expended a great deal of energy trying to con­ ceal their identities (Berg & Millbank, 2009). In giving their narrative, however, asylum seekers are expected to recount the personal details of their own sexual ori­ entation or gender identity, despite any shame and fear they may feel in disclosing (Reading & Rubin, 2011) and any retraumatizing that may occur in the process (Shidlo & Ahola, 2013). This narrative may include intimate information such as their first sexual experiences (Berg & Millbank, 2009), and it often is recounted while asylum seekers are fighting their own internalized homophobia (Piwowarczyk et al., 2017). In addition, asylum seekers carry tremendous risk if they are denied asylum and are required to return to their countries of origin. Heller (2009) discusses asylum seekers’ experience as one of covering and reverse-covering. Covering is the process of covering up one’s identity, and reversecovering is the process of accentuating aspects of one’s identity. To be granted asylum, LGBTQ asylum seekers may feel compelled to prove their identity by conform­ ing to LGBTQ stereotypes, hoping to be more con­ vincing to the decision makers. Heller (2009) argues that both covering and reverse-covering are oppressive and potentially harmful to the asylum seeker. Refugees and asylum seekers face many challenges in their journeys from their countries of origin to the host country. They may express distrust toward offi­ cials that is the result of past experiences of persecu­ tion at the hands of people holding power, which may then extend to host-country government officials, law enforcement officers, and medical and mental health

providers (Reading & Rubin, 2011; Renner, 2009). For example, in a sample of LGBT asylum seekers, Hop­ kinson and colleagues (2017) found that 65 percent identified government authorities as one of the groups that persecuted them. In a study of transgender Mexi­ can asylum seekers, participants frequently mentioned experiencing violence by police (Cheney et al., 2017). Refugees and asylum seekers also face challenges of acculturation as they adapt to their new environments (Reading & Rubin, 2011; Renner, 2009). Their efforts to obtain housing, food, and transportation may be hampered by language barriers and the extreme stress of fleeing their countries of origin. Complicating matters is the high burden of dis­ tress asylum seekers carry with them, in the forms of depression, post-traumatic stress disorder (PTSD), anxiety, grief (Slobodin & de Jong, 2015), loneliness and isolation (Hopkinson et al., 2017; Reading & Rubin, 2011), and significant trauma histories (Heller, 2009; Piwowarczyk et al., 2017; Renner, 2009). In gen­ eral, asylum seekers and refugees regularly report experiencing many atrocities in their countries of ori­ gin, such as threats, arrests and detainment, physical assaults, sexual assaults, withholding of food or med­ ical care, witnessing the harming or killing of loved ones, and being forced to move repeatedly (Alessi, 2016; Hopkinson et al., 2017; Piwowarczyk et al., 2017). LGBTQ asylum seekers in particular also report expe­ riencing forced heterosexual marriage, forced con­ version therapy, “corrective rape” (Alessi, 2016, p. 203), losing their jobs, and being evicted (Piwowarczyk et al., 2017). Hopkinson and colleagues (2017) found that LGBT asylum seekers reported higher rates of sexual trauma and suicidality when compared to nonLGBT asylum seekers. In addition to living with these traumas and their effects, asylum seekers face the possibility of becoming retraumatized when having to recount these experiences of persecution in their narrative testimony (Reading & Rubin, 2011). Whereas some refugees and asylum seekers find social support within local immigrant communities in their host countries, LGBTQ asylum seekers may encounter anti-LGBTQ attitudes from residents coming from their countries of origin (Hopkinson et al., 2017; Portman & Weyl, 2013; Shidlo & Ahola, 2013). Unlike others seeking asylum, LGBTQ people Clinical Work with LGBTQ Asylum Seekers 169

usually cannot depend on their own families for sup­ port because their families often were part of the antiLGBTQ abuse they experienced in their home coun­ try (Hopkinson et al., 2017; Shidlo & Ahola, 2013). LGBTQ asylum seekers have reported either not disclosing their identities to local immigrant commu­ nities or avoiding local communities so as not to be retraumatized (Alessi, 2016; Piwowarczyk et al., 2017). Asylum seekers may find it challenging to access quality mental health care because of differences in expectations about care and difficulties communicat­ ing that are due to language barriers (Slobodin & de Jong, 2015). Asylum seekers may not trust Western practices such as psychotherapy and may perceive seeking assistance for mental health from a stranger to be stigmatizing (Reading & Rubin, 2011). Even with many barriers to treatment, LGBTQ asylum seekers can benefit from engaging in therapy. Creating a safe space for the client is paramount, given the client’s traumatic experiences and the generally unsettled life of an asylum seeker (Alessi, 2016; Piwo­ warczyk et al., 2017; Reading & Rubin, 2011). Cul­ tural sensitivity is also a priority in any interventions with asylum seekers and should be the foundation regardless of techniques used (Slobodin & de Jong, 2015). Social service and legal agencies may refer asy­ lum seekers to mental health services to help them cope with the distressing nature of the asylum-seeking process (Reading & Rubin, 2011). Asylum seekers may also look for therapy to cope with symptoms of PTSD, depression, and anxiety (Renner, 2009). Slobodin and de Jong (2015) conducted a review of mental health interventions for refugees and asy­ lum seekers. The two types of interventions with most empirical support were trauma-focused cognitive behavioral therapy (CBT) and narrative exposure ther­ apy (NET) (Slobodin & de Jong, 2015). In one study cited, a culturally sensitive CBT treatment was devel­ oped on the basis of somatic symptoms experienced by Cambodian refugees (Hinton et al., 2005). In a repeated-measures crossover design, all participants were randomly assigned to immediate or delayed treat­ ment with the culturally sensitive CBT. The authors found that participants in the immediate treatment showed significant improvement in PTSD and anxiety symptoms (Hinton et al., 2005). 170 Wadler, Maroney, & Horne

Studies that included NET in clinical work were also effective in reducing PTSD symptoms (Slobodin & de Jong, 2015). In one study, asylum seekers were assigned to receive either treatment as usual or NET; after treatment, those who had received NET experi­ enced a decrease in PTSD symptoms (Neuner et al., 2010). In another study, refugees and asylum seekers received either NET or stress inoculation training (SIT), and researchers found that NET was more effec­ tive in reducing PTSD symptoms (Hensel-Dittmann et al., 2011). Overall, Slobodin and de Jong (2015) argued that NET was helpful in reducing PTSD symp­ toms among refugees and asylum seekers, but that NET was not necessarily more effective than usual treatment for depression and anxiety. Although research has supported CBT and NET, there is limited ability to generalize from this research because the sample sizes tend to be small or the study is specific to a certain group (Slobodin & de Jong, 2015). Slobodin and de Jong (2015) also discussed the assertion that group therapy can improve the mental health of refugees and asylum seekers. Reading and Rubin (2011) found that group therapy was especially beneficial because it can address asylum seekers’ isola­ tion, shame, and need for social support by increasing universality and sharing of experiences. Much work with asylum seekers and refugees focuses on their symptoms, deficits, and challenges (e.g., Cheney et al., 2017). However, in the face of immense challenges, asylum seekers have shown great resilience (Hopkinson et al., 2017). In a study of resil­ ience among minority sexual and gender identity refugees and asylum seekers, Alessi (2016) provided a definition of resilience as “positive adaptation within the context of significant adversity” (p. 204). In his study, Alessi (2016) identified six themes of resilience: staying hopeful and positive; relying on support from significant others and friends; doing whatever it takes; giving back; spiritual upkeep (for African and Carib­ bean people); and, the most critical, using commu­ nity and legal services. He found that lower symptoms of depression, anxiety, PTSD, stress, and somatic ail­ ments are associated with resilience. Therapists can help clients recognize and foster this resilience, which can have long-term benefits for asylum seekers as they settle in their new country. In clinical practice,

Alessi (2016) suggests that clinicians find ways to help connect LGBTQ clients to community services so that their basic needs can be met, they can find assis­ tance with the asylum process, and they can start to build a supportive community, which will boost their resilience. Therapists who are working with asylum seekers and refugees need to be aware of and examine their own assumptions about therapy, asylum seekers, and forced migration experiences (Reading & Rubin, 2011). Asylum seekers may express different ideas about mental health, sexuality, and gender that are specific to their cultural background; therefore, gaining aware­ ness of what may contribute to their cultural context can benefit therapeutic work (Reading & Rubin, 2011). Clinicians may find it challenging to hear asylum seek­ ers’ violent narratives, as Brice (2011) described when sharing his internal reactions to his client’s narrative. Understanding what LGBTQ asylum seekers have experienced can help clinicians build a therapeutic relationship with these clients. Therapists should have a good understanding of internalized homophobia and internalized transphobia because many asylum seekers have internalized the negative messages from their countries of origin (Reading & Rubin, 2011). Therapists also should familiarize themselves with the clients’ countries of origin and current events there to the degree possible (Renner, 2009). In addition, a trauma-informed approach can shift the focus of ther­ apy from symptoms to understanding how the symp­ toms are attempts to cope with trauma (Alessi, 2016). Asylum seekers and refugees are entitled to ethical treatment and rights as set forth by the United Nations’ Universal Declaration of Human Rights (UN Gen­ eral Assembly, 1948) and other international ethical guidelines (International Panel of Experts, 2017; Inter­ national Union of Psychological Science, 2008). In the American Psychological Association’s (APA) “Ethical Principles of Psychologists and Code of Conduct,” the general principles of beneficence and nonmaleficence, fidelity and responsibility, integrity, justice, and respect for people’s rights and dignity are all applicable to work with LGBTQ asylees (APA, 2017). Clinicians should be aware of their own com­ petence and its limits and work to maintain their com­ petence about LGBTQ asylum seekers (APA, 2017,

standard 2). The activity in this chapter can help clini­ cians identify areas in which clients need additional assistance, which may be beyond clinicians’ compe­ tence. In their work with this population, clinicians also should be especially aware of nationality- or lan­ guage-based discrimination that asylees may face and cooperate with their many other care providers (APA, 2017, standard 3). This activity can help clini­ cians learn about clients’ other needs and other pro­ viders working with the clients. Assessment of asy­ lum clients should be conducted, interpreted, and used thoughtfully, and the clients’ cultural back­ grounds and the limitations of the assessments should be kept in mind (APA, 2017, standard 9). Especially important is that clinicians provide informed con­ sent in a language clients understand well (APA, 2017, standard 10). The following activity should not be used unless the client is comfortable using English or the activity has been correctly translated into the client’s language. Instructions

The following exercise can be used either as a handout for clients to complete, allowing them an opportu­ nity to share experiences that may be challenging for them to disclose in therapy, or as a guide for thera­ pists in sessions with asylum-seeking clients or recent asylum grantees. Therapists can use the exercise during intake, once a relationship has been established, or at multiple points during therapy. Questions can be clini­ cian-administered or self-administered. Clients can respond to questions using the 0–4 scale or a yes/no response, if the latter is more comfortable or easier because of language differences. Open-ended questions include question prompts in parentheses, which are optional. The resources may be adapted to share with clients, as appropriate. Therapists are encouraged to speak with an immigration attorney experienced in LGBTQ asylum cases for the most accurate and up-to­ date legal information. Brief Vignette

Sam, age twenty-six, is an asylum seeker from Somalia who identifies as a cisgender gay man and a Muslim. He fled his refugee camp several months before, after receiving multiple death threats because of rumors Clinical Work with LGBTQ Asylum Seekers 171

about his sexual encounters with other men. Sam has been experiencing nightmares, fatigue, and insomnia that his primary doctor could not explain, so he has been referred to Joan, a counselor at the community health center. As part of building rap­ port in the second session, Joan asks Sam, “What have been your experiences so far with housing?” Through this process she learns that Sam is having trouble finding safe and stable housing. With this information, Joan refers Sam to the case manager at the local resettlement agency, who is able to help resolve the housing concerns. After exploring his experiences finding a welcoming religious or spiri­ tual community, Joan also learns the importance of Islam in Sam’s life, and how he is missing this source of strength and support in the United States. Joan con­ nects Sam to a local LGBTQ- affirming Muslim com­ munity, which he later reports is very helpful and comforting to him. Through listening to and working to address Sam’s immediate concerns, Joan builds enough trust with Sam that he feels comfortable answering questions from the first page of the activ­ ity (e.g., How often do you have trouble sleeping?). Joan and Sam then start to address his nightmares, insomnia, and fatigue. Suggestions for Follow-up

The exercise as a handout can be repeated at the con­ clusion of therapy or at the beginning and conclusion of a therapy group. It can then be used to set goals for post-treatment or to realign goals for continued work. Contraindications for Use

This exercise should not be used with clients who cannot read English with understanding, unless it has been professionally translated into a language the client can understand. Professional Readings and Resources Center for Victims of Torture. (n.d.). Heal torture. https:// www.healtorture.org/content/mental-health-resources. Heartland Alliance. (n.d.). Rainbow response: A practical guide to resettling LGBT refugees and asylees. Chicago: Heart­ land Alliance. http://www.rainbowwelcome.org/uploads/ pdfs/Rainbow%20Response_Heartland%20Alliance%20 Field%20Manual.pdf.

172 Wadler, Maroney, & Horne

Heartland Alliance International. (n.d.). Rainbow Welcome Initiative. www.rainbowwelcome.org. LGBT Freedom Asylum Network (FAN). (n.d.). http://www. lgbt-fan.org/. McGuirk, S., Niedzwiecki, M., Oke, T., & Volkova, A. (2015). Stronger together: A guide to supporting LBGT asylum seekers in the US. Washington, DC: LGBT Freedom Asy­ lum Network. http://www.lgbt-fan.org/wp-content/ uploads/2015/06/Stronger_Together_FINAL.pdf. Mulé, N. J., & Gates-Gasse, E. (2012). Envisioning LGBT ref­ ugee rights in Canada: Exploring asylum issues. http:// www.ocasi.org/downloads/Envisioning_Exploring_ Asylum_Issues.pdf. Muller, R. T. (2015, September 10). LGBTQ refugees lack mental healthcare. Psychology Today. https://www. psychologytoday.com/blog/talking-about-trauma/ 201509/lgbtq-refugees-lack-mental-healthcare. Organization for Refuge, Asylum and Migration (ORAM). (n.d.). http://oramrefugee.org/. Organization for Refuge, Asylum & Migration (ORAM). (2012). Rainbow bridges: A community guide to rebuilding the lives of LGBTI refugees and asylees. http://www.refugee legalaidinformation.org/sites/srlan/files/fileuploads/ oram-rainbow-bridges-2012.pdf.

Resources for Clients Okparanta, C. (2015). Under the udala trees. Boston: Hough­ ton Mifflin Harcourt. Papalexandris, J. (2016). Five bells: Being LGBT in Australia. New York: New Press. Quesada, U., Gomez, L., & Vidal-Ortiz, S. (eds.). (2015). Queer brown voices: Personal narratives of Latino/a LGBT activ­ ism. Austin: University of Texas Press. Spijkerboer, T. (ed.). (2013). Fleeing homophobia: Sexual ori­ entation, gender identity, and asylum. New York: Routledge.

References Alessi, E. J. (2016). Resilience in sexual and gender minority forced migrants: A qualitative exploration. Traumatology, 22 (3), 203–213. doi:10.1037/trm0000077. American Psychological Association (APA). (2017). American Psychological Association ethical principles of psycholo­ gists and code of conduct. https://www.apa.org/ethics/ code/. Berg, L., & Millbank, J. (2009). Constructing the personal narratives of lesbian, gay, and bisexual asylum claimants. Journal of Refugee Studies, 22 (2), 195–223. doi:10.1093/ jrs/fep010. Brice, A. (2011). “If I go back, they’ll kill me . . .”: Personcentered therapy with lesbian and gay clients. PersonCentered & Experiential Psychotherapies, 10 (4), 248–259. doi:10.1080/14779757.2011.626624.

Brodie, K., Craig, A., & Amaro, J. (2015, October 15). Report to support LGBT asylum seekers released by HRC, LGBT FAN, and National LGBTQ Task Force. https://www.hrc. org/press/groundbreaking-report-to-support-lgbt­ asylum-seekers-released-today-by-hrc. Cheney, M. K., Gowin, M. J., Taylor, E. L., Frey, M., Dunnington, J., Alshuwaiyer, G., . . . Wray, G. C. (2017). Living out­ side the gender box in Mexico: Testimony of transgender Mexican asylum seekers. American Journal of Public Health, 107, 1646–1652. doi:10.2105/AJPH.2017.303961. Department of Homeland Security Office of Immigration Statistics (DHS-OIS). (2019). Annual flow report: Refugees and asylees: 2017. https://www.dhs.gov/sites/default/files/ publications/Refugees_Asylees_2017.pdf. Heller, P. (2009). Challenges facing LGBT asylum-seekers: The role of social work in correcting oppressive immigration processes. Journal of Gay & Lesbian Social Services, 21 (2–3), 294–308. doi:10.1080/10538720902772246. Hensel-Dittmann, D., Schauer, M., Ruf, M., Catani, C., Oden­ wald, M., Elbert, T., & Neuner, F. (2011). The treatment of victims of war and torture: A randomized controlled com­ parison of narrative exposure therapy and stress inocu­ lation training. Psychotherapy and Psychosomatics, 80, 345–352. doi:10.1159/000327253. Hinton, D. E., Chean, D., Pich, V., Safren, S. A., Hofmann, S. G., & Pollack, M. H. (2005). A randomized controlled trial of cognitive-behavior therapy for Cambodian refugees with treatment-resistant PTSD and panic attacks: A cross-over design. Journal of Traumatic Stress, 18, 617– 629. doi:10.1002/jts.20070. Hopkinson, R. A., Keatley, E., Glaeser, E., Erickson-Schroth, L., Fattal, O., & Nicholson Sullivan, M. (2017). Persecution experiences and mental health of LGBT asylum seekers. Journal of Homosexuality, 64 (12), 1650–1666. doi:10.108 0/00918369.2016.1253392. International Panel of Experts (2017). The Yogyakarta principles: Additional principles and state obligations on the applica­ tion of international human rights law in relation to sex­ ual orientation, gender identity, gender expression and sex characteristics to complement the Yogyakarta principles. www.yogyakartaprinciples.org/principles-en/yp10. International Union of Psychological Science (2008). Univer­ sal declaration of ethical principles for psychologists.

http://www.iupsys.net/about/governance/universal­ declaration-of-ethical-principles-for-psychologists.html. McGuirk, S., Niedzwiecki, M., Oke, T., & Volkova, A. (2015). Stronger together: A guide to supporting LBGT asylum seekers in the US. Washington, DC: LGBT Freedom Asy­ lum Network. http://www.lgbt-fan.org/wp-content/ uploads/2015/06/Stronger_Together_FINAL.pdf. Neuner, F., Kurreck, S., Ruf, M., Odenwald, M., Elbert, T., & Schauer, M. (2010). Can asylum seekers with posttrau­ matic stress disorder be successfully treated? A random­ ized controlled pilot study. Cognitive Behavioral Therapy, 39, 81–91. doi:10.1080/16506070903121042. Piwowarczyk, L., Fernandez, P., & Sharma, A. (2017). Seeking asylum: Challenges faced by the LGB community. Jour­ nal of Immigrant and Minority Health, 19 (3), 723–732. doi:10.1007/s10903-016-0363-9. Portman, S., & Weyl, D. (2013). LGBT refugee resettlement in the US: Emerging best practices. Forced Migration Review, 1 (42), 44–47. Reading, R., & Rubin, L. R. (2011). Advocacy and empower­ ment: Group therapy for LGBT asylum seekers. Trauma­ tology, 17 (2), 86–98. doi:10.1177/1534765610395622. Renner, W. (2009). The effectiveness of psychotherapy with refugees and asylum seekers: Preliminary results from an Austrian study. Journal of Immigrant and Minority Health, 11, 41–45. doi:10.1177/0020764014535752. Shidlo, A., & Ahola, J. (2013). Mental health challenges of LGBT forced migrants. Forced Migration Review, 1 (42), 9–11. Slobodin, O., & de Jong, J. T. V. M. (2015). Mental health inter­ ventions for traumatized asylum seekers and refugees: What do we know about their efficacy? International Journal of Social Psychiatry, 61 (1), 17–26. doi:10.1177/ 0020764014535752. United Nations (UN) General Assembly. (1948). Universal declaration of human rights. https://www.ohchr.org/EN/ UDHR/Documents/UDHR_Translations/eng.pdf. United Nations High Commissioner for Refugees (UNHCR). (2011). Handbook and guidelines on procedures and crite­ ria for determining refugee status: Under the 1951 conven­ tion and the 1967 protocol relating to the status of refugees. Geneva: United Nations. http://www.unhcr.org/3d58e13b4. pdf.

Clinical Work with LGBTQ Asylum Seekers 173

HOW I FEEL: EXPERIENCES OF ASYLUM SEEKERS Please answer the following questions thinking about how you have felt over the past seven days. Use the following scale to respond by writing the number that corresponds to how you feel. 0 Not at all

1 A little

2 Sometimes

3 Quite a bit

4 Extremely

1. How often have you had repeated thoughts about hurtful things that happened to you in the past? 2. How often do you feel connected to your new country? 3. How often do you avoid things that remind you of hurtful things that happened in the past? 4. How often do you have trouble sleeping? 5. How often have you felt accepted as an LGBTQ person in this community? 6. How often do you lose interest in daily activities? 7. How often have you felt unsure about who it is safe to come out to in your new country? 8. How often do you have angry outbursts? 9. How often have you felt that it is easier to be an LGBTQ person here in this country? 10. How often do you feel disconnected from other people? 11. How often have you gotten to know people in your new country? 12. How often is it hard to concentrate? 13. How often have you felt relief that you are in your new country? 14. How often do you have trouble with your memory?

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Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne

What have been your experiences since arrival in your host country? Please answer the questions about your experiences in the following parts of your life. 1. Housing? (Have you found safe, stable housing? Are you having any trouble with your living situation? What are the current challenges, if any?)

2. Food? (Do you have enough food? Are you able to find food you like?)

3. Religion or spirituality? (If this is important to you, have you been able to find a welcoming place of worship or a religious or spiritual community?)

4. Employment or volunteer work? (Have you obtained an employment authorization document? Do you need English language classes to prepare for employment?)

5. The asylum process? (What is the status of your asylum claim? Have you connected with immigration legal counsel?)

6. Being an LGBTQ person living here? (Are you able to be open about your LGBTQ identity? What has it been like with new friends? Where you live?)

7. In your transition to the United States, who has been helpful? (What people, resources, organizations are helpful? Whom can you count on?)

8. What helps you keep going? (What things specific to you as a person have helped you overcome so many barriers so far? What are your strengths?)

9. What else do you think I should know about you? What will help me understand your experience?

Brianna M. Wadler, Meredith R. Maroney, and Sharon G. Horne

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20 VALUE-DRIVEN EXPLORATION OF INTERSECTIONS BETWEEN SEXUAL AND RELIGIOUS IDENTITY Angelica Terepka and Jennifer Lancaster Suggested Use: Activity Objective:

This activity is designed to facilitate integration of sexual and religious identities through a valuesexploration process. Rationale for Use

Individuals who both are religious and identify as a sexual minority member must navigate the complex terrain of integrating their sexual identity with reli­ gious messages (both affirming and nonaffirming) about sexual orientation. Because of the potential con­ flict between these identities, individuals may be tempted to deny one aspect of themselves and uphold the other; doing so may result in a sense of loss and a lack of integration of the individual as a whole (Shea, 2005). Additionally, research suggests that cultural factors affect the integration of religious and sexual identities (Akerlund & Cheung, 2000; Sremac & Ganzevoort, 2015). For example, Caucasian American religious LGBT individuals are more likely than eth­ nic minorities to leave one affiliation and opt for a more LGBT-affirming religion (Marin, 2016). It would seem that white individuals experience more freedom to explore other religious options as a means of decreasing conflict between their religious and sexual identities, whereas members of minority populations feel a sense of responsibility to family and communi­ ties of fellowship, which decreases their likelihood of leaving their religious community (Marin, 2016). Thus, the path to integration of religious and sexual identi­ ties may look different across people of varying racial

groups and cultures (Adamczyk & Pitt, 2009; Lease, Horne, & Noffsinger-Frazier, 2005). Assisting clients who identify as both a sexual minority and religious in an exploration of their values pertaining to both aspects of identity may help them experience growth and integration in these domains rather than feeling they must choose one over the other (Bozard & Sanders, 2011). The ethical code states that psychologists must be aware of and respect diver­ sity, including religious and sexual identity domains (American Psychological Association [APA], 2017, principle E); professionals should thus aim to help clients identify and integrate values derived from both identities in a manner that upholds both aspects of client diversity. For example, Bozard and Sanders (2011) developed a counseling model aimed at assess­ ment of the salience of religious identity and sexual identity as well as determination of potential conflict between these domains. The authors further propose interventions aimed at integration of these identities in an effort to recover religion as a source of strength for LGB clientele. Although the current activity does not specifically use Bozard and Sanders’s (2011) model, it does offer a way of exploring these meaningful identities in an effort to move toward a successful inte­ gration for individuals who identify as both religious and LGBT. Furthermore, research has shown that self-acceptance and increased knowledge are instru­ mental in successful integration of LGBT and religious identities (Dahl & Galliher, 2009); identification of values related to both identities may contribute to the increased knowledge and self-awareness necessary for healthy integration.

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

176

The American Psychological Association urges psychologists to understand how multiple minority statuses may complicate and exacerbate the oppres­ sion and discrimination that clients experience (APA, 2017, principle E, standard 2.01). Further, integration of multiple identities may be challenging for some individuals who identify with two or more commu­ nities that have conflicting views. For example, people who identify with the Mormon religion may feel pro­ hibited from expressing their sexual orientation as gay or lesbian (Goodwill, 2008). Psychologists are there­ fore encouraged to help clients explore the domains of diverse identities in an effort to find commonali­ ties and compatible intersections between identities, while recognizing and working to reduce conflicting values in these domains of identity (APA, 2008). In accordance with this effort, models for assessment and integration of religious and sexual identity in coun­ seling have been developed (Bozard & Sanders, 2011). The manner in which LGBT individuals are viewed in a religious milieu varies among religious denominations and cultural contexts (Adamczyk & Pitt, 2009; Lease et al., 2005). Some individuals may find their religion affirming of their sexual orienta­ tion and, as a result, experience little to no conflict in expressing both aspects of their identity. However, the majority of individuals find religious traditions to be nonaffirming of sexual minorities (Gibbs, 2015); there­ fore, religious LGBT people may fear rejection from family, clergy, and their congregation. Another diffi­ culty religious LGBT individuals may experience involves discrimination by nonreligious LGBT people. O’Brien (2004) suggests that a “double stigma” (p. 181) exists for LGBT Christians who feel rejected by their religious community and also feel rejected by other LGBT persons, who may be contemptuous of Christi­ anity, for being openly religious. Such circumstances increase the psychological distress religious LGBT indi­ viduals may experience when attempting to integrate and express both religious and sexual identities (e.g., Rodriguez & Ouellette, 2000; Wood & Conley, 2014). The varying stance of LGBT individuals among reli­ gious traditions in combination with the individual’s own religious inclination leads to several ways in which LGBT people may express religious identities. MacDonald (2006) describes the following five cate­

gories of religious expression by LGBT individuals: • Religion is personally irrelevant: Individuals identify as atheists or nonfaithful. They do not experience a need to express themselves through religious means. Persons in this category do not typically experience a personal conflict between religious beliefs and sexual orientation. • Religious moratorium: Notions of religion and spir­ ituality are actively rejected. Negative emotional energy such as anger and resentment may be directed toward religion. This type of religious expression by LGBT people may be reactionary following rejec­ tion by a specific religious institution or protection from future potential rejection by a religion. • Adoption of alternative spiritualities: Individuals may foster their spiritual life through adoption of new religious beliefs. Some individuals may leave their original place or community of worship for another, more affirming congregation or faith tradition. As a result, individuals may experience loss of relation­ ships associated with their religious community and a change in their religious identity. • Assimilation within a traditional religion while affirming one’s sexual identity: LGBT individuals may acknowledge their sexual orientation and decide to continue associating with their religious community despite negative responses from that community. Some individuals in this position may feel obligated to continue engaging in their religious traditions or may lack awareness of more affirming religious traditions. Others may find that the religious tenets of their faith tradition continue to play a large role in their lives regardless of the rejection of their sex­ ual orientation (Pietkiewicz & KołodziejczykSkrzypek, 2016). • Accommodation of the moral tenets of traditional religions by rejection or suppression of personal sex­ ual identity: Individuals in this position may keep their sexual orientation a secret and denounce this aspect of their identity; they may even seek more religiously orientated conversion-type therapies. This position is both psychologically and spiritually damaging (Kelliher, 2012). The following activity aims to help clinicians and clients Value-Driven Exploration of Sexual and Religious Identity 177

explore values related to two different domains of identity (sexuality and religiosity) and find ways in which clients can integrate these domains in a healthy manner. The activity is based on components of Accep­ tance and Commitment Therapy (ACT; Hayes, 2013). One of the key components of ACT is to help the cli­ ent choose to focus on thoughts and behaviors that are consistent with the values held by the client (Robb, 2007). The aim of values clarification in ACT is to help clients identify what is important in their lives. Val­ ues can be defined as principles chosen by individuals as important standards of behavior, which become the predominant reinforcer of behavior. These values may be innate or socially derived from the construc­ tions of religion, family, education, and other areas. Many people experience difficulty when one or more of these value systems are inconsistent or perceived to be in conflict (Hayes et al., 2013). When faced with this dissonance, it is common for clients to attempt to “decide” between the two values or sys­ tems, rather than try to integrate them. This activity centers on the goal of helping psychologists carry out their ethical responsibility to acknowledge and respect aspects of diversity (including those based on religion and sexual identity) (APA, 2017, principle E; standard 2.01) and aid clients with the integration of their distinct identities. Additionally, the foundation of this activity in ACT allows for the exploration of values in an affirmative and inclusive manner (Hays, 2009), one in which clients can embrace their sexual identity and religious identity simultaneously within the context of their values. Further, the purpose of the activity is in line with the ethical guidelines for multicultural education, training, research, and practice devised by the APA (2008). Specifically, guideline 2 notes the importance of multicultural sensitivity, responsiveness, knowledge, and understanding of factors contributing to the diversity of individuals (APA, 2008). Inherent in the proposed activity is the identification of client values related to two specific identities that clients may hold. Additionally, the activity will allow mental health pro­ viders to better implement guideline 5, which encour­ ages the application of culturally appropriate skills in clinical practice (APA, 2008). The exercise can help

178 Terepka & Lancaster

therapists develop the skill of exploring the client’s val­ ues and identifying possible conflicts among those values to help preserve the unique multicultural iden­ tities held by the client. Instructions

This exercise is best used in individual settings but could be easily adapted for group treatment. Addition­ ally, this activity can be completed during sessions in collaboration with a therapist, or it can be assigned as homework for the client to complete independently. The main purpose of the activity is to stimulate explo­ ration and discussion of values (religious and social) pertinent to the client. Questions to prompt consideration of values in general, as well as values specific to religion and sex­ uality, are provided. Following initial consideration, clients are encouraged to complete the activity (specific instructions are provided on the worksheet). Last, collaborative review of the worksheet should take place with specific emphasis on identification of val­ ues that appear to be inconsistent with the integration of religious and sexual identities. Brief Vignettes

Jenna is an eighteen-year-old cisgender Arab Ameri­ can woman who identifies as Muslim and bisexual. She is heavily involved in her religious community and an active member of her Saudi Arabian cultural center. She has not disclosed her sexual orientation to her family or religious community. Jenna also vol­ unteers at a local LGBTQ center, where she is out and provides support for individuals who identify as members of sexual minorities. Jenna presents for ther­ apy with anxiety and depression, stating that she feels as though she is “leading a double life.” The clinician engages in the values-driven exploration activity, and Jenna is able to realize that her work in all social con­ texts derives from her core values of community, car­ ing, and compassion. Once Jenna recognizes the sim­ ilarities among her work in her religious community, cultural center, and the LGBTQ center, she is able to consider other possible values that are relevant to her religious and sexual identities (e.g., importance of relationships and intimacy). Furthermore, Jenna’s ther­

apeutic exploration and integration of her own val­ ues help her understand how others around her may also begin to view her as both bisexual and religious. James is a thirty-two-year-old gay cisgender Polish American male presenting for treatment with symp­ toms of depression. He was raised in a strict Catholic household and was very much involved with his church as an adolescent. In his early twenties, he explored his sexual orientation and recognized his identity as gay; at this time, he also became distant from his church and religious beliefs. Although he has disclosed his sexual orientation to his family and is currently in a healthy, committed same-sex relationship, he reports experiencing symptoms of depression and the feel­ ing that “something is missing from [his] life.” While working with James, his clinician encourages him to consider his life journey as a religious man and his life journey as gay separately; in session, James and his clinician compare his experiences, and James realizes that his coming out coincided with his loss of reli­ gious identity. He notes his childhood assumption that his Catholic faith completely denounced homosexu­ ality, which resulted in uncomfortable cognitive dis­ sonance. James completes the values-driven activity to explore both his religious and sexual identities. He is able to identify the Catholic virtue of an all-loving and accepting God along with his own value of accept­ ing his sexual identity. He also finds correlations between his identities on values such as relationships, respect, love, compassion, and connection; James even recalls biblical stories of same-sex individuals who were depicted as loving and caring for each other deeply. Exploring similarities among values supporting both identities helps James integrate his self-under­ standing as a gay Catholic man. Suggestions for Follow-up

This is a values-identification exercise. The next step is to examine consistencies and inconsistencies between clients’ religious and sexual identities and determine a value-driven plan of action for identity integration. For example, clients may consider ways in which they may fulfill their religious or spiritual growth needs in the context of an LGBT sexual identity. Clients may also consider finding a supportive religious commu­ nity or engaging in bibliotherapy offering affirmative interpretations of religious scripture.

Contraindications for Use

Clients who are just beginning to explore their sexual identity or their religious identity may find that this exercise is too involved. Integrations of values assess­ ment are more easily accessible for clients who have more thoroughly explored each individual aspect of their identity. Readings for the Professional American Psychological Association (APA) (2009). Report of the APA’s Task Force on Appropriate Therapeutic Responses to Sexual Orientation. Washington, DC: APA. Beagan, B. L., & Hattie, B. (2015). Religion, spirituality, and LGBTQ identity integration. Journal of LGBT Issues in Counseling, 9 (2), 92–117. doi:10.1080/15538605.2015.10 29204. Bozard, R. L., & Sanders, C. J. (2011). Helping Christian les­ bian, gay, and bisexual clients recover religion as a source of strength: Developing a model for assessment and inte­ gration of religious identity in counseling. Journal of LGBT Issues in Counseling, 5 (1), 47–74. Faulkner, S. L., & Hecht, M. L. (2011). The negotiation of closetable identities: A narrative analysis of lesbian, gay, bisexual, transgendered queer Jewish identity. Journal of Social and Personal Relationships, 28 (6), 829–847. Pietkiewicz, I. J., & Kołodziejczyk-Skrzypek, M. (2016). Living in sin? How gay Catholics manage their conflicting sex­ ual and religious identities. Archives of Sexual Behavior, 45 (6), 1573–1585. Shah, S. (2016). Constructing an alternative pedagogy of Islam: The experiences of lesbian, gay, bisexual and transgender Muslims. Journal of Beliefs & Values: Studies in Religion & Education, 37 (3), 308–319.

Resources for Clients Human Rights Campaign. (2019). Resources: Religion and faith. https://www.hrc.org/resources/topic/religion-faith. Marin, A. (2016). Us versus us: The untold story of religion and the LGBT community. Colorado Springs, CO: NavPress. Michaelson, J. (2011). God vs. gay? The religious case for equal­ ity. Boston: Beacon Press. Siraj al-Haqq Kugle, S. (2010). Sexual diversity in Islam: Is there room in Islam for lesbian, gay, bisexual and transgender Muslims? www.mpvusa.org/sexuality-diversity/.

References Adamczyk, A., & Pitt, C. (2009). Shaping attitudes about homo­ sexuality: The role of religion and cultural context. Social Science Research, 38 (2), 338–351. Akerlund, M., & Cheung, M. (2000). Teaching beyond the defi­ cit model: Gay and lesbian issues among African Ameri­ cans, Latinos, and Asian Americans. Journal of Social Work Education, 36 (2), 279–292. Value-Driven Exploration of Sexual and Religious Identity 179

American Psychological Association (APA). (2008). Report of the Task Force on the Implementation of the Multicultural Guidelines. Washington, DC: Author. https://www.apa. org/about/policy/multicultural.aspx. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Bozard, R. L., & Sanders, C. J. (2011). Helping Christian les­ bian, gay, and bisexual clients recover religion as a source of strength: Developing a model for assessment and inte­ gration of religious identity in counseling. Journal of LGBT Issues in Counseling, 5 (1), 47–74. Dahl, A. L., & Galliher, G. V. (2009). LGBQQ young adult experiences of religious and sexual identity integration. Journal of LGBT Issues in Counseling, 9 (2), 92–112. Gibbs, J. J. (2015). Religious conflict, sexual identity, and sui­ cidal behaviors among LGBT young adults. Archives of Suicide Research, 19 (4), 472–488. Goodwill, K. A. (2008). Religion and the spiritual needs of gay Mormon men. Journal of Gay and Lesbian Social Services, 11 (4), 23–37. Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013). Acceptance and commitment ther­ apy and contextual behavioral science: Examining the progress of a distinctive model of behavioral and cogni­ tive therapy. Behavior Therapy, 44 (2), 180–198. http:// doi.org/10.1016/j.beth.2009.08.002. Hays, P. A. (2009). Integrating evidence-based practice, cog­ nitive-behavior therapy, and multicultural therapy: Ten steps for culturally competent practice. Professional Psy­ chology: Research and Practice, 40 (4), 354–360. Kelliher, A. (2012). The challenges of supporting the spiritual and religious journey of lesbian, gay, bisexual and transgender clients. Inside Out, 68. http://iahip.org/inside-out/ issue-68-autumn-2012/the-challenges-of-supporting-the­ spiritual-and-religious-journey-of-lesbian-gay-bisexualand-transgender-clients.

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Lease, S. H., Horne, S. G., & Noffsinger-Frazier, N. (2005). Affirming faith experiences and psychological health for Caucasian lesbian, gay, and bisexual individuals. Journal of Counseling Psychology, 52 (3), 378–388. MacDonald, S. V. (2006). Spiritual journey mapping with les­ bian, gay, and bisexual clients. In K. B. Helmeke & C. F. Sori (eds.), The therapist’s notebook for integrating spiri­ tuality in counseling II: More homework, handouts, and activities for use in psychotherapy, 177–188. Binghamton, NY: Haworth Press. Marin, A. (2016). Us versus us: The untold story of religion and the LGBT community. Colorado Springs, CO: NavPress. O’Brien, J. (2004). Wrestling the angel of contradiction: Queer Christian identities. Culture and Religion, 5, 179–202. Pietkiewicz, I. J., & Kołodziejczyk-Skrzypek, M. (2016). Living in sin? How gay Catholics manage their conflicting sex­ ual and religious identities. Archives of Sexual Behavior, 45 (6), 1573–1585. Robb, H. (2007). Values as leading principles in acceptance and commitment therapy. International Journal of Behavioral Consultation and Therapy, 3 (1), 118–122. Rodriguez, E. M., & Ouellette, S. C. (2000). Gay and lesbian Christians: Homosexual and religious identity integration in the members and participants of a gay-positive church. Journal for the Scientific Study of Religion, 39 (3), 333–347. Shea, J. J. (2005). Finding God again: Spirituality for adults. Lanham, MD: Rowman and Littlefield. Sremac, S., & Ganzevoort, R. R. (eds.). (2015). Religious and sexual nationalisms in central and eastern Europe: Gods, gays, and governments. Leiden: Brill. Stitt, A. L. (2014). The cat and the cloud: ACT for LGBT locus of control, responsibility, and acceptance. Journal of LGBT Issues in Counseling, 8 (3), 282–297. Wood, A. W., & Conley, A. H. (2014). Loss of religious or spir­ itual identities among the LGBT population. Counseling and Values, 59, 95–111.

QUESTIONS TO AID THE PROCESS OF GENERAL VALUES EXPLORATION Consider your personal values. Think of the different domains of your life, including relationships (friendships, romantic connections, family), spirituality, work or education, and leisure time. What really matters to you? What do you want to accomplish with your time? What type of person do you want to be? Which personal qualities do you admire in others? Which qualities do you want to develop? Questions to aid the process of exploring values related specifically to religion and sexuality: • Can you tell me about the religious life in your family when you were young?

• How did you know religion was important for your relatives?

• How did you know religion was important to you?

• How do you experience your religion? (e.g., uplifting, hopeful, encouraging, harsh, punishing, shaming)

• When and how did you realize you were LGBT?

• How did you experience and interpret your attraction to same-sex individuals?

• What changes in your behavior have you noticed since you identified as LGBT?

• What experiences have you had in the coming-out process? Were there times when what happened was different from your expectations? What was that like?

• How did your relatives and religious community refer to sexuality?

• What did your family and religious community think about homosexuality? How did that affect you?

• How do religious beliefs affect you as an LGBT person?

• How does being LGBT affect your spiritual or religious practice?

• Which of your religious beliefs uphold respect for your sexuality or gender identity? Angelica Terepka and Jennifer Lancaster

181

ACTIVIT Y: CL ARIF Y YOUR VALUES Here is a list of some common values people may find important. Please read through the list and determine how important each value is to you, on a scale of 1 to 4 (1 = not at all important; 2 = not very important; 3 = somewhat important; 4 = very important). Once you have identified which values are important to you, consider if the values that are important to you affirm your religious identity and your sexual orientation. Value

Importance

Religious identity

Acceptance/self-acceptance Adventure Authenticity Caring/self-care Community Compassion/self-compassion Connection Courage Encouragement Fairness and justice Forgiveness/self-forgiveness Freedom and independence Gratitude Honesty Intimacy Kindness Love Relationships Respect/self-respect Sexuality Supportiveness Trust Other: Other: 182

Angelica Terepka and Jennifer Lancaster

Sexual orientation

SECTION III

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

RELATIONSHIPS

Value-Driven Exploration of Sexual and Religious Identity 183

There are many facets to relationships that are unique to individuals who identify as LGBTQ+. Differences in levels of being out, management of oppression and stigma, and internalized homonegativity, heterosex­ ism, and transphobia can all play significant roles in relational dynamics (Meladze & Brown, 2015). This section provides activities and handouts to help clients navigate these themes as well as issues related to inter­ secting religious, racial, ethnic, and social-class iden­ tities. They address social media, sexuality, eroticism, intimacy, violence, and power in innovative and pow­ erful ways. Group therapy is particularly useful for learning and practicing relationship skills. Luke R. Allen shares a group activity for trans youth about creating safe and positive connections in “Transgender Youth and Healthy Relational Skills” (Chapter 23). Because trans youth receive too little relationship skill development that is designed specifically for their experiences, this exercise seeks to answer important questions for these youth and provides essential modeling of healthy relat­ ing. In “Two Stars and a Wish: Termination Activities for Groups with Sexual- and Gender-Identity Diverse Clients” (Chapter 24), Theodore R. Burnes introduces a group therapy exercise to work on an often-avoided skill: the ability to say a meaningful good-bye. Burnes points out that it can be especially disappointing for sexual and gender minorities to leave supportive relationships when they face so much oppression outside the therapeutic group. Assisting them in processing the relationships in the group helps them use termination as a way to deepen the connections they have formed and empowers them to internalize what they have gained to use in current and future relationships. With regard to sexuality in relationships, two chapters focus specifically on open communication about desire and needs. In “Exploring and Navigating Sexual Desire in Relationships” (Chapter 21), Sara K. Bridges outlines the ways in which societal and cul­ tural messages regarding gender roles, sexual iden­ tity, and sexuality come into play when communicating and experiencing sexual desire. In her exercises, cli­ ents are guided through deep exploration of the per­ sonal meanings they have constructed regarding sexual desire so that they can more effectively communicate 184

these preferences and wants with their partners. Kandice H. van Beerschoten introduces another way to help clients explore their sexual desires in “BDSM Exploration and Communication within LGBT Rela­ tionships” (Chapter 27). Van Beerschoten notes that LGBT clients often face more judgment about BDSM practices than do cisgender and heterosexual indi­ viduals, which makes it harder for them to find sup­ portive spaces within which to explore their interests. Because safety and excellent communication are crit­ ical to the practice of BDSM, it is important for cli­ ents to have an affirming place and methods to dis­ cuss their issues of safety, fears, and health concerns. Theodore R. Burnes offer another way of helping clients explore their needs and the messages they have received about relationships in Chapter 25, “The Quadrant Exercise of Relationship Exploration for Sexual- and Gender-Identity Diverse Clients.” This handout can be used with groups or in individual ther­ apy. It provides clients with a nonjudgmental stance by which they can clarify their own values and needs while also identifying negative societal messages that they don’t want to endorse. It is crucial for therapists to address violence of any kind in romantic relationships. As Sabina de Vries notes in “Intimate Partner Violence: Initial Interven­ tions for LGBTQ Clients” (Chapter 22), there are sim­ ilar or higher rates of interpersonal violence among sexual minorities than among heterosexual women, yet there are fewer services available for battered part­ ners in same-sex relationships. These statistics make the need for LGBTQ-affirming therapists even more pressing in this area. Taking into account the ways in which clients may be isolated because of both their sexual identity and their status as a survivor of intimate partner violence, the author helps therapists provide extensive psychoeducation and create an appropriate safety plan for their clients. No discussion of relationships would be complete without exploring the role of social media. Nathaniel Amos addresses the client’s well-being as well as the nuances of the therapeutic relationship in the age of technology in Chapter 26, “Negotiating Information and Communication Technologies with Sexual and Gender Minority Youth and Young Adults.” Use of social media and online resources is salient for LGBTQ

youth because many turn to the Internet for connec­ tion when they experience rejection at home or school. As a result, clients may be having negative experiences online that are important to process. It is also possi­ ble for boundaries between the therapist and client to be blurred when there is more information available about both parties in cyberspace than is being shared in the room. Amos provides therapists with effective

strategies to assess the client’s “digital footprint” as well as the therapist’s use of technology and its influ­ ence on the therapeutic relationship. Reference Meladze, P., & Brown, J. (2015). Religion, sexuality, and inter­ nalized homonegativity: Confronting cognitive dissonance in the Abrahamic religions. Journal of Religion and Health, 54 (5), 1950–1962. doi:10.1007/s10943-015-0018-5.s.

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21 EXPLORING AND NAVIGATING SEXUAL DESIRE IN RELATIONSHIPS Sara K. Bridges Suggested Uses: Homework, handout Objective

The aim of these activities and the corresponding homework is to help couples explore their individual and relational experiences of sexual desire and its fluc­ tuations. In particular, these exercises are designed to help dispel implicit adherence to societal assumptions about desire and desire discrepancy in relationships by expanding awareness of personal and relational sexual desire independent of societal expectations. Rationale for Use

Sexual relationships are complex, and the assumption of mutual pleasure and desire that ultimately result in synchronized mutual orgasms is a myth maintained by popular culture. This myth perpetuates both a notion of how good sex should look and feel (McCarthy & Wald, 2015) and how much partners should desire each other, which often results in feelings of inadequacy or failure. In reality, couples routinely expe­ rience different degrees of desire, and the presence or absence of desire fluctuates over time. Additionally, over the course of a relationship, sexual desire often changes because of contextual issues such as relation­ ship satisfaction, stress, health, and the simple fatigue that comes from responding to the tasks of daily living (McCarthy & Wald, 2015). However, the recent trend toward the medicalization of sexuality (Meixel, Yan­ char, & Fugh-Berman, 2015; Tiefer, 2012) has high­ lighted the issue of desire difficulties and has prob­ lematized these normal fluctuations even further. Thus, what could formerly be perceived as a common ebb and flow of sexual desire within a relationship

despite cultural norms is frequently seen, owing in part to societal expectations and media representation, as pathological or necessarily problematic. Conversely, other research has shown that for many lesbian cou­ ples, sexual desire discrepancies are problematic only if the couple themselves view the discrepancies as a problem (Bridges & Horne, 2007), and shifts in desire for same-sex couples are not necessarily an indication of a change in love or affection (Diamond, 2013). For same-sex partners, issues related to level of “outness,” internalized homonegativity, stigma, and gender-based stereotypes (e.g., gay male couples have copious amounts of sex and are open about casual extrarelational sex, and lesbian couples have a sex life that dwindles over time) can all play a role in the experience and expression of sexual desire (Diamond, 2013; Meladze & Brown, 2015). Additionally, the underlying assumption of sexual similarity is particu­ larly tempting for same-sex couples who often feel that they should at least have a general idea about their partner’s likes and desires that is based on their shared gender background (Felmlee, Orzechowicz, & Fortes, 2010). Yet often these assumptions are errone­ ous and lead to misunderstanding, confusion, and hurt. Further, to assume that gender is a constant con­ struct that is not shaped by gender identity, gender expression, or the internal sense of conformity or nonconformity to gender norms is to chance missing essential components of desire that are connected to some degree to one’s own unique experience of gender (Diamond, 2004). Culture and ethnicity also can play a significant role in how sexual desire is experienced or expressed (Hatfield, Rapson, & Martel, 2007; Hatfield & Rapson,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

186

1993) because of the multiple ways culture often influ­ ences the expression of sexuality. How conservative or liberal someone is sexually, the degree to which desire can or should be displayed, the role of sexual­ ity within a relationship, and even the amount of guilt one feels owing to one’s sexuality can all be influ­ enced by culture and ethnicity to some degree (Tol­ man et al., 2014). Likewise, age, ability status, and reli­ gion can influence the experience of sexuality in multiple ways and add to the complexity inherent in understanding sexual desire (see Meladze & Brown, 2015; Sowe, Brown, & Taylor, 2014). Clearly, understanding sexual desire and its mean­ ings is complicated and multifaceted (Holmberg & Blair, 2009). Therefore, it becomes necessary to under­ stand individual desire and its fluctuations as well as the role of desire in the unique sexual lives of a couple. The exercises in this chapter are designed to help individuals and couples explore their own desire, the meanings behind the presence or absence of desire, and the ways in which desire is or is not problematic on the basis of a couple’s own understandings of desire—all in cooperation with the multitude of iden­ tity influences (e.g., orientation, gender expression and gender identity, religion, culture, ethnicity, age, ability). Constructivist therapeutic techniques are uniquely situated to help elaborate the meanings of sexual desire both individually and relationally (Brickell, 2006; Butt, 2005). Looking at core understandings or con­ structs of sexual desire can help individuals under­ stand the origins and functions of their desire while also understanding the origins and functions of their partners’ sexual desire (Zumaya, Bridges, & Rubio, 1999). The ability to understand the constructions of the other allows the couple to enter into a role rela­ tionship (Kelly, 1963). Role relationships (Leitner & Thomas, 2003) are relationships that emphasize both understanding one’s own constructions and under­ standing the construing processes of the other. These relationships require advanced perspective taking and empathic understanding—both qualities that lead to better communication and connection. The use of constructivist methodologies for the elaboration and exploration of personal meaning struc­ tures is well documented (see Hardison & Neimeyer, 2012). The pursuit of true understanding of one’s own

formation of sexual meanings and the facilitation of communicating these meanings with a significant other can lead to a deeper affirmation of desire, sex­ uality, and satisfaction within a relationship. Of course, any exploration of core meanings and constructs could uncover uncomfortable feelings or experiences, so it is necessary to obtain explicit permission from clients that is based on their complete understanding that looking for underlying meanings and experience could come with strong emotions (Tolman et al., 2014). Moreover, as clinicians, we are all held to a standard of ethics that requires us to engage in affirming prac­ tice and to be very clear whom we are treating and what our relationship with each client will be, espe­ cially when working with couples (American Psy­ chological Association, 2017). Therefore, although we may be working more directly with one member of a couple and that person’s unique personal meanings related to sexual desire, this is always done in the con­ text of the couple and with an understanding that personal meanings are intertwined and connected to the meanings of the other (Bridges & Neimeyer, 2005; Neimeyer & Neimeyer, 1994). Instructions

Before implementing these exercises, clinicians are bound by an ethical responsibility to ensure that they are not working outside their scope of practice and that the clients are emotionally and relationally ready to explore the sexual aspects of their relationship. Further, assessment of physical or emotional abuse or coercion within the relationship should be conducted to ensure that neither partner is completing these exercises under duress. Exploring and navigating sexual desire can be facilitated through two core exercises: self-character­ ization sketch and holonic mapping of sexual desire. These exercises can be initiated in session and also carried out in more detail in a written homework exer­ cise. Initially it is best to explore meanings associ­ ated with sexual desire in session in the presence of the therapist rather than attempting to deepen and elaborate sexual meanings relationally at home. In the first exercise clients are instructed to write or speak in the third person as a way of establishing a nonthreatening and nonevaluative setting (CrittenExploring and Navigating Sexual Desire in Relationships 187

den & Ashkar, 2012). In the second exercise, the cli­ ents are asked first to explore their own personal holonic structure of sexual desire and then to look at how their structures interact and combine to form a couple’s holonic structure. Exercise 1: Self-Characterization Sketch of Sexual Desire

In this exercise clients are asked to write a self-charac­ terization of their sexual desire from the perspective of someone who knows them very well, “better than anyone ever could really know you” (Kelly, 1955/1991, p. 241). This sketch is a technique of personal con­ struct therapy and an adaptation of George Kelly’s selfcharacterization sketch (Crittenden & Ashkar, 2012). Kelly believed that phrasing the prompt in this way moved clients away from trying to guess what the per­ spective of someone close to them might be and toward a fuller examination of themselves independent of societal expectations or norms. In the current adap­ tation of the original self-characterization sketch (which was more generally about the whole person), clients are asked to focus on one aspect of themselves— their sexual desire: I want you to write a character sketch about [client name] and [identified possessive pronoun] sexual desire, just as if [identified personal pronoun] were the principal character in a play. Write it as it might be written by a friend who knew [identified pronoun] very intimately and very sympathetically, perhaps bet­ ter than anyone ever really could know [identified pronoun]. Be sure to write it in the third person. For example, start out by saying, “[client name] is . . .” (adapted from Kelly, 1955/1991, p. 241). Kelly then advised clinicians and partners to take a credulous approach in attempting to understand the sketch and the clients’ sexual desire through the cli­ ents’ eyes. True empathic understanding (the ability to understand the construing processes of the other) is a vital step to entering into a role relationship and forming deeper connections. These connections and understandings can alleviate hurt feelings and mis­ understandings regarding the absence or presence of sexual desire and its many relational and nonrela­ tional influences. 188 Bridges

Exercise 2: Holonic Structure of Sexual Desire

This exercise is a variation of the “Exploring and Negotiating Sexual Meanings” (Bridges & Neimeyer, 2003) exercise in The Therapist’s Notebook for Lesbian, Gay, and Bisexual Clients: Homework, Handouts, and Activities for Use in Psychotherapy (Whitman & Boyd, 2003). Though the initial exercise was designed to look at sexual meaning making in general, this varia­ tion is focused specifically on understanding the per­ sonal meanings and understandings of sexual desire. Thus, this exercise includes a full exploration of sex­ ual desire based on holonic mapping. A holon is a part of a larger meaning system that has sufficient inter­ nal complexity to be considered a whole meaning sys­ tem in and of itself. Therefore, a holonic map is an elaborate exploration of four subcomponents of sexual desire: eroticism, interpersonal bonding, reproduc­ tion/children, and gender. To construct the map, ques­ tions are asked of clients in session, and they are given a handout that can be used as a way of discovering and elaborating on their own understanding of sexual desire and its many components (see the “Holonic System of Sexual Desire Meanings” handout on page 192). Each member of the couple completes the map individually, and then the two people work together to find ways their maps overlap and depart, allowing for deeper understanding and collaborative navigation. Brief Vignette

Dewaine and Paul have been together as a couple for ten years, married for the last four years, and have three-year-old twin girls. Dewaine is African Ameri­ can and Paul is Caucasian, and both men identify as cisgender. Dewaine was raised in a strict Baptist house­ hold, whereas Paul reported that his family would celebrate the “big holidays” but was not particularly religious. They presented for therapy because of a marked decrease in sexual activity and a feeling that there might be something wrong with their relation­ ship because they have gay male friends who are still “sexual maniacs” later in life. Both men said they felt sexually satisfied when they did have sex, but the spon­ taneous flairs of sexual desire that used to be a big part of their relationship had diminished over the past several years. In creating the self-characterization sketches about their sexual desire, it became clear that

Dewaine had created meanings regarding sexual desire from his first feelings of same-sex desire as an adolescent that necessitated secrecy. He never fully exhibited his desire out in the open, even though he was very comfortable with his sexual orientation. Dewaine reported that this comfort took a long time to achieve as an African American man from a reli­ gious family. His family had eventually come to accept his relationship with Paul over the last few years; however, he knew there would always be an underlying disapproval of his sexual orientation that resulted from his family’s religious beliefs. Paul, on the other hand, had always felt free to disclose his sexual orientation because he came from a very open and accepting family. He reported that for his family, family always came first, and they would do anything for him. Through the self-characterization sketch he revealed that he really felt desire only at the end of the day, when all tasks and chores had been attended to and their kids had been put to bed. For Paul, desire was a reward for getting all things done and for being the kind of parent his own par­ ents were to him. For Dewaine, desire was some­ thing to be carefully managed and revealed only when he could do so in private. Taking these fuller understandings of the meanings of their sexual desire into consideration, it became clear that Dewaine was consistently constricting the erotic holon, whereas Paul was dilating the reproduction/children holon. In navigating their maps and meanings, the couple dis­ covered that their sexual activity and desire were not necessarily problematic or indicative of deeper prob­ lems at this point in their relationship. Instead, they realized that spontaneous, earth-moving desire was a product of societal and gender norm–based expec­ tations rather than a representation of their own attraction, love, and commitment to each other. They both agreed that, eventually, they would like to have sex more often, but for now they were not concerned about their relationship, sexually or otherwise. Fur­ ther, they began to examine ways that societal pressures and “shoulds” were infiltrating their relationship, and they agreed that regular monthly sessions would help keep their relationship on track as they raised their girls.

Suggestions for Follow-up

Often, exploring sexual desire in this in-depth way can be surprising to clients and their therapists. The pressure to be sexual in certain ways or even at cer­ tain times (celebrations, weekends, etc.) can be both implicit and pervasive in a culture inundated with sex but deprived of accurate sexuality information or edu­ cation. Helping clients understand their own thoughts, feelings, and meanings about sexual desire can be very freeing for them, while also highlighting how different these feelings may be when compared to a societal or media-based norm. Continued discussions about desire as it shows up in day-to-day life will deepen their individual and couple understanding of desire and how to navigate discrepancies in desire. Contraindications for Use

Speaking about sexuality can be uncomfortable for many clients. Therefore, building rapport and an empathic alliance is crucial before delving into these topics. Assessment of interpersonal violence, medi­ cal concerns, or hidden extrarelational partnering is necessary and would need to be addressed before work on sexual desire. Additionally, some clients may be uncomfortable with writing or speaking about themselves in the third person and do not feel threat­ ened by first-person exploration. It is still advisable for the clients to initially attempt to write or speak in the third person as an avenue for deeper understand­ ing of underlying constructs. These constructs may not be as readily available if writing in the first per­ son. Finally, these exercises require openness to selfexploration, partner communication, and both self and partner understanding. It may be necessary to do some initial work on communication and empathy before initiating the exercises. Professional Resources and References American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Brickell, C. (2006). The sociological construction of gender and sexuality. Sociological Review, 54 (1), 87–113. doi:10. 1111/j.1467-954X.2006.00603.x. Bridges, S. K., & Horne, S. G. (2007). Sexual satisfaction and desire discrepancy in same-sex women’s relationships.

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Journal of Sex and Marital Therapy, 33 (1), 41–53. doi:10. 1080/00926230600998466. Bridges, S. K., & Neimeyer, R. A. (2003). Exploring and nego­ tiating sexual meanings. In J. S. Whitman & C. J. Boyd (eds.), The therapist’s notebook for lesbian, gay, and bisexual clients, 145–149. Binghamton, NY: Haworth Press. Bridges, S. K., & Neimeyer, R. A. (2005). The relationship between eroticism, gender, and interpersonal bonding: A clinical illustration of sexual holonic mapping. Journal of Constructivist Psychology, 18 (1), 15–24. doi:10.1080/107 20530590523008. Brown, J. D., & Bobkowski, P. S. (2011). Older and newer media: Patterns of use and effects on adolescents’ health and well-being. Journal of Research on Adolescence, 21 (1), 95–113. doi:10.1111/j.1532-7795.2010.00717.x. Butt, T. (2005). Editorial foreword: The construction of sexu­ alities. Journal of Constructivist Psychology, 18 (1), 1–2. doi:10.1080/10720530590522955. Crittenden, N., & Ashkar, C. (2012). The self-characterization technique: Uses, analysis, and elaboration. In P. Caputi, L. L. Viney, B. M. Walker, & N. Crittenden (eds.), Personal construct methodology, 109–128. Hoboken, NJ: John Wiley & Sons. Diamond, L. M. (2004). Emerging perspectives on distinctions between romantic love and sexual desire. Current Direc­ tions in Psychological Science, 13 (3), 116–119. doi:10.1111/ j.0963-7214.2004.00287.x. Diamond, L. M. (2006). The intimate same-sex relationships of sexual minorities. In A. L. Vangelisti & D. Perlman (eds.), The Cambridge handbook of personal relationships, 293–312. New York: Cambridge University Press. doi:10.1017/CBO9780511606632.017. Diamond, L. M. (2013). Links and distinctions between love and desire: Implications for same-sex sexuality. In C. Hazan & M. I. Campa (eds.), Human bonding: The science of affectional ties, 226–250. New York: Guilford Press. Felmlee, D., Orzechowicz, D., & Fortes, C. (2010). Fairy tales: Attraction and stereotypes in same-gender relationships. Sex Roles, 62 (3–4), 226–240. doi:10.1007/s11199-009 -9701-x. Hardison, H. G., & Neimeyer, R. A. (2012). Assessment of personal constructs: Features and functions of construc­ tivist techniques. In P. Caputi, L. L. Viney, B. M. Walker, & N. Crittenden (eds.), Personal construct methodology, 3–51. Hoboken, NJ: John Wiley & Sons. Hatfield, E., & Rapson, R. L. (1993). Historical and cross-cul­ tural perspectives on passionate love and sexual desire. Annual Review of Sex Research, 467–497. Hatfield, E., Rapson, R. L., & Martel, L. D. (2007). Passionate love and sexual desire. In S. Kitayama & D. Cohen (eds.), Handbook of cultural psychology, 760–779. New York: Guilford Press.

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Holmberg, D., & Blair, K. L. (2009). Sexual desire, communi­ cation, satisfaction, and preferences of men and women in same-sex versus mixed-sex relationships. Journal of Sex Research, 46 (1), 57–66. doi:10.1080/002244908026 45294. Kelly, G. A. (1955/1991) The psychology of personal constructs, vol. 1. New York: Routledge. Kelly, G. A. (1963). A theory of personality: The psychology of personal constructs. New York: W. W. Norton. Leitner, L., & Thomas, J. (2003). Experiential personal con­ struct psychotherapy. In F. Fransella (ed.), International handbook of personal construct psychology, 257–264. Hoboken, NJ: John Wiley & Sons. doi:10.1002/04700 1337.ch25. McCarthy, B., & Wald, L. M. (2015). Strategies and techniques to directly address sexual desire problems. Journal of Family Psychotherapy, 26 (4), 286–298. doi:10.1080/0897 5353.2015.1097282. Meixel, A., Yanchar, E., & Fugh-Berman, A. (2015). Hypoac­ tive sexual desire disorder: Inventing a disease to sell low libido. Journal of Medical Ethics: Journal of the Institute of Medical Ethics, 41 (10), 859–862. doi:10.1136/medethics­ 2014-102596. Meladze, P., & Brown, J. (2015). Religion, sexuality, and inter­ nalized homonegativity: Confronting cognitive dissonance in the Abrahamic religions. Journal of Religion and Health, 54 (5), 1950–1962. doi:10.1007/s10943-015-0018-5. Neimeyer, G., & Neimeyer, R. A. (1994). Constructivist meth­ ods of marital and family therapy: A practical precis. Jour­ nal of Mental Health Counseling, 16 (1), 85–104. Sowe, B. J., Brown, J., & Taylor, A. J. (2014). Sex and the sinner: Comparing religious and nonreligious same-sex attracted adults on internalized homonegativity and distress. Amer­ ican Journal of Orthopsychiatry, 84 (5), 530–544. doi:10. 1037/ort0000021. Tiefer, L. (2012). Medicalizations and demedicalizations of sexuality therapies. Journal of Sex Research, 49 (4), 311– 318. doi:10.1080/00224499.2012.678948. Tolman, D. L., Diamond, L. M., Bauermeister, J. A., George, W. H., Pfaus, J. G., & Ward, L. M. (2014). APA handbook of sexuality and psychology, vol. 1, Person-based approaches. Washington, DC: American Psychological Association. doi:10.1037/14193-000. Whitman, J. S., & Boyd, C. J. (eds.). (2003). The therapist’s note­ book for lesbian, gay, and bisexual clients: Homework, hand­ outs, and activities for use in psychotherapy. Binghamton, NY: Haworth Clinical Practice Press. Zumaya, M., Bridges, S. K., & Rubio, E. (1999). A constructivist approach to sex therapy with couples. Journal of Construc­ tivist Psychology, 12 (3), 185–201. doi:10.1080/10720539 9266064.

Resources for Clients American Association of Sexuality Educators. (n.d.). Coun­ selors and Therapists referral directory. https://www. aasect.org/referral-directory. Diamond, L. (2009). Sexual fluidity: Understanding women’s love and desire. Cambridge: Harvard University Press.

National Coalition for Sexual Freedom. (n.d.). Kink Aware Professionals Directory. https://ncsfreedom.org/key-pro grams/kink-aware-professionals-59776. Sexuality Information and Education Council of the United States. (2018). https://www.siecus.org/.

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HOLONIC SYSTEM OF SEXUAL DESIRE MEANINGS (adapted from Bridges & Neimeyer, 2003)

GENDER

EROTICISM

REPRODUCTION

INTERPERSONAL BONDING

Our sexual identity, and consequently our sexual desire, is made up of four interrelated systems of meanings. These systems differ from one person or relationship to another. Because it can be confusing to sort through these meanings with a partner (or even on one’s own), it is often helpful to reflect on each of these areas in turn, as they bear on your thoughts, feelings, and preferences about issues related to gender, erotic pleasure, interpersonal bonding, and reproduction. As a guide, you might find it helpful to try to answer some of the following questions for yourself, before discussing similar questions with your partner. A few suggestions for exploring each of these systems follows, as well as some questions that focus on their interaction. Other topics related to these areas might occur to you as you reflect on each, so the following prompts should be considered only a general guide to how your exploration might evolve. 1. Gender holon: the way we see ourselves as female, male, lesbian, gay, bisexual, transgender, or heterosexual within society and all the implications this has for our lives. Sample questions: • How does your personal conception of your gender identity shape your sexual desire? What aspects of your gender identity do you value? • Are the gender roles adopted by you and your partner compatible, complementary, or conflictual in their implications for sexual desire within your relationship? How flexible or fixed are your respective roles in the relationship? 2. Eroticism holon: our desire for sexual excitement, pleasure, and orgasm. Sample questions: • What forms of sexual activity give you pleasure? Are there times your desire for these activities changes? What influences your desire for different kinds of sexual activity? • What meanings or fantasies enhance or intensify your excitement and erotic potential? What mean­ ings inhibit it? How comfortable are you sharing these meanings and fantasies with your partner?

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• How compatible are your erotic preferences with your partner’s erotic preferences? Which aspects of your erotic preferences are most difficult to speak about? Which are easily misunderstood? • How does your ability to be open about your erotic preferences affect your sexual desire? 3. Interpersonal Bonding holon: our capacity to develop intense feelings in regard to the pres­ ence or absence, availability or unavailability of another specific human being. Sample questions: • To what extent does your sexual desire influence how you seek versus retreat from meaningful attachment relationships? How are these forms of drawing close or distancing expressed in words or actions? • Is the form of closeness sought by both of you similar or dissimilar? How might you signal your need for greater connection or space in a way that is constructive for you both? How are you able to be connected and close with or without the presence of sexual desire? 4. Reproduction holon: the human potential to create or foster the development of individuals. Sample questions: • What role, if any, does having or raising children play in your sexual desire? Has this changed over time, and if so, how? • How compatible are your hopes or wishes concerning the desirability or timing of raising chil­ dren with those of your partner? How might such wishes be navigated? Holonic interactions: the subtle interplay among your four systems of sexual desire meanings, or between your meanings and those of your partner. Sample questions: • Are some of your holons isolated from the others, so that it is not clear that they connect with other domains of your sexual desire? How would your sense of your sexual desire change if they were more completely integrated? • Are some of your holons “bigger” or more important than others? What would this map look like if you drew them to scale? How would your map compare with your partner’s holonic structure? • Is there a distinctive “firing order” of your holons? That is, does the activation of one (for exam­ ple, interpersonal bonding) tend to trigger the activation of another (such as eroticism)? Is the sequencing of your activation similar to or different from that of your partner? This handout can also be found online at the Constructivist Sexuality Research Lab website: https://skbridges.wixsite.com/csrl.

Sara K. Bridges

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22 INTIMATE PARTNER VIOLENCE: INITIAL

INTERVENTIONS FOR LGBTQ CLIENTS

Sabina de Vries

Suggested Uses: Activity, homework Objective

This activity is designed for clients who find them­ selves in an abusive relationship and want to leave their partners. Safety and psychoeducation are of utmost importance when working with clients strug­ gling to leave an abusive relationship. The goal of this activity is to provide initial tools to help LGBTQ cli­ ents increase safety and gain greater understanding of abusive relationship patterns that are found in intimate relationships and those that are specific to same-sex relationships. Rationale for Use

Intimate partner violence (IPV) is a wide-ranging problem in the United States, and LGBTQ commu­ nities are not immune. It can be defined as violence that occurs in romantic relationships and may include emotional, physical, and sexual abuse (Kubicek, McNeeley, & Collins, 2016). Prevalence of IPV among sexual minorities was found to be similar to or higher than that of heterosexual women (Kubicek et al., 2016). The National Violence Against Women survey found that 21.5 percent of men and 35.4 percent of women living with a same-sex partner had experienced physi­ cal violence, as opposed to those in heterosexual relationships, which were reported as 7.1 percent and 20.4 percent, respectively. In addition, the Centers for Disease Control and Prevention found that 41 per­ cent of lesbians, 61 percent of bisexual women, and 35 percent of heterosexual women had experienced rape, physical violence, or stalking by an intimate

partner. It was also found that 26 percent of gay men, 37 percent of bisexual men, and 29 percent of hetero­ sexual men had experienced rape, physical violence, or stalking by an intimate partner. Intimate partner violence can have deadly consequences. For example, in 2000, 1,247 women and 440 men were killed by a partner; 33 percent of female victims and 4 percent of male victims were murdered by an intimate partner (American Bar Association, n.d.). These data do not account for those who commit suicide because of intimate partner violence. Though concrete data are difficult to obtain, it is speculated that of the roughly 6,000 women who commit suicide each year, a signif­ icant number were abused by an intimate male partner (Websdale, 2003). Currently, about 2,000 agencies provide services to survivors of IPV (Hines & Malley-Morrison, 2005). According to feminist-based philosophies, most domestic violence services are geared toward young, heterosexual women (Hines & Douglas, 2011). Today most domestic violence agencies also provide services to underserved populations such as LGBTQ clients; however, it was found that overall services and out­ reach were still lacking for these domestic violence survivors (Hines & Douglas, 2011). Adolescents as well as men receive the least amount of services (Hines & Douglas, 2011). Research indicates that those in sexual minority relationships may be at a higher risk for dating violence when compared to their heterosexual counterparts (Dank, Lachman, Zweig, & Yahner, 2014). Factors such as discrimination, internalized homophobia, and general victimization may contrib­ ute to increased risk of IPV (Lewis, Milletich, Kelley, & Woody, 2012).

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

194

Before moving on to specific interventions, we need to highlight unique aspects of working with LGBTQ clients who are experiencing IPV. For exam­ ple, counselors should practice only in accordance with their competencies. The American Counseling Association (ACA) Code of Ethics, section C.2, Pro­ fessional Competence (ACA, 2014), indicates that counselors need to possess multicultural counseling competencies to work with a variety of clients, which includes those from LGBTQ backgrounds. In addi­ tion, the ACA Code of Ethics stipulates that counsel­ ors need to possess or acquire skills and competencies in order to provide effective and affirmative counsel­ ing interventions. Counselors working with clients in IPV relationships in general, and from an LGBTQ background specifically, need to obtain crucial knowl­ edge and skills. For example, counselors should have a working knowledge of processes involved in trau­ matic bonding and the Stockholm syndrome (Wallace, 2007). Counselors should also understand and accept that survivors of IPV frequently return to the abusive partner. Leaving an abusive relationship is usually a long, intricate, painful, and frustrating journey for the survivor. Counselors working with this population need to provide services in accordance with the Asso­ ciation for LGBT Issues in Counseling (ALGBTIC) competencies and understand the implications of the intersectionality of IPV, sexual minority status, and multiple-minority status (Harper et al., 2013). IPV presents an additional viewpoint to intersectionality. Many sexual minority victims are double-closeted (Stephenson, Khosropour, & Sullivan, 2010), meaning they have not come out or not completely come out and they are also hiding the abuse. To date, no targeted prevention or interventions have been developed for underserved populations such as sexual minorities (Kubicek et al., 2016). The lim­ ited literature that addresses IPV concerns of sexual minorities has focused primarily on lesbian relation­ ships (Stephenson et al., 2010). One of the few studies focusing on IVP in gay male relationships found rel­ atively high levels of IPV among gay and bisexual men (Stephenson et al., 2010). The ALGBTIC compe­ tencies stipulate that practitioners have awareness, a solid knowledge base, and skills when working with LGBTQ clients (Harper et al., 2013). Therefore, it is

important for LGBTQ-affirming counselors to be aware of and keep track of these trends in populations they serve. It is important for survivors of IPV to be exposed to the concept of the cycle of violence. The cycle of vio­ lence consists of a repeating pattern of tension build­ ing, explosion, and honeymoon phases. Frequently, survivors are only vaguely aware of the existence of such patterns, and processing this information can help the victim understand that the abuser and the abusive relationship are similar to those others have experienced (Walker, 1979). The inability to recog­ nize abusive patterns might stem from “gaslighting” (Salerno & Garro, 2016), which refers to the abuser’s attempt to manipulate the victim into doubting their memories, perceptions, and sanity. The abuser’s goal is to confuse, control, and keep the victim off bal­ ance. It can be helpful for the survivor to know that they are not crazy (Bancroft, 2003, p. 136) and that many others have suffered through abusive relation­ ships and, in the end, were able to leave (Bancroft, 2003). Finally, it is imperative to explore the strategies that abusive partners may use to overpower and con­ trol their victims. Counselors working with LGBT clients need to understand how abusive patterns unfold in order to offer affirmative counseling services and to be in compliance with ALGBTIC counseling com­ petencies (Harper et al., 2013). For example, threats, coercion, intimidation, and violence are used to instill fear in the partner. Among other things, the abuser may be using emotional, economic, physical, or sexual abuse to control the victim (Walker, 1979). The abuser may also use children or pets to manipulate or to instill fear. The GLBT Power and Control Wheel (see page 200) is similar to the heterosexual power and control wheel; however, the LGBT version also high­ lights the fact that same-sex couples are also nega­ tively affected by heterosexism and by homo-, trans-, and biphobia (Chavis & Hill, 2008). For example, the abuser may threaten to out the victim as an LGBTQ person if the victim has not come out, not come out completely, or come out only to specific individuals (Kulkin et al., 2007). The abuser may insist that no one is willing to help because of the victim’s sexual iden­ tity, or may insist that the victim deserves being abused Intimate Partner Violence: Interventions for LGBTQ Clients 195

owing to sexual orientation (National Domestic Vio­ lence Hotline, n.d.). Another tactic used in LGBTQ battering is to question the victim’s LGBTQ status as defined by the abuser; this tactic serves as an emotional battering tool as well as an attempt to isolate the victim from com­ munity support (National Domestic Violence Hotline, n.d.). LGBTQ batterers also may try to monopolize and manipulate supportive family and friends to cut vic­ tims off from their support system (National Domes­ tic Violence Hotline, n.d.). Last, the abuser may attempt to portray the violence as consensual, espe­ cially in gay battering relationships (National Domes­ tic Violence Hotline, n.d.). Instructions

There is a paucity of research on interventions for sexual-minority IPV victims or IPV perpetrators (Edwards, Sylaska, & Neal, 2015). However, the follow­ ing widely accepted IPV interventions can be adapted to suit the needs of LGBTQ clients. These exercises can be used as initial tools to help individual LGBTQ clients understand and make sense of abusive relation­ ship patterns. They are best used in the safety of the counselor’s office. The activities presented here consist of an initial Safety First activity, followed by the Cycle of Violence and GLBT Power and Control Wheel. Safety First. It is of utmost importance that the survivor of IPV has a structured plan in place to stay safe. To fit the needs of abused LGBTQ clients and to promote safety, one option is to adapt safety plans developed to serve women leaving an abusive hetero­ sexual relationship. Such a safety plan should address safety during an IPV situation, safety when preparing to leave, safety in a personal residence (possibly obtain­ ing protective orders), safety in public places or at work, safety involving alcohol and drug abuse, and emotional safety. It is also vital to stash away impor­ tant items such as money, critical paperwork, identi­ fication documents, and the like. A comprehensive personalized safety plan form can be obtained from the National Center on Domestic and Sexual Violence and can be tailored to fit the individual needs of cli­ ents wanting to leave abusive relationships. Time in the counselor’s office can be spent on helping the survivor work on and process a personal safety plan. 196 de Vries

In accordance with the ACA Code of Ethics (ACA, 2014, A.4.a, Avoiding Harm), it is imperative that the personalized safety plan is kept in a secure location and out of the abuser’s reach so as not to invite more abuse and harm. Cycle of Violence and GLBT Power and Control Wheel. Counselors should spend some time process­ ing the Cycle of Violence and GLBT Power and Con­ trol Wheel with their clients: many survivors of IPV are not completely aware of the patterns involved in abusive relationships. In addition, these tools can help correct mistaken beliefs frequently held by vic­ tims, such as their having any measure of control over abusive patterns. Understanding the Cycle of Violence and GLBT Power and Control Wheel can provide much-needed information about abusive relationship patterns. For example, the Cycle of Violence can be used to guide the relationship narrative as the client and counselor work on creating a cohesive story line regarding how the client arrived at this particular and distressing point. The client and counselor can work through each of the eight sections that contain the power and con­ trol strategies. The client will be asked to examine how the abuser uses each strategy to assert power and control in the current relationship. The main purpose is to identify and gain clarity regarding abusive strat­ egies and how these affect the victim. Brief Vignette

Maria, a young cisgender lesbian Latina, came to see Joann, a counselor in private practice, because she was concerned about her relationship with Julie. She reported that Julie had been abusive toward her at an ever-increasing level. She felt confused by the fact that Julie at times would be the way she used to be when the couple first fell in love, but the good times would never last. Joann used the Cycle of Violence handout to help Maria understand the cyclical nature of abusive relationships, and to emphasize that Maria was not to blame for the periodic violent eruptions. Maria reported that she had become afraid for her life because the most recent incident caused her to need stitches. In a violent outburst, Julie had pushed her through a glass door in the couple’s dining room. Maria stated that she had left the abusive relationship before.

She had even gone to a local battered women’s shelter; however, Julie followed her there, claiming that she was also a victim of IPV. Out of fear and because she viewed Julie as all-powerful, Maria returned to the relationship, but things got increasingly worse. Maria felt that she could not call on her family for help. She stated that her parents didn’t know that she was in a same-sex relationship. Maria told them that she and Julie were just roommates. She reported that her family had come to the U.S. as undocu­ mented immigrants from a Latin American country. Maria described her family as very traditional and noted that they viewed a gay or lesbian identity as a violation of divine and natural law. She feared that her family would reject her for being in a lesbian relationship. In the past, Julie had threatened to out Maria to her family. Julie had also threatened to report Maria to the local immigration authorities if she were to leave her. Maria stated that for these rea­ sons she had stayed in the relationship far too long, but she also felt that she couldn’t endure the abuse any longer. Joann spent some time developing a personalized safety plan with Maria, including identifying safe places and safe people to whom to reach out for help. Joann and Maria also reviewed the GLBT Power and Control Wheel handout. They discussed how Julie took advantage of Maria’s illegal immigrant status and her not being out to her parents. Julie had used these vulnerabilities to bully Maria into submission. Maria found it empowering to move from confusion about her relationship struggles and self-blame to under­ standing that there are clear and predictable abusive patterns in her relationship with Julie. She requested to leave the handouts and her personalized safety plan at Joann’s office until she was able to find safer living arrangements. Maria feared that Julie would find them if she were to take them home, and that this would escalate the violence. Suggestions for Follow-up

These activities can be revisited in subsequent sessions for further processing and discussions. Leaving an abusive relationship is frequently a developmental pro­ cess, and insights and resolve to leave develop over time. Also, it is important to note that insight created

by working through these exercises can lead to emo­ tional distress and anxiety, as well as produce a height­ ened sense of urgency in clients to leave the abusive relationship. It may be prudent to remind clients that it might be safer to have a suitable escape plan in place instead of acting on impulse. It is important to remem­ ber that clients caught up in abusive relationships are at increased danger when attempting to leave. It is essential for counselors to have a list of resources avail­ able, such as LGBTQ-friendly shelter information and other vital assistance available in the community. Contraindications for Use

The above resources should not be used if they put the LGBTQ client who is experiencing IPV at increased risk of abuse. Also, clients who are experiencing heightening stress responsivity and emotional reactiv­ ity because of the abuse they are experiencing may have to work on emotional stabilization first. Professional Resources Domestic Abuse Intervention Programs. (n.d.). Home of the Duluth model: What is the Duluth model? https://www. theduluthmodel.org/about/index.html. Herman, J. L. (1992). Trauma and recovery: The aftermath of violence—from domestic abuse to political terrorism. New York: Guilford. Kulkin, H. S., Williams, J., Borne, H. F., de la Bretonne, D., & Laurendine, J. (2007). A review of research on violence in same-gender couples: A resource for clinicians. Journal of Homosexuality, 53 (4), 71–87. doi:10.1080/009183608 02101385. Merrill, G. S., & Wolfe, V. A. (2000). Battered gay men: An exploration of abuse, help seeking, and why they stay. Journal of Homosexuality, 39 (2), 1–30. Stiles-Shields, C., & Carroll, R. A. (2015). Same-sex domestic violence: Prevalence, unique aspects, and clinical impli­ cations. Journal of Sex and Marital Therapy, 41 (6), 636– 648. doi:10.1080/0092623X.2014.958792.

Resources for Clients Fontes, L. A. (2015). Invisible chains: Overcoming coercive control in your intimate relationship. New York: Guilford. Gay, Lesbian, Bisexual and Transgender Power and Control Wheel. (n.d). http://www.ncdsv.org/images/TCFV_glbt_ wheel.pdf. National Center on Domestic and Sexual Violence. (n.d.). Domestic Violence Personalized Safety Plan. http:// www.ncdsv.org/images/DV_Safety_Plan.pdf.

Intimate Partner Violence: Interventions for LGBTQ Clients 197

National Coalition Against Domestic Violence. http://www. ncadv.org/. National Domestic Violence Hotline. https://www.thehotline. org/.

References American Bar Association. (n.d.). Domestic violence statis­ tics. https://www.americanbar.org/groups/domestic_vio­ lence/ initiatives/resources/statistics/. American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. Bancroft, L. (2003). Why does he do that? Inside the minds of angry and controlling men. New York: Berkley. Chavis, A. Z., & Hill, M. S. (2008). Integrating multiple inter­ secting identities: A multicultural conceptualization of the power and control wheel. Women and Therapy, 32 (1), 121–149. doi:10.1080/02703140802384552. Dank, M., Lachman, P., Zweig, J. M., & Yahner, J. (2014). Dat­ ing violence experiences of lesbian, gay, bisexual, and transgender youth. Journal of Youth and Adolescence, 43 (5), 846–857. doi:10.1007/s10964-013-9975-8. Dutton, D., & Golant, S. (1995). The batterer: A psychological profile. New York: Basic Books. Edwards, K. M., Sylaska, K. M., & Neal, A. M. (2015). Intimate partner violence among sexual minority populations: A critical review of the literature and agenda for future research. Psychology of Violence, 5 (2), 112–121. doi:10. 1037/a0038656. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H., Loos, B., & Lambert, S. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi :10.1080/15538605.2013.755444. Hines, D. A., & Douglas, E. M. (2011). The reported availabil­ ity of US domestic violence services to victims who vary by age, sexual orientation, and gender. Partner Abuse, 2 (1), 3–30. doi:10.1891/1946-6560.2.1.3. Hines, D., & Malley-Morrison, K. (2005). Family violence in the United States: Defining, understanding, and combat­ ing abuse. Thousand Oaks, CA: Sage.

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Kaschak, E. (2001). Intimate betrayal: Domestic violence in lesbian relationships. Women and Therapy, 23 (3), 1–5. doi:10.1300/J015v23n03_01. Kubicek, K., McNeeley, M., & Collins, S. (2016). Young men who have sex with men’s experiences with intimate part­ ner violence. Journal of Adolescent Research, 31 (2), 143– 175. doi:10.1177/0743558415584011. Kulkin, H. S., Williams, J., Borne, H. F., de la Bretonne, D., & Laurendine, J. (2007). A review of research on violence in same-gender couples: A resource for clinicians. Journal of Homosexuality, 53 (4), 71–87. doi:10.1080/0091836 0802101385. Lewis, R. J., Milletich, R. J., Kelley, M. L., & Woody, A. (2012). Minority stress, substance use, and intimate partner vio­ lence among sexual minority women. Aggression and Violent Behavior, 17 (3), 247–256. McClennen, J. C. (2005). Domestic violence between samegender partners: Recent findings and future research. Jour­ nal of Interpersonal Violence, 20 (2), 149–154. doi:10. 1177/0886260504268762. National Domestic Violence Hotline. (n.d.). https://www.the hotline.org/is-this-abuse/lgbt-abuse/. Salerno, A., & Garro, M. (2016). Relational dynamics in samesex couples with intimate partner violence: Coming out as a protective factor. International Journal of Humanities and Cultural Studies, 1 (2), 131–140. Stephenson, R., Khosropour, C., & Sullivan, P. (2010). Report­ ing of intimate partner violence among men who have sex with men in an on-line survey. Western Journal of Emer­ gency Medicine, 11 (3), 242–246. http://escholarship.org/ uc/item/2gb740tj. Walker, L. E. (1979). The battered woman. New York: Harper & Row. Wallace, P. (2007). How can she still love him? Domestic vio­ lence and the Stockholm syndrome. Community Practi­ tioner, 80 (10), 32–34. Walters, M. L., Chen, J., & Breiding, M. J. (2013). The National Intimate Partner and Sexual Violence Survey (NISVS): 2010 findings on victimization by sexual orientation. Atlanta: National Center for Injury Prevention and Control, Cen­ ters for Disease Control and Prevention. Websdale, N. (2003). Reviewing domestic violence deaths. National Institute of Justice Journal, 250, 26–31.

THE CYCLE OF VIOLENCE

DENIAL

O

N

BATTERER I’m sorry / begs forgiveness / promises HER RESPONSE to get counseling / goes to church/AA • Agrees to stay, sends flowers / brings presents / return, or take “I’ll never do it again” / wants to him back make love / declares love / • Attempts to stop legal proceedings enlists family support / • Sets up counseling cries appointments for him • Feels happy, hopeful

O

G

TE

Rape Use of weapons Beating

ON

ON BU I LD I S N IN

PL

SI

BATTERER Hitting Choking Humiliation Imprisonment

EX

HER RESPONSE • Protects herself any way she can • Police called by her her kids, neighbor • Tries to calm him • Tries to reason • Leaves • Fights back

O

HER RESPONSE • Attempts to calm him • Nurturing • Silent / talkative BATTERER • Stays away from Moody family, friends Nitpicking • Keeps kids Isolates her quiet Withdraws affection • Agrees Puts down • Withdraws Yelling • Cooks his Drinking or drugs favorite Threatens dinner Destroys property • General feeling Criticizes of walking Sullen on eggshells Crazy making

ACUT E

HON

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M Y E

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GAY, LE S BIA N, BIS EXUA L , A ND T RA NS P OWER A ND CO NT RO L WH EEL

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DOMES TIC VIO LE N C E P E RSONA L IZED S A F ET Y P L A N Name: __________________________________________________ Date:_____________________________ The following steps represent my plan for increasing my safety and preparing in advance for the possi­ bility for further violence. Although I do not have control over my partner’s violence, I do have a choice about how to respond to him/her and how to best get myself and my children to safety. STEP 1: Safety during a violent incident. People cannot always avoid violent incidents. In order to increase safety, battered persons may use a variety of strategies. I can use some of the following strategies: A. If I decide to leave, I will _____________________________________________________________________. (Practice how to get out safely. What doors, windows, elevators, stairwells, or fire escapes would you use?) B. I can keep my purse or wallet and car keys ready and put them (location) _______________________________ in order to leave quickly. C. I can tell ___________________________________ about the violence and request that she or he call the police if she or he hears suspicious noises coming from my house. D. I can teach my children how to use the telephone to call 911. E. I will use _________________________________________ as my code with my children or my friends so they can call for help. F. If I have to leave my home, I will go to _____________________________________________. (Decide this even if you don’t think there will be a next time.) G. I can also teach some of these strategies to some or all of my children. H. When I expect we’re going to have an argument, I’ll try to move to a place that is low risk, such as ___________________________________. (Try to avoid arguments in the bathroom, garage, kitchen, near weapons, or in rooms without access to an outside door.) I. I will use my judgment and intuition. If the situation is very serious, I can give my partner what he/she wants to calm him/her down. I have to protect myself until I/we _________________________________. STEP 2: Safety when preparing to leave. Battered persons frequently leave the residence they share with the battering partner. Leaving must be done with a careful plan in order to increase safety. Batterers often strike back when they believe that a battered partner is leaving a relationship. I can use some or all of the following strategies: A. I will leave money and an extra set of keys with ____________________________ so I can leave quickly. B. I will keep copies of important documents or keys at _____________________________. C. I will open a savings account by _____________________________, to increase my independence. D. Other things I can do to increase my independence include: ____________________________________ ________________________________________________________________________________________ E. I can keep my phone with me at all times. I understand that if my batterer and I share a cellphone account, he or she my be able to track my phone calls, and I should leave a disposable phone with _____________________________. F. I will check with ______________________________ and _____________________________ to see who would be able to let me stay with them or lend me some money. Sabina de Vries

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G. I can leave extra clothes or money with _____________________________________. H. I will sit down and review my safety plan every __________________ in order to plan the safest way to leave the residence. _______________________ (domestic violence advocate or friend’s name) has agreed to help me review this plan. I. I will rehearse my escape plan and, as appropriate, practice it with my children. STEP 3: Safety in my own residence. There are many things that a person can do to increase his or her safety in her own residence. It may be impossible to do everything at once, but safety measures can be added step by step. Safety measures I can use: A. I can change the locks on my doors and windows as soon as possible. B. I can replace wooden doors with steel or metal doors. C. I can install security systems, including additional locks, window bars, poles to wedge against doors, an electronic system, etc. D. I can purchase rope ladders to be used for escape from second-floor windows. E. I can install smoke detectors and fire extinguishers for each floor of my house or apartment. F. I can install an outside lighting system that is activated when a person is close to the house. G. I will teach my children how to call me or __________________ (name of friend, etc.) in the event that my partner takes the children. H. I will tell the people who take care of my children which people have permission to pick up my chil­ dren and that my partner is not permitted to do so. The people I will inform about pick-up permission include: _____________________________________ (name of school)

_____________________________________ (name of babysitter)

_____________________________________ (name of teacher)

_____________________________________ (name of Sunday-school teacher)

_____________________________________ (name[s] of others)

I. I can inform _____________________________________ (neighbor) and ____________________________ (friend) that my partner no longer resides with me and that they should call the police if he or she is observed near my residence. STEP 4: Safety with an Order of Protection. Many batterers obey protection orders, but one can never be sure which violent partner will obey and which will violate protective orders. I recognize that I may need to ask the police and the courts to enforce my protective order. The following are some steps I can take to help the enforcement of my protection order: A. I will keep my protection order _______________________ (location). Always keep it on or near your person. If you change wallets or purses, that’s the first thing that should go in the new one. B. I will give my protection order to police departments in the community where I work, in those com­ munities where I visit friends or family, and in the community where I live. C. There should be county and state registries of protection orders that all police departments can call to confirm a protection order. I can check to make sure that my order is on the registry. The telephone numbers for the county and state registries of protection orders are: _______________________ (county) and _______________________ (state). D. I will inform my employer; my minister, rabbi, etc.; my closest friend; and ___________________ that I have a protection order in effect. 202

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E. If my partner destroys my protection order, I can get another copy from the clerk’s office. F. If the police do not help, I can contact an advocate or an attorney and file a complaint with the chief of the police department or the sheriff. G. If my partner violates the protection order, I can call the police and report the violation, and/or contact _____________________________. STEP 5: Safety on the job and in public. Each battered person must decide if and when she or he will tell others that her or his partner has battered her or him and that she or he may be at continued risk. Friends, family, and coworkers can help protect such a person. Each woman or man should carefully consider which people to invite to help secure her or his safety. I might do any or all of the following: A. I can inform my boss, the security supervisor, and_____________________________ at work. B. I can ask _____________________________ to help me screen my telephone calls at work. C. When leaving work, I can ________________________________________________________________. D. If I have a problem while driving home, I can _______________________________________________. E. If I use public transit, I can ________________________________________________________________. F. I will go to different grocery stores and shopping malls to conduct my business and shop at hours that are different from those I kept when residing with my battering partner. G. I can use a different bank and go at hours that are different from those I kept when residing with my battering partner. STEP 6: Safety and drug or alcohol use. Most people in this culture use alcohol. Many use mood-altering drugs. Much of this is legal, although some is not. The legal outcomes of using illegal drugs can be very hard on a battered person, may hurt his or her relationship with his or her children, and can put him or her at a disadvantage in other legal actions with the battering partner. Therefore, battered persons should carefully consider the potential cost of the use of illegal drugs. Beyond this, the use of alcohol or other drugs can reduce a person’s awareness and ability to act quickly to protect himself or herself from the battering partner. Furthermore, the use of alcohol or other drugs by the batterer may give him or her an excuse to use violence. Specific safety plans must be made concerning drugs or alcohol use. If drug or alcohol use has occurred in my relationship with my battering partner, I can enhance my safety by some or all of the following: A. If I am going to use, I can do so in a safe place and with people who understand the risk of violence and are committed to my safety. B. If my partner is using, I can ______________________________________________________________ and/or ________________________________________________________________________________. C. To safeguard my children I might _________________________________________________________. STEP 7: Safety and my emotional health. The experience of being battered and verbally degraded by partners is usually exhausting and emotionally draining. The process of building a new life takes much courage and incredible energy. To conserve my emotional energy and resources and to avoid hard emotional times, I can do some of the following:

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A. If I feel down and am returning to a potentially abusive situation, I can _____________________________ ___________________________________________________________________________________________. B. When I have to communicate with my partner in person or by telephone, I can _____________________ ____________________________________________________________________. C. I will try to use “I can . . .” statements with myself and be assertive with others. D. I can tell myself, “______________________________________________________________” whenever I feel others are trying to control or abuse me. E. I can read __________________________________________________________ to help me feel stronger. F. I can call ____________________________________ and ________________________________ for support. G. I can attend workshops and support groups at the domestic violence program or __________________ _____________________ to gain support and strengthen relationships. STEP 8: Items to take when leaving. When battered persons leave partners, it is important to take certain items. Beyond this, they sometimes give an extra copy of papers and an extra set of clothing to a friend just in case they have to leave quickly. Money: Even if I never worked, I can take money from jointly held savings and checking accounts. If I do not take this money, my partner can legally take the money and close the accounts. Items on the following lists with asterisks by them are the most important to take with me. If there is time, the other items might be taken, or stored outside the home. These items might best be placed in one location, so that if we have to leave in a hurry, I can grab them quickly. When I leave, I should take: • Identification for myself • Children’s birth certificates • My birth certificate • Social Security cards • School and vaccination records • Money • Cellphone • Checkbook, ATM card • Credit cards • Keys—house, car, office • Driver’s license and registration • Medications • Copy of protection order • Welfare identification, work permits, green cards • Passport(s), divorce papers • Medical records—for all family members • Lease/rental agreement, house deed, mortgage payment book • Bank books, insurance papers • Address book • Pictures, jewelry • Children’s favorite toys and/or blankets • Items of special sentimental value

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Telephone numbers I need to know: Police/sheriff’s department (local)—911 or _________________________________ Police/sheriff’s department (work _________________________________________ Police/sheriff’s department (school )_______________________________________ Prosecutor’s office ______________________________________________________ Battered women’s program (local) ________________________________________ National Domestic Violence Hotline: 800-799-SAFE (7233) 800-787-3224 (TTY) www.ndvh.org County registry of protection orders ______________________________________ State registry of protection orders_________________________________________ Work number __________________________________________________________ Supervisor’s home number _______________________________________________ I will keep this document in a safe place and out of the reach of my potential attacker. Review date: _______________________________

Source: Adapted from National Center on Domestic and Sexual Violence.

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23 TRANSGENDER YOUTH AND HEALTHY RELATIONAL SKILLS Luke R. Allen

Suggested Use: Group activity, workshop Objective

In this group activity, participants are able to engage in an interactive discussion that provides a way of com­ municating about relationships. The goal is to offer transgender and gender-diverse youth a semi-anony­ mous, safe space in which they can ask questions about relationships in a supportive peer group. Through this collaborative group activity, participants can come to think more concretely and define more clearly their expectations for creating, participating in, and main­ taining healthy, safe relationships; they also expand their personal knowledge as they explore new intimate relationships. Rationale for Use

Transgender youth receive little to no relationship or sexual health education designed uniquely for them (Magee, Bigelow, DeHaan, & Mustanski, 2012). Rather, youth often see widespread negative media presen­ tation of transgender identities and relationships (McInroy & Craig, 2015; Ringo, 2002). If genderdiverse young persons are not exposed to what healthy and safe intimate relationships look like (through edu­ cational efforts, positive media representation, or per­ sonal life), then they might lack information on how healthy and safe relationships are established, operate, or are maintained. Because of this lack of education, poor media representation, and other societal and institutional stressors (Capous-Desyllas & Barron, 2017), the conditions might be such that genderdiverse youth encounter difficulties in communicat­ ing about sex and gender, which is an essential

aspect of successful intimate relationships (Levitt & Ippolito, 2014). They may face additional obstacles in navigating the formation of romantic relationships owing to their marginalized identities of sexuality and/ or gender (Greene et al., 2015). Gender-diverse youth can face more challenges than their cisgender counterparts encounter. These challenges include more extreme and pervasive soci­ etal stressors, discrimination, and interpersonal vio­ lence (Dank, Lachman, Zweig, & Yahner, 2014). Those who transition with the aid of gender-affirming medi­ cal interventions may experience more drastic shifts in the social aspect of their identities, such as the loss or gain of perceived gender privilege (American Coun­ seling Association [ACA], 2010). Identities are fluid (Shields, 2008; Singh, 2013), and even the understand­ ing of one’s sexual orientation can change during or after transition (Auer et al., 2014; Bockting, Benner, & Coleman, 2009; Katz-Wise, Reisner, Hughto, & KeoMeier, 2016; Meier, Pardo, Labuski, & Babcock, 2013). Trans youth can also encounter intersecting forms of oppression in response to their other held margin­ alized identities and aspects of self (e.g., age, sexual orientation, nationality, race, political beliefs, ability status, socioeconomic status) from individuals as well as systems and institutions of power in society (Crenshaw, 1991; Daley, Solomon, Newman, & Mishna, 2007; Warner & Shields, 2013; see also American Psychological Association [APA], 2015, guideline 3). In 2013, for instance, transgender survivors of inti­ mate partner violence who were persons of color were 2.6 times more likely than the overall population of lesbian, gay, bisexual, transgender, and queer (LGBTQ) survivors to experience discrimination within inti-

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mate partner relationships (National Coalition of Anti-Violence Programs [NCAVP], 2014). In 2014 transgender people of color were twice as likely to experience threats and intimidation than the overall LGBTQ population (NCAVP, 2015). Young persons (ages fourteen to twenty-four) are particularly at risk; in 2015 they were three times more likely to experience hate violence from relatives and acquaintances compared to those twenty-four or older (NCAVP, 2016). Nonetheless, transgender youth can display tremendous resilience (DiFulvio, 2015; Singh, Hays, & Watson, 2011). Peer contact and support and seeking out and cultivating meaningful relationships are important aspects of this resilience for sexually and gender-diverse youth (Asakura, 2015; Riley, Sithar­ than, Clemson, & Diamond, 2013; Singh et al., 2011). Bockting and colleagues (2013) found that enhancing peer support is also an important aspect of developing resilience for the transgender population. Because this is a group activity, there is potential for participants to develop new connections and facili­ tate peer support, creating friendships that can carry over outside the activity. Singh and dickey (2017) identify some of the theo­ retical perspectives that mental health professionals may use in their work with transgender clients, includ­ ing the minority-stress model (Meyer, 2003), strengthsbased and resilience approaches (ACA, 2010; APA, 2015), and multicultural and social justice advocacy approaches (Ratts et al., 2015). The minority-stress theory posits that sexual, gender, and racial minorities are at greater risk for mental and physical health prob­ lems by way of increased psychological distress result­ ing from the regular exposure to prejudice, discrimi­ nation, and stigma to which they are subject (Meyer, 2003). Through the theory lens of minority stress, the therapist would not view such observed health dis­ parities in transgender and gender-diverse clients as reflecting inherent pathology, but rather as the sequelae of persistent stigma directed toward them (Hatzen­ buehler & Pachankis, 2016; Meyer, 2003). From the strength-based perspective, the counselor would assess and maintain an awareness of the clients’ strengths and sources of support, and whether they are internal, such as personality characteristics, or external, such as community support (Chang & Singh, 2016).

The application of social justice advocacy approaches may take a variety of forms, depending on context and the individual, and should integrate a systemic, multicultural approach to wellness (ACA, 2010; Ratts, DeKruyf, & Chen-Hayes, 2007). At a foundational level, counselors should seek to understand how their own cultural background and experiences influence their beliefs about gender, gender identity, and how we conceptualize the coun­ seling needs of gender-diverse clients (ACA, 2010; Singh & dickey, 2017). Social justice and advocacy efforts on the counselor’s part may range from teach­ ing clients self-advocacy skills to advocating that gender-inclusive restrooms are available in our work­ places, to working directly with school administrators when necessary, and beyond (dickey & Loewy, 2010; dickey, Singh, Chang, & Rehrig, 2017; Holman & Goldberg, 2006; Ratts et al., 2007). Guidelines for working with transgender and gender-nonconforming persons emphasize that when gender-diverse persons receive social support and trans-affirmative care, they tend to experience more positive life outcomes (APA, 2015, guideline 11). Ethical principles and guidelines direct us to work with our clients in a way that is respectful of their gender, gender identity, and sexual orientation, among other aspects of cultural and individual differences (ACA, 2010, competencies B.1 & D.7; ACA, 2014; APA, 2017, principle E). We must also be able to recognize that gender is a nonbinary construct (ACA, 2010, compe­ tencies A.1 & B.6; APA, 2015, guideline 1). Such affirmative work may aid in counteracting the wide range of societal, personal, and environmental dis­ crimination transgender youth can face. Clinicians have observed that transgender adoles­ cents have questions related to sexual health that are often left unanswered (Bungener, Steensma, CohenKettenis, & de Vries, 2017). In a qualitative study exploring preferred sexual health interventions for sexually and gender-diverse youth, the strongest pref­ erences were for group-type interventions whose con­ tent focuses on communication and relationship vio­ lence (Greene et al., 2015). Thus, informed by the literature, this collaborative intervention invites transgender youth to ask the questions that are most salient to their own lives and intimate relationships in a group Transgender Youth and Healthy Relational Skills 207

setting. Subsequently, the activity allows for the impor­ tant benefit of learning from others who may be navi­ gating, or have already experienced, similar concerns. The activity also creates psychoeducational opportu­ nities for the mental health professional facilitator. Instructions

Materials required: note cards and pens or pencils (all of the same color). Optional: white board, chalk­ board, or easel pad. This activity could be conducted within a time frame of forty-five to ninety minutes, and the number of participants can range from six to eighteen. The summary of the event to be included in programming event materials should encourage participants to come prepared to engage in hands-on activities and begin to uncover what is important to them in main­ taining healthy intimate relationships. To set up this activity, provide note cards and writing utensils to attendees. Instruct participants to write a question they have regarding how to navigate their relationships on the card. Collect the cards, shuffle, and redistrib­ ute them to participants. Ask attendees to read out loud the question on the card they have received. Facil­ itate dialogue and provide psychoeducation when appropriate. Give sufficient time for the group to dis­ cuss the question. Then have another participant read the next question. Continue this process until no questions remain. A facilitator instructional sheet (to be used when running the group) is provided at the end of this chapter; it contains more detailed sugges­ tions, typical occurrences, and commonly asked par­ ticipant questions (see page 211). Successful facilitation of group activities requires that the therapist maintain an awareness of potential critical incidents to exploit as a learning opportunity. As in group therapy, confidentiality cannot be guar­ anteed by the workshop facilitator, and the limitation of confidentiality should be explained (ACA, 2014, B.4.a.; APA, 2017, 10.03). However, the therapist can help promote confidentiality by asking participants not to share any identifying information about other participants in the workshop group. This request for confidentiality serves the important function of help­ ing participants feel safe to share.

208 Allen

Brief Vignette

Avien is a fifteen-year-old nonbinary biracial adoles­ cent of Latino and English ethnicity living in a group home. Avien uses they, them, and their. They were one of seventeen group attendees of various gender identities, at different stages of exploring their gender and sexual identities, and of varying backgrounds and resources, ages fourteen to seventeen. During the activity (after cards had been collected, shuffled, and redistributed), in response to one question asked, Avien described experiencing anticipatory anxiety about disclosing their transgender identity to potential partners and friends. At this time, the leader seized on this critical incident and posed a question to the group as a whole: “Have any of you had similar wor­ ries, either in the past or present, and how did you navigate that corresponding anxiety and fear?” Other participants indeed had gone through similar experi­ ences and were able to share what it had been like for them. One participant shared the recollection that they had also been scared about disclosing and sharing their true self with others; however, once they had, they felt great relief. “I did lose some friends,” the par­ ticipant told Avien during the discussion, “but the friends that stayed are the greatest I’ve ever had.” Here the facilitator acknowledged the difficulty of coming out and the myriad contextual intersecting consider­ ations (e.g., privilege and oppression, cultural beliefs about sex and gender, perceptions of potential future negative feedback and reactions, coping strategies, and available local sources of social support) to keep in mind when weighing the costs and benefits of dis­ closing identities. In participant workshop feedback, Avien and several others later mentioned the impor­ tance of being open and honest in relationships and with partners as a takeaway from this workshop that will affect their own life in a positive way. Suggestions for Follow-up

Because this is a workshop activity, follow-up may not be appropriate. However, attendees may benefit from a list of both national and local resources for transgen­ der youth that includes hotline numbers, transgender­ affirmative doctors, and mental health professionals.

Contraindications for Use

This activity was originally designed for gender-expan­ sive youth from ages thirteen to seventeen who were attending the workshop with the consent of their guardians. Though the workshop may be delivered to a slightly younger or older group, it might not be appro­ priate to include children under thirteen. If there is too broad an age range, questions may not be develop­ mentally relevant enough to all participants, which could potentially make common themes harder to iden­ tify in the given time constraints. Facilitators should be mindful of the potential for the focus of the group to be about how to educate the cisgender community, rather than focusing on other salient needs of the par­ ticular group at hand. Moreover, the geographical location, culture, and climate of where this activity is conducted should be taken into account. For instance, youth living in more progressive or resource-abun­ dant areas may be more likely to find peers, friends, and partners who are supportive of their relevant iden­ tities than those participants who live in less progres­ sive areas with fewer resources. Professional Readings and Resources Brill, S., & Kenney, L. (2016). The transgender teen: A hand­ book for parents and professionals supporting transgender and non-binary teens. Jersey City, NJ: Cleis Press. Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Yalom, I. D., & Leszcz, M. (2005). Theory and practice of group psychotherapy, 5th edition. New York: Basic Books.

Resources for Clients Gender Spectrum Lounge. Provides a space for gender-expan­ sive teens, their parents, and affirmative professionals to connect with one another. https://genderspectrum.org/ lounge. Testa, R. J., Coolhart, D., & Peta, J. (2015). The gender quest workbook: A guide for teens and young adults exploring gender identity. Oakland, CA: New Harbinger. TrevorSpace. Social networking site for LGBTQ youth (ages thirteen to twenty-four), their friends, and their allies. https://www.trevorspace.org.

References American Counseling Association (ACA). (2010). Compe­ tencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4, 135–159. doi:10.1080/15 538605.2010.524839.

American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832– 864. doi:10.1037/a0039906. American Psychological Association (APA). (2017). Ethical principles of psychologists and code of conduct. https:// www.apa.org/ethics/code/index.aspx. Asakura, K. (2015). Theorizing pathways to resilience among LGBTQ youth: A grounded theory study. PhD diss., University of Toronto. Auer, M. K., Fuss, J., Höhne, N., Stalla, G. K., & Sievers, C. (2014). Transgender transitioning and change of self-re­ ported sexual orientation. PloS One, 9 (10), 1–11. doi:10.1371/journal.pone.0110016. Bockting, W., Benner, A., & Coleman, E. (2009). Gay and bisexual identity development among female-to-male transsexuals in North America: Emergence of a transgender sexuality. Archives of Sexual Behavior, 38 (5), 688–701. doi:10.1007/s10508-009-9489-3. Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103 (5), 943–951. doi:10.2105/AJPH.2013.301241. Bungener, S. L., Steensma, T. D., Cohen-Kettenis, P. T., & de Vries, A. L. C. (2017). Sexual and romantic experiences of transgender youth before gender-affirmative treatment. Pediatrics, 139 (3), 1–9. doi:10.1542/peds.2016-2283. Capous-Desyllas, M., & Barron, C. (2017). Identifying and navigating social and institutional challenges of transgender children and families. Child and Adolescent Social Work Journal, 34 (6), 527–542. doi:10.1007/s10560-017­ 0491-7. Chang, S. C., & Singh, A. A. (2016). Affirming psychological practice with transgender and gender nonconforming people of color. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 140–147. doi:10.1037/sgd0000153. Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and violence against women of color. Stanford Law Review, 43 (6), 1241–1299. Daley, A., Solomon, S., Newman, P. A., & Mishna, F. (2007). Traversing the margins: Intersectionalities in the bullying of lesbian, gay, bisexual and transgender youth. Journal of Gay and Lesbian Social Services, 19 (3–4), 9–29. doi:10. 1080/10538720802161474. Dank, M., Lachman, P., Zweig, J. M., & Yahner, J. (2014). Dat­ ing violence experiences of lesbian, gay, bisexual, and transgender youth. Journal of Youth and Adolescence, 43 (5), 846–857. doi:10.1007/s10964-013-9975-8. dickey, l. m., & Loewy, M. I. (2010). Group work with transgender clients. Journal for Specialists in Group Work, 35

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(3), 236–245. doi:10.1080/01933922.2010.492904. dickey, l. m., Singh, A. A., Chang, S. C., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gender nonconforming clients. In A. A. Singh & l. m. dickey (eds.), Affirmative counseling and psychologi­ cal practice with transgender and gender nonconforming clients, 247–262. Washington, DC: American Psycholog­ ical Association. DiFulvio, G. T. (2015). Experiencing violence and enacting resilience: The case story of a transgender youth. Violence against Women, 21 (11), 1385–1405. doi:10.1177/107780 1214545022. Greene, G. J., Fisher, K. A., Kuper, L., Andrews, R., & Mus­ tanski, B. (2015). “Is this normal? Is this not normal? There is no set example”: Sexual health intervention pref­ erences of LGBT youth in romantic relationships. Sexu­ ality Research and Social Policy, 12 (1), 1–14. doi:10.10 07/s13178-014-0169-2. Hatzenbuehler, M. L., & Pachankis, J. E. (2016). Stigma and minority stress as social determinants of health among lesbian, gay, bisexual, and transgender youth. Pediatric Clinics of North America, 63 (6), 985–997. doi:10.1016/j. pcl.2016.07.003. Holman, C. W., & Goldberg, J. M. (2006). Ethical, legal, and psychosocial issues in care of transgender adolescents. International Journal of Transgenderism, 9 (3–4), 95–110. doi:10.1300/J485v09n03_05. Katz-Wise, S. L., Reisner, S. L., Hughto, J. W., & Keo-Meier, C. L. (2016). Differences in sexual orientation diversity and sexual fluidity in attractions among gender minority adults in Massachusetts. Journal of Sex Research, 53 (1), 74–84. doi:10.1080/00224499.2014.1003028. Levitt, H. M., & Ippolito, M. R. (2014). Being transgender: Navigating minority stressors and developing authentic self-presentation. Psychology of Women Quarterly, 38 (1), 46–64. doi:10.1177/0361684313501644. Magee, J. C., Bigelow, L., DeHaan, S., & Mustanski, B. S. (2012). Sexual health information seeking online: A mixed-meth­ ods study among lesbian, gay, bisexual, and transgender young people. Health Education and Behavior, 39 (3), 276–289. doi:10.1177/1090198111401384. McInroy, L. B., & Craig, S. L. (2015). Transgender representa­ tion in offline and online media: LGBTQ youth perspec­ tives. Journal of Human Behavior in the Social Environment, 25 (6), 606–617. doi:10.1080/10911359.2014.995392. Meier, S. C., Pardo, S. T., Labuski, C., & Babcock, J. (2013). Measures of clinical health among female-to-male transgender persons as a function of sexual orientation. Archives of Sexual Behavior, 42 (3), 463–474. doi:10.1007/s10508­ 012-0052-2.

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Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129 (5), 674–697. doi:10.1037/0033-2909.129.5.674. National Coalition of Anti-Violence Programs (NCAVP). (2014). Lesbian, gay, bisexual, transgender, queer, and HIVaffected intimate partner violence in 2013. https://avp. org/resources/reports/. National Coalition of Anti-Violence Programs (NCAVP). (2015). Lesbian, gay, bisexual, transgender, queer, and HIVaffected hate violence in 2014. https://avp.org/resources/ reports/. National Coalition of Anti-Violence Programs (NCAVP). (2016). Lesbian, gay, bisexual, transgender, queer, and HIVaffected hate violence in 2015. https://avp.org/resources/ reports/. Ratts, M., DeKruyf, L., & Chen-Hayes, S. (2007). The ACA advocacy competencies: A social justice advocacy frame­ work for professional school counselors. Professional School Counseling, 11 (2), 90–97. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., & McCullough, J. R. (2015). Multicultural and social justice counseling competencies. http://www.counseling.org/ docs/default-source/competencies/multicultural-and-so cial-justice-counseling-competencies.pdf?sfvrsn=20. Riley, E. A., Sitharthan, G., Clemson, L., & Diamond, M. (2013). Recognising the needs of gender-variant children and their parents. Sex Education, 13 (6), 644–659. doi:10. 1080/14681811.2013.796287. Ringo, P. (2002). Media roles in female-to-male transsexual and transgender identity formation. International Journal of Transgenderism, 6 (3), 1–22. Shields, S. A. (2008). Gender: An intersectionality perspective. Sex Roles, 59 (5), 301–311. doi:10.1007/s11199-008­ 9501-8. Singh, A. A. (2013). Transgender youth of color and resilience: Negotiating oppression and finding support. Sex Roles, 68 (11), 690–702. doi:10.1007/s11199-012-0149-z. Singh, A., & dickey, l. (2017). Introduction. In A. Singh & l. dickey (eds.), Affirmative counseling and psychological practice with transgender and gender nonconforming cli­ ents, 3–18. Washington, DC: American Psychological Association. doi:10.1037/14957-001. Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling and Development, 89 (1), 20–27. doi:10.1002/j.1556-6678.2011.tb00057.x. Warner, L. R., & Shields, S. A. (2013). The intersections of sexuality, gender, and race: Identity research at the cross­ roads. Sex Roles, 68 (11), 803–810. doi:10.1007/s11199­ 013-0281-4.

FACILITATOR INSTRUCTION SHEET After a short discussion on confidentiality, intro­ ductions, and an optional ice breaker, the facilitator distributes pens or pencils and note cards to partici­ pants. Participants are instructed to write on one side of the card a question they have regarding how to navigate their relationships. The facilitator should explain that the purpose of using identical note cards and writing only on one side is to help create some degree of anonymity. After attendees have written their questions, the facilitator collects the cards, shuffles them, and then redistributes them to partici­ pants. The facilitator then asks the attendees to read out loud the question on the card they have received. Cards are read one at a time, and the group does not move forward to the next card until the first question has been discussed. When there are very similar questions, the redundant questions may be skipped (as the substance of the question would have already been discussed). Cards are read until no questions remain. Note cards provide an easy format for sharing and discussing. This is where the interactivity and dialogue begin. The time attendees spend on each question can range from thirty seconds to eight minutes, although it is more common for the group to devote four to six minutes on average. Naturally for this type of activity, common discussion themes may become apparent. For example, attendees may mention characteristics of what they believe to be healthy and unhealthy relationships. The facilitator can choose to use a writing board or paper easel to compose a list of these characteristics for visual representation or to track the group’s ideas. New perspectives and advice from peers, as well as the normalizing experience often accompanying these ideas, can be tremen­ dously beneficial. Facilitators are encouraged to pro­ vide psychoeducation when appropriate. In this activ­ ity, psychoeducation may include themes related to relationship cycles, communication, knowing one’s own boundaries, information about the effects of medical interventions, safe-sex practices, knowledge of legal rights for transgender persons, and local resources. Because of the challenge of being transgender in a cisgender-normative world, the lived experience of transgender youth can be highly complex as they navigate the stigma to which they will be subject. Understanding of one’s sexual orientation can change

during or after transition, and there can be difficul­ ties in trusting cisgender persons. Some may use avoidance as a means of coping with their con­ cerns about relational dynamics. The questions they ask during the exercise reflect their experi­ ence. Common questions include the following: Handling Disclosure • “ When would be an appropriate time to come out to a partner?” • “ Does anyone else feel uncomfortable or unsure about what to do when cisgender heterosexual people are attracted to you?” • “ How do you come out or talk about being trans to a straight partner? What do you do when your partner says they’re straight while dating someone of the same gender?” Creating Relationships and Meeting Others • “How do I approach someone I like? Do I start off by telling them I’m [trans]?” • “How do you approach men for dating as a gay (trans) man?” • “I really like this guy from work. My parents don’t want me dating (at all, no matter what). How do I convince them? Should I even try?” • “How do you go about finding a non-straight relationship in a heterocentric world?” Partner Struggles and Navigation • “ How do I handle my partner transitioning?” • “ How will it be different [from normal dating]?” • “ How do you navigate intimacy with cisgen­ der people while dating? Sex, etc.” • “How do I help my partner feel comfortable talking about his sexuality with me?” • “How do I get her to believe that she is truly beautiful and special to me?” • “Is a relationship healthy if my partner is struggling with my gender identity?” Intimacy • “ Is it okay not to want vaginal sex (when dating a guy, for someone who identifies as FTM)?” • “ Would a lesbian not be comfortable with being intimate with a person with a vagina but no boobs?” • “How the hell do you know if you’re attracted to someone in a romantic or platonic way?” 211

24 TWO STARS AND A WISH: TERMINATION ACTIVITIES

FOR GROUPS WITH SEXUAL- AND GENDER-IDENTITY

DIVERSE CLIENTS Theodore R. Burnes Suggested Use: Activity Objective

The objective of this activity is to increase clients’ comfort with the ending of a counseling group and to decrease feelings of anxiety and sadness with the ending of a group. Rationale for Use

Clients in a counseling group (e.g., a long-term therapy group, interpersonal process group, support group, or psychoeducation group) who have experienced systemic oppression and marginalization because of their sexual and/or gender identities may often expe­ rience difficulty in navigating healthy intimate rela­ tionships (Burnes & Ross, 2010). They may also have difficulty navigating the shift in these relationships that comes with the termination of a counseling group. Termination in any group setting has proven to be a tricky stage of group development to navigate for cli­ ents and therapists alike (Fehr, 2003; Shapiro, 2017); however, for clients with diverse sexual and gender identities, such difficulty may, in part, stem from hav­ ing formed a bond with other group members who have also endured various forms of societal homopho­ bia and oppression (Burnes & Ross, 2010). For groups that are focused on topics related to diverse sexual and gender identities (e.g., a support group for lesbian, bisexual, and queer-identified women; a psychoeducation group for transgender youth on changing one’s identity documents such as driver’s licenses and passports), such termination can

pose additional challenges, as the social support fos­ tered in the group may be difficult for clients to find in other areas of their lives (Burnes & Hovanesian, 2017). In addition, many therapists who have worked with sexual- and gender-identity diverse clients may not have specific competence in conducting group therapy (Horne, Levitt, Reeves, & Wheeler, 2014) or in having to induce termination and thereby shift rela­ tional intimacy (Burnes & Hovanesian, 2017). Further, as all groups are by definition multicultural (DeLu­ cia-Waack, Kalodner, & Riva, 2013), the need for cli­ ents to address how various clients in the group may have different rituals, meaning, and cultural under­ standings of saying good-bye is of paramount impor­ tance when inducing termination in a counseling group. Thus, the need for therapists to have interven­ tions that are specific to working with termination in groups that are focused on working with LGBTQ clients is paramount. Various sets of guidelines from professional orga­ nizations in mental health disciplines have noted the importance of group counseling and psychological practices in group settings for sexually and genderdiverse clients. The American Psychological Associa­ tion (APA) (2011) notes the importance of psycholo­ gists’ attention to relationships for LGB individuals in various domains of psychological practice, includ­ ing group work; this importance is also stressed in guidelines for psychological practice with transgender and gender-nonconforming individuals (APA, 2015). Further, the American Group Psychotherapy Associ­ ation (AGPA) (2007) has published guidelines that

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note the specific competencies needed for effective group work in a variety of settings and with a variety of different populations to attend to various group members’ respective constellations of privileged and oppressed identities. Despite these standards, there are data to support the idea that sexual- and gender-identity diverse cli­ ents may use group psychotherapy and psychoedu­ cational outreach workshops in ways that are different from those of clients outside these groups, in part because of their need for social support from and con­ nection to individuals who have endured similar experiences of discrimination and oppression (Burnes & Hovanesian, 2017; Paul, 2016). Therapists may not be able to understand the specific needs and parame­ ters that occur within a group context in which one or more members have a sexually and/or genderdiverse identity, and they thus may not ask the right questions or implement the right interventions (Paul, 2016). Such skills are part of the ethical mandates of various mental health professions (e.g., ACA, 2014; APA, 2011) to engage with the different facets of mul­ ticultural competence. Therefore, therapists need to consider how their clients’ gender and sexual identi­ ties may affect the termination process within a psy­ chotherapy group. Group workers may face chal­ lenges in termination with clients, including setting appropriate boundaries during termination, helping make appropriate referrals for some clients’ ongoing mental health issues, and ensuring confidentiality about the group’s process. Instructions

Clients can complete this activity, called “Two Stars and a Wish,” as the final activity in a group counseling session. Therapists should introduce the activity by alerting clients that this activity is designed to help them think about their relationships with group mem­ bers as they close and also to provide one another feedback for growth. Group members should sit in a circle. The therapist should begin by identifying this session as a time in which clients have come together and formed a community that is built in part on their sexually and gender-diverse identities. The therapist should then alert group members that they are going to do an activity that allows for information to be

shared as the group prepares to end and members pre­ pare to say good-bye. The therapist should then ask for a volunteer to go first. Once a client (e.g., client no. 1) volunteers to go first, each of the other clients will provide “two stars” for client no. 1 and one “wish” for client no. 1 (see page 216). Each client should have one turn to give their feedback to client no. 1. (It is better and more time effective, for example, for cli­ ent no. 2 to give both stars and a wish to client no. 1 in one turn than for every client to give one star to client no. 1, then every client give a second star, etc.) Clients completing the activity in a small group (five to six clients) counseling session should be given at least forty-five minutes in the session to complete this activity. If there are more than six clients, the group facilitators should allow an additional fifteen minutes. After completion of the activity, therapists should ask clients a series of questions to help them process the activity. Specifically, questions that can be helpful to propel such a process include: (a) What was completing this activity like for you? (b) What are the ways that you might stay connected after the group has ended? (c) What was it like to receive such feedback? (d) What will it be like not to come to group next week? How are we feeling as our time together ends? The facilitator should explicitly address the possibility of connection between members after the group has ended, especially because this group may have pro­ vided members with valued social support and insight into their own identity development. Some members may not want such a connection, and some members may want varied types of connections with other members (e.g., client no. 1 only wants to be friends on Facebook with other group members, whereas client no. 2 hopes that members can get together for coffee once a month). Therapists should be able to process these intricate group interactions with an attention to how members’ reflections have built a community for people of diverse sexual and gender identities within the group. This activity can be helpful to clients in a range of settings. In a psychoeducation group format, this activity can help sexually and gender-diverse clients identify their own future goals for personal growth Two Stars and a Wish 213

that have emerged from their work in the group. This activity can also help members recognize the ways that the group has addressed issues of societal homo­ phobia and oppression (Burnes & Hovanesian, 2017). This activity is best used through interactive, small group work across different age ranges (e.g., high school students, college students, individuals in mid­ dle adulthood, older adults). Brief Vignette

The last session (session twelve of a twelve-session closed support group) of the nonbinary gender sup­ port group had five members: Guadalupe, Cole, Max, Stuart, and Keenan. The group facilitator, Theo, decided to use the “Two Stars and a Wish” activity during the group’s final therapy session. Cole, a thirty­ five-year-old African American, heterosexual client, decided to engage in the activity first. Each group member went around and gave Cole two stars and a wish. In one interaction, Guadalupe, a twenty-nine­ year-old Mexican American, lesbian-identified group member, shared how she found Cole’s coming out as nonbinary as “really instrumental and a good example for me as I chose to share my own identity with my families.” In another interaction, Max, a forty-one-year­ old Caucasian heterosexual client, shared a hope that he had for Cole: for Cole to be able to share their nonbinary gender identity with their coworkers. After each client took a turn as the center of the group’s process, Theo went over the activity with the group. The clients found that, as the group was ending, there were similar feelings among members: sadness about ending the group and wanting connection out­ side the group. Theo was then able to help facilitate the discussion about termination, whether or not they would like to stay connected after the group disbanded, and the differing ways that various members could stay connected. This activity can be used in individual sessions (in which the therapist and client do a modified version of this activity). Depending on the type of group ses­ sion, clinicians can have clients complete the activity as a whole group, or cluster the individuals into small groups (five to six people per small group), have each small group complete the activity, and then process the activity with the whole group. 214 Burnes

Suggestions for Follow-up

At the end of the activity, facilitators should ensure that participants in the group are okay with terminat­ ing. If there are clients who are at risk for harming themselves or others, facilitators should make appro­ priate referrals to individual counselors or to outside providers (and follow up to ensure that attendees have connected with these providers) to ensure that all risk is handled ethically and properly. Facilitators working in various settings should consult with the policies and procedures of their set­ ting to inquire about follow-up with clients after the clients have terminated from group counseling and are no longer clients. If follow-up is appropriate and clini­ cally indicated, facilitators may want to do a survey check-in that assesses participants’ experiences of the group and directly assesses their experience of the termination activity. Specifically, counselors can ask an open-ended question such as, “How did you expe­ rience the termination activity during the last group session? Did you feel as though it was helpful, and do you have any ideas for improving this activity?” Contraindications for Use

This activity should not be used with children who have not yet reached a cognitive capacity to engage in abstract reasoning (Broderick & Blewitt, 2010). Fur­ ther, individuals who may have had difficulty process­ ing loss and/or saying good-bye to one another in a group setting may need additional time or a more emotion-focused activity. Professional Readings and Resources American Group Psychotherapy Association (AGPA). (2007). Practice guidelines for group psychotherapy. https:// www.agpa.org/docs/default-source/practice-resources/ download-full-guidelines-(pdf-format)-group-works!ev idence-on-the-effectiveness-of-group-therapy. pdf?sfvrsn=2. Craig, S. L., Austin, A., & McInroy, L. B. (2014). School-based groups to support multiethnic sexual minority youth resiliency: Preliminary effectiveness. Child and Adoles­ cent Social Work Journal, 31 (1), 87–106. doi:10.1007/ s10560-013-0311-7. Heck, N. C., Croot, L. C., & Robohm, J. S. (2015). Piloting a psychotherapy group for transgender clients: Descrip­ tion and clinical considerations for practitioners. Profes­ sional Psychology: Research and Practice, 46 (1), 30–36. doi:10.1037/a0033134.

Lindsay, T., & Orton, S. (2014). Groupwork practice in social

work. Thousand Oaks, CA: Sage/Learning Matters.

Smith, N. G., Hart, T. A., Moody, C., Willis, A. C., Andersen,

M. F., Blais, M., & Adam, B. (2016). Project PRIDE: A cognitive-behavioral group intervention to reduce HIV risk behaviors among HIV-negative young gay and bisexual men. Cognitive and Behavioral Practice, 23 (3), 398–411. doi:10.1016/j.cbpra.2015.08.006. Travers, J. C., Tincani, M. J., & Lang, R. (2014). Facilitated communication denies people with disabilities their voice. Research and Practice for Persons with Severe Disabilities, 39 (3), 195–202. doi:10.1177/15407969 4556778.

Resources for Clients CenterLink. (2017). Local, state, and national LGBT organiza­ tions and groups. https://www.lgbtcenters.org. Cook, J. T. (2016). Group glue: The connective power of how simple questions lead to great conversations. Oklahoma City: Redinals Publishing. Drebing, C. (2016). Leading peer support and self-help groups: A pocket resource for peer specialists and support group facilitators. Holliston, MA: Alderson Press. Gibson, S. (2017). Relationship help: How to say goodbye to a group. Conflict to Peace in Relationships. www.conflict topeaceinrelationships.com/relationship-help-how-to-say­ goodbye-to-a-group/. Smith, J. (2016). Psychotherapy: A practical guide. New York: Routledge.

References American Counseling Association (ACA). (2014). 2014 ACA code of ethics. Alexandria, VA: American Counseling Association. American Group Psychotherapy Association (AGPA). (2007). Practice guidelines for group psychotherapy. https:// www.agpa.org/docs/default-source/practice-resources/ download-full-guidelines-(pdf-format)-group-works!­ evidence-on-the-effectiveness-of-group-therapy.pdf?s fvrsn=2. American Psychological Association (APA). (2011). Guide­ lines for psychological practice with gay, lesbian, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659.

American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Broderick, P. C., & Blewitt, P. (2010). The life span: Human development for helping professionals, 3rd edition. New York: Pearson/Prentice Hall. Burnes, T. R., & Hovanesian, P. N. T. (2017). Psychoeducation groups in LGBTQ psychology. In T. R. Burnes & J. L. Stanley (eds.), Teaching LGBTQ psychology: Queering innovative pedagogy and practice, 117–138. Thousand Oaks, CA: Sage. Burnes, T. R., & Ross, K. (2010). Applying social justice to oppression and marginalization in group process: Inter­ ventions and strategies for group counselors. Journal for Specialists in Group Work, 35 (2), 169–176. doi:10.1080/0 1933921003706014. DeLucia-Waack, J. L., Kalodner, C. R., & Riva, M. (eds.). (2013). Handbook of group counseling and psychotherapy. Thou­ sand Oaks, CA: Sage. Fehr, S. S. (2003). Introduction to group therapy: A practical guide, 2nd edition. New York: Routledge. Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. Journal of Counseling Psychology, 56 (1), 97. doi:10.1037/a0012844. Horne, S., Levitt, H. M., Reeves, T., & Wheeler, E. (2014). Group work with gay, lesbian, bisexual, and transgender clients: Discussing invisible differences. In J. L. DeLuciaWaack, D. A. Gerrity, C. R. Kalodner, & M. T. Riva (eds.), Handbook of group counseling and psychotherapy. Thou­ sand Oaks, CA: Sage. Nerses, M., Kleinplatz, P. J., & Moser, C. (2015). Group ther­ apy with international LGBTQ+ clients at the intersec­ tion of multiple minority status. Psychology of Sexualities Review, 6 (1), 99–109. Paul, P. L. (2016). Affirmative therapy with sexual minority clients. In K. A. DeBord, A. R. Fischer, K. J. Bieschke, & R. M. Perez (eds.), Handbook of sexual orientation and gender diversity in counseling and psychotherapy, 131–156. Washington, DC: American Psychological Association. Shapiro, J. L. (2017). A five-stage technique to enhance ter­ mination in group therapy. In S. S. Fehr (ed.), 101 inter­ ventions in group therapy, 2nd edition, 86–89. New York: Routledge.

Two Stars and a Wish 215

T WO STARS AND A WISH For each of the two stars, clients should provide one of the following: a. a strength that they have seen in client no. 1

b. a way that client no. 1 has grown in their sexually and gender-diverse community during the duration of the group

c. an attribute related to their sexually and/or gender-diverse identity/identities that they admire in client no. 1

d. one aspect of client no. 1 that they will miss

For each wish, clients should provide one of the following: a. a goal for client no. 1 to continue growing as a sexually or gender-diverse person after the group ends

b. an area for client no. 1 to continue working on that is relevant to the client’s group goals (or the overall goals of the group)

c. a positive hope for client no. 1’s future

216

Luke R. Allen

25 THE QUADRANT EXERCISE OF RELATIONSHIP EXPLORATION FOR SEXUAL- AND GENDER-IDENTITY DIVERSE CLIENTS Theodore R. Burnes Suggested Use: Activity Objective

The goal of this activity is to increase sexual- and gender-identity diverse individuals’ knowledge about what they desire in a relationship with one or more individuals. Rationale for Use

Individuals who have experienced systemic oppression and marginalization on the basis of their sexual and/ or gender identities may often experience difficulty in beginning or maintaining healthy intimate relation­ ships (Frost & Meyer, 2009). Such difficulty stems, in part, from a variety of factors related to societal homophobia and oppression (Frost, 2013). However, many therapists who have experience working with sexual- and gender-identity diverse clients may not have experience working with issues of sexual expres­ sion and relational intimacy (Burnes, 2016; Burnes, Singh, & Witherspoon, 2017). Thus, therapists need to plan specific interventions to increase sexual- and gender-identity diverse clients’ self-awareness and knowledge about their desires and needs for their intimate relationships. In addition, it is important for therapists to be aware that sexual- and gender-identity diverse clients may transcend the boundaries of traditional monog­ amous relationships. Specifically, some individuals may engage in polyamorous relationships, or sexual and relational practices in which there may be multi­

ple concurrent partners and various structures of sexual relationships (Burnes et al., 2017). Thus, a client want­ ing a relationship may be one member of a polyam­ orous relationship who wants specific relational needs to be filled that are either partially being filled by another partner or not being filled at all. Therefore, it’s important for therapists to fully investigate rela­ tional needs and desires with a sensitivity to diverse relational structures. Various sets of guidelines from professional orga­ nizations in mental health disciplines have noted the importance of intimate relationships for sexually and gender-diverse clients. The American Psychologi­ cal Association (APA) (2011) noted the importance of psychologists’ attention to relationships for LGB individuals. Further, the APA (2015) has recently noted the importance of psychologists’ acquisition of knowl­ edge, attitudes, and skills for transgender and gendernonconforming (TGNC) clients; the authors of this document note the importance of having an overall understanding of healthy intimate relationships and partnerships for TGNC people. Despite these standards, there are data to support the conclusion that sexual- and gender-identity diverse clients may have difficulty determining their needs and desires for intimate relationships, specifically within a therapeutic context (Patterson, 2016). Therapists may not be able to understand the needs and parameters that are specific to relationships in which one or more members have a sexually and/or gender-diverse iden­ tity, and they thus do not ask the right questions or

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

218

implement the right interventions (Patterson, 2016). Therefore, therapists need to consider how their cli­ ents’ gender and sexual identities may influence which factors they look for in starting and maintaining a healthy relationship. Further, because therapists may not be adequately trained in areas of sexuality and intimate relationships for these clients (Burnes et al., 2017), they risk engaging in unethical practice related to working with sexual- and gender-identity diverse clients, including (a) making relationship issues a focal point of therapy when they don’t need to be, (b) avoid­ ing relationship topics when clients with a sexual- and/ or gender-diverse identity want to talk about their relationships in therapy, and (c) not seeking appropri­ ate consultation or supervision related to relationship issues for sexual- and/or gender-identity diverse cli­ ents (APA, 2011; Haldeman, 2012). Further, given that sexual- and gender-identity diverse clients form and maintain intimate relationships within a unique con­ text of oppression that includes homophobia, bipho­ bia, cissexism, and transphobia, the need for therapists to consider unique relationship issues is paramount (Burnes, 2017).

After completion of the activity, therapists should ask clients a series of questions to help them process it. Specific questions that can be helpful to stimulate such a process include: (a) What was completing this activity like for you? (b) What were the similarities in your four lists? How do you understand those similarities? (c) What were the differences in your four lists? How do you understand those differences? (d) What were the three most important things that you learned about yourself by completing this activity? (e) As you reflect on this activity, what do you think are messages from LGBTQ communities that you have received about an ideal relationship? (f) As you reflect on this activity, what do you think are messages from your various communities (e.g., your family of origin, your racial or ethnic community) that you have received about an ideal relationship?

Instructions

(g) How do you think that having identities that are culturally and/or systemically oppressed has affected your ability to find a relationship?

Clients can complete this activity, called the Quadrant Exercise (see page 222), as homework or in a counsel­ ing session. Therapists should tell clients that this activity is designed to help them think about and identify what they might be looking for in a relation­ ship. They should provide clients with a copy of the Quadrant handout and a writing instrument and ask them to complete each of the four lists. Therapists should tell clients to answer the questions in each of the four boxes by creating four separate lists. Thera­ pists should tell clients that they can write down qual­ ities on multiple lists (i.e., the same quality can appear in more than one quadrant). Clients completing the activity in an individual or a group counseling session should be given ten minutes to complete this activity (clients in a group counseling session should each complete the Quadrant activity individually). If clients are completing the activity outside session, therapists should ask clients to time themselves for ten minutes to complete the activity and bring the completed activity to the next session.

This activity can be used in individual sessions (in which the therapist and client process the activity after it’s completed) or in a group counseling session. If used in a group session, clinicians can (a) have clients complete the activity individually and then pro­ cess the activity with the whole group, (b) have cli­ ents complete the activity individually, cluster the indi­ viduals into small groups (two or three people per small group), have small groups each process the activ­ ity, and then process the activity with the whole group, or (c) cluster the individuals into small groups (two to three people per small group) and have small groups each complete the activity together, and then process the activity with the whole group. This activity can be helpful with clients in a range of settings. In a psychoeducation group format, this activity can help sexual- and gender-identity diverse clients recognize symptoms of societal homophobia and oppression (Burnes & Hovanesian, 2017) through interactive, small-group work across different age The Quadrant Exercise of Relationship Exploration 219

ranges (e.g., high school students, college students, individuals in middle adulthood, older adults). Fur­ ther, this is a good activity to also use with youth and young adults who may “want a relationship” but do not know how to articulate what they need in a rela­ tionship. This activity may also be a good topic for a particular session of a support group provided for sexual- and gender-identity diverse clients (e.g., an empowerment group for queer women). Brief Vignette

Maria is a thirty-year-old Mexican American woman who came out as a transgender-identified, lesbianidentified female. She and her therapist have been working together for almost three years (in which Maria worked on therapy goals related to strengthen­ ing her transgender identity), and Maria has recently identified wanting to be in an intimate partnership. Maria’s therapist provided Maria with a copy of the Quadrant Exercise and asked Maria to complete the activity as homework. Maria came back to session the next week. She had completed the four lists. She and her therapist noted the similarities between her List 1 and her List 3, and Maria was able to gain the insight that what she was looking for in a relationship was also what she would be able and willing to offer in a relationship. For example, Maria noted that she was out as transgender and had worked to develop her sense of self in terms of both her ethnic and her gender identities. Maria also noted that she wanted “someone who was out,” and that “level of outness is a deal breaker for me. I can’t date someone who’s not out as being a queer woman or who wants me to go into the closet about my transgender identity.” Maria was able to recognize that her desires related to a potential partner’s out­ ness mirrored her own values about her own outness. Maria also recognized that her shortest list was the list of qualities that she was willing to compromise on in another person, and she was able to have a subse­ quent conversation with her therapist about how she often had difficulty compromising in her relationships. She and her therapist articulated the idea that learn­ ing ways to compromise would be a good goal for her next phase of counseling.

220 Burnes

Suggestions for Follow-up

Given the objective of this learning activity, it is help­ ful to think about accurately assessing individuals’ knowledge gained from this activity as a two-step model. First, clinicians using this activity in an individ­ ual therapeutic context can use subsequent sessions to ask clients about insights gained from this activity and assess clients’ self-report. In addition, it would be helpful for clients to use behavioral indicators as a measure for follow-up. Specifically, if clients indicate explicit criteria that they are looking for in a rela­ tionship, they may exhibit ways that they are looking for those criteria in possible partners and thus indi­ cate ways that the activity has had a positive outcome on their well-being. For example, clients may com­ plete this activity and gain the insight that they want a partner who is open to the prospect of having chil­ dren. Thus, the client may use subsequent therapy ses­ sions to craft ways of bringing this desire into con­ versations (e.g., role-playing with the therapist different ways of bringing up the topic of children with possi­ ble partners) and eventually implement these ways in conversations with potential partners. Contraindications for Use

Clinicians using this activity should reflect on the range of sexual expression that exists for clients, including individuals who are not sexually attracted to anyone and who may want a relationship that consists exclu­ sively of romantic and emotional connection. Specif­ ically, asexual people may not identify with or define themselves by their sexuality. Asexual identities reflect a range of experiences (including wanting to engage in romantic, affectional relationships) and often do not include a focus on sexuality (Burnes, 2017; Scott, McDonnell, & Dawson, 2016). Thus, clinicians can use modified versions of this activity to ensure well­ being for those clients. In addition, individuals who have survived phys­ ical or emotional abuse or domestic violence in a relationship may have difficulty completing this activ­ ity. Individuals who have survived emotional and/or physical abuse in same-sex relationships may find it difficult to engage in their communities to find other partners for fear of stigma and rejection (Renzetti &

Miley, 2014). Clinicians should thoroughly assess clients’ emotional well-being after such abuse-related incidents, and they may wait to engage in this activity until clients have thoroughly processed such abuse and its clinical implications on their lives. Professional Resources Easton, D., & Hardy J. W. (2009). The ethical slut: A practical guide to polyamory, open relationships, and other adven­ tures. New York: Celestial Arts. Gamarel, K. E., Reisner, S. L., Laurenceau, J. P., Nemoto, T., & Operario, D. (2014). Gender minority stress, mental health, and relationship quality: A dyadic investigation of transgender women and their cisgender male partners. Journal of Family Psychology, 28 (4), 437. doi:10.1037/ a0037171. Macapagal, K., Greene, G. J., Rivera, Z., & Mustanski, B. (2015). “The best is always yet to come”: Relationship stages and processes among young LGBT couples. Journal of Family Psychology, 29 (3), 309. doi:10.1037/fam0000094. Reuter, T. R., Newcomb, M. E., Whitton, S. W., & Mustanski, B. (2017). Intimate partner violence victimization in LGBT young adults: Demographic differences and asso­ ciations with health behaviors. Psychology of Violence, 7 (1), 101. doi:10.1037/vio0000031. Whitton, S. W., & Kuryluk, A. D. (2014). Associations between relationship quality and depressive symptoms in samesex couples. Journal of Family Psychology, 28 (4), 571– 576. doi:10.1037/fam0000011.

Resources for Clients Chapman, G. D. (1995). The five love languages: The secret to love that lasts. Chicago: Northfield Publishing. Clunis, M. D., & Green, G. D. (2004). Lesbian couples: A guide to creating healthy relationships. Chicago: Northfield Publishing. Easton, D., & Hardy, J. W. (2009). The ethical slut: A practical guide to polyamory, open relationships, and other adven­ tures. New York: Celestial Arts. Niedra, A. How to find real, lasting love without looking for it. Tiny Buddha. http://tinybuddha.com/blog/how-to­ find-real-lasting-love-without-looking-for-it. Proud, B., & Windsor, B. (2014). First comes love: Portraits of enduring LGBTQ relationships. New York: Soleil. Scott, S., McDonnell, L., & Dawson, M. (2016). Stories of non‐ becoming: Non‐issues, non‐events and non‐identities in asexual lives. Symbolic Interaction, 39 (2), 268–286. doi:10.1002/symb.215. Travis, R. L. (2013). Gay men’s guide to love and relationships. Boston: RLT Publishing.

References American Psychological Association (APA). (2011). Guidelines for psychological practice with gay, lesbian, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/ a0024659. American Psychological Association (APA). (2015). Guide­ lines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70 (9), 832–864. doi:10.1037/a0039906. Burnes, T. R (2016). Working with gay, lesbian, bisexual, and queer students. In H. S. Hamlet (ed.), School counseling practicum and internship: 30 essential lessons, 96–103. Thousand Oaks, CA: Sage. Burnes, T. R. (2017). Flying faster than the birds and the bees: Toward a sex-positive theory and practice in multicultural education. In R. K. Gordon, T. Akutsu, J. C. McDermott, & J. W. Lalas (eds.), Challenges associated with cross-cul­ tural and at-risk student engagement, 171–189. Hershey, PA: IGI Global Publishing. Burnes, T. R , & Hovanesian, P. T. (2017). Psychoeducation groups in LGBTQ psychology. In T. R. Burnes & J. L. Stanley (eds.), Teaching LGBTQ psychology: Queering innovative pedagogy and practice, 117–138. Thousand Oaks, CA: Sage. Burnes, T. R., Singh, A. A., & Witherspoon, R. G. A. (2017). Sex-positivity training in counseling psychology: An exploratory analysis. Counseling Psychologist, 45 (4), 470–486. doi:10.1177/0011000017710216. Frost, D. M. (2013). Stigma and intimacy in same-sex relation­ ships: A narrative approach. Journal of Family Psychology, 25 (1), 1–10. doi:10.1037/a0022374. Frost, D. M., & Meyer, I. H. (2009). Internalized homophobia and relationship quality among lesbians, gay men, and bisexuals. Journal of Counseling Psychology, 56 (1), 97–109. Haldeman, D. (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychol­ ogist, 67 (1), 10–42. doi:10.1037/a0024659. Patterson, C. J. (2016). Lesbian, gay, bisexual, and transgender family issues in the context of changing legal and social policy environments. In K. A. DeBord, A. R. Fischer, K. J. Bieschke, & R. M. Perez (eds.), Handbook of sexual ori­ entation and gender diversity in counseling and psycho­ therapy, 313–332. Washington, DC: American Psycho­ logical Association. Renzetti, C. M., & Miley, C. H. (2014). Violence in gay and lesbian domestic partnerships. New York: Routledge. Scott, S., McDonnell, L., & Dawson, M. (2016). Stories of non-becoming: Non‐issues, non‐events and non‐identities in asexual lives. Symbolic Interaction, 39 (2), 268–286. doi:10.1002/symb.215. Veaux, F., & Rickert, E. (2014). More than two: An ethical guide to polyamory. Seattle: Thorntree Press.

The Quadrant Exercise of Relationship Exploration 221

THE Q UA DRA NT EXERCIS E

LIST 1. What are qualities that you believe you are looking for in a relationship?

LIST 2. What are qualities that you believe you don’t want in a relationship, but would be willing to compromise on if a potential partner possessed these qualities?

LIST 3. What are qualities that you believe you would provide to others in a relationship?

LIST 4. What are deal breakers (qualities that, if a potential partner had them, would be reason not to continue to engage with that person)?

222

Theodore R. Burnes

26 NEGOTIATING INFORMATION AND COMMUNICATION TECHNOLOGIES WITH SEXUAL AND GENDER MINORITY YOUTH AND YOUNG ADULTS Nathaniel Amos Suggested Uses: Activity, homework Objective

The goal of this chapter is twofold. First, it aims to sup­ port the clinician and client in developing a shared language regarding how clients use information and communication technologies (ICTs) in their lives. The shared language supports the clinician and client in better understanding the role of technology as it affects a client’s overall well-being. Second, the chapter aims to proactively address discovery of the clinician’s per­ sonal information online and includes recommenda­ tions on how to assess potential boundary violations (e.g., if a client “friends” a clinician on Facebook). Rationale for Use

This activity is designed for use with sexual and gen­ der minority youth (SGMY). Sexual and gender minority is used to refer to people identifying along the LGBTQIAA spectrum, whereas youth is a fluidly defined category. Generally, researchers frame youth as the period of psychological transition between childhood and adulthood, yet no universally accepted age range exists. For the purposes of this chapter, youth is referred to in keeping with the United Nations definition and refers to people between fifteen and twenty-four years old (United Nations, n.d.). SGMY are at risk of experiencing an increased amount of social isolation and, so, often turn to digital means to achieve social connectedness, decreased isolation, and an improved sense of well-being (GLSEN, CiPHR, &

CCRC, 2013; Hillier & Harrison, 2007; Kosciw et al., 2012; Tao, 2014). Multiple population-based studies have documented use rates among youth broadly and the ways in which SGMY use ICTs. Information and communication technologies is a comprehensive term designed to capture the wide variety of technology SGMY might be using. It includes, but is not limited to, social media networks, the Internet (broadly), video game consoles, and cell phones (Craig et al., 2015), which SGMY use differently from their non-SGMY peers (GLSEN et al., 2013; Lenhart, 2015). Most nota­ bly, the Gay, Lesbian, and Straight Education Network (GLSEN) documented that SGMY spend an average of five hours per day online, which is approximately forty-five minutes more than non-SGMY (GLSEN et al., 2013). GLSEN’s study documented four modes of ICT use among SGMY, including seeking safer social spaces, information seeking regarding identity devel­ opment and sexual health, accessing peer supports, and civic participation (GLSEN et al., 2013). Recent research has also demonstrated that the Internet and ICTs function as a haven for SGMY (Ybarra, Mitchell, Palmer, & Reisner, 2015). Compared to their non-SGMY peers, SGMY face an increased risk of rejection and verbal, physical, and sexual vic­ timization at home and school, which contributes to clinical concerns such as substance use, depression, post-traumatic stress, and elevated suicidality (Craig et al., 2015; GLSEN et al., 2013). SGMY thus may seek supportive social spaces online because they do not have access to such spaces in person (Ybarra et

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al., 2015). Online resources also support SGMY in researching identity development, seeking access to sexual health information, and participating in social activism (Craig & McInroy, 2014; GLSEN et al., 2013). Having access to such online resources is strongly correlated to improved quality of life for SGMY (Craig & McInroy, 2014; Craig et al., 2015; Ybarra et al., 2015). Given that SGMY are using ICTs in such varied modes, clinicians in a variety of contexts could ben­ efit from having a frame established regarding the various ways in which SGMY might be engaging with ICTs (Ybarra et al., 2015). There are multiple gains to be made from doing so, including (but not limited to) an improved understanding of clients in their social environment, an improved understanding of how peer support functions for a client, and improved therapeutic rapport by demonstrating empathic curi­ osity regarding a client’s social world (Craig & McIn­ roy, 2014). In an increasingly interconnected world, clinicians working with SGMY must be ready to directly con­ front the ethical conflicts inherent when interfacing with technology (Duncan-Daston, Hunter-Sloan, & Fullmer, 2013; Judd & Johnston, 2012; Kays, 2011; Tunick, Mednick, & Conroy, 2011). Ethical standards regarding technology usage vary across therapeutic disciplines and training (ACA, 2014; APA, 2017; NASW, 2017). The American Counseling Association (ACA) has developed a thorough listing of ethical practices. At its core, the ACA advocates that “coun­ selors understand the additional concerns related to the use of distance counseling, technology, and social media and make every attempt to protect confidenti­ ality and meet any legal and ethical requirements for the use of such resources” (ACA, 2014, p. 3). Ethicists argue that clinicians across all disciplines are individu­ ally responsible for addressing ethical issues involved in ICT use with their clients, unless otherwise directed by workplace leadership (Halabuza, 2014). Two broad dilemmas are associated with working with clients in terms of ICT usage. First, potential risks of increased ICT usage among SGMY might include cyberbullying and sexual predation (Giffords, 2009; Ybarra et al., 2015). Second, the relationship between clinician and client might become blurred by the avail­ ability of more information available online or if a

clinician has a website or social media presence (Hal­ abuza, 2014). Specific concerns might include (but are not limited to) confidentiality concerns, privacy breaches, and establishment of dual relationships (Halabuza, 2014; Kolmes & Taube, 2016). With an increase in ICT use, SGMY may be tar­ geted by cyberbullies and potential sexual predators (Giffords, 2009; Ybarra et al., 2015). Caretakers have historically expressed concerns about online sexual victimization of SGMY as well as exposure to sexually explicit material made more easily available on the Internet (Jones, Mitchell, & Finkelhor, 2012). These concerns continue to remain a key component of policy debates; however, research conducted over a five-year period from 2005 to 2010 found that sexual victimization might be on the decline (Jones et al., 2012). Researchers cite such improvements as result­ ing from increased rates of online literacy as well as increased parental involvement (Guan & Subrah­ manyam, 2009). Despite gains made, researchers con­ tinue to call for improved methods of understanding and preventing sexual victimization of SGMY using ICTs (Jones et al., 2012). The etiology and development of cyberbullying presents a complex research question (Ybarra et al., 2015). In the non-cyber world, researchers estimate that about 82 percent of SGMY report being ver­ bally taunted and 38 percent report being physically harassed in school settings, and online rates are correspondingly high (Kosciw et al., 2012). Newer research has suggested, however, that online com­ munities may support SGMY in feeling safer, thus decreasing the deleterious effects of cyberbullying (Ybarra et al., 2015). Researchers continue to call for an improved understanding of cyberbullying gener­ ally and to study more effective methods of bullying prevention (Ybarra et al., 2015). As with any new resources, clinicians must be mindful of risks inherent in using ICTs. Ethics researchers recommend that clinicians review pros and cons with clients to improve understanding of potential risks involved in using ICTs (Giffords, 2009). This includes reviewing privacy policies of social media and networking websites as well as monitoring client ICT use (Giffords, 2009). If a SGMY’s family is supportive, clinicians may also consider working

Negotiating Information and Communication Technologies 225

with parents to review online “tip sheets” developed by government and nonprofit agencies to ensure that SGMY are supported (Ybarra et al., 2015). Ethics researchers highly recommend that clini­ cians themselves, in addition to monitoring client use, continue to monitor their own social media use (Zur & Zur, 2011). Potential boundary violations might occur if a clinician unknowingly or, in some cases, intentionally invites clients to participate in a clinician’s personal social media network (Halabuza, 2014; Judd & Johnston, 2012; Zur & Zur, 2011). Along with potential privacy violations, clinicians should also monitor potential dual relationships unintentionally developed through social media networking sites (Zur & Zur, 2011). Ethicists thus recommend that clinicians review the privacy settings on their social media accounts and carefully monitor the information made available online through periodic Internet searches (e.g., using a Google search to identify what informa­ tion a clinician might have available over the Inter­ net) (Halabuza, 2014; Kolmes & Taube, 2016). Ethics researchers also recommend that clinicians review the privacy limitations on electronic communication (email or phone text messages) and set clear guidelines with clients regarding the use of electronic commu­ nication (Halabuza, 2014; Kolmes & Taube, 2016). Instructions

Activity 1: Assessing a Client’s Digital Footprint The first activity provided here is designed for use in therapy. It can be used with the standard clinical assessment a clinician may use when first meeting a client. It can also be used at any point where social media use becomes indicated in the clinical relation­ ship, such as when a client discloses experiencing cyberbullying. A clinician may introduce the activity by presenting copies of the activity to the client. The clinician can clarify that the activity is designed to support the client and clinician in developing a shared language that furthers cohesion in the therapeutic relationship and helps the client invite the clinician into the client’s technological world. The activity itself is a brief, semi-structured ques­ tionnaire. In it clinicians will find space for client name, preferred pronouns, and date of birth; questions dedicated to identifying a client’s digital footprint, 226 Amos

which includes subsections for identifying what kinds of technology a client uses (e.g., the Internet, social media), frequency of usage, and current level of privacy settings; and questions dedicated to understanding a client’s motivation to use ICTs. Questions are adapted from GLSEN and colleagues’ 2013 report, Out Online, as well as research from the Pew Research Center’s 2015 report on teens, social media, and technology (Lenhart, 2015). Activity 2: Clinician Self-Assessment The second activity is a self-assessment. A clinician may choose to take the self-assessment at any point. The self-assessment might also be useful for training settings and in supervisory relationships to help new clinicians clarify their use of technology and the ways in which it might affect the therapeutic relationship. The assessment is a brief, semi-structured ques­ tionnaire. It is a self-report instrument for clinicians. It asks similar questions regarding a clinician’s digital footprint and is also adapted from the GLSEN and Pew reports. The activity supports clinicians in differ­ entiating appropriate curiosity from potential cyberstalking behavior. The latter subsection is adapted from ethics-focused literature aimed at supporting cli­ nicians in maintaining appropriate clinical boundaries in an increasingly digitized age (Zur, 2008). Activity 3: Assessing a Client’s Search for Information This activity is designed to be used when a client attempts to contact a clinician by technological means. It can be used at any point in which it becomes indi­ cated in the clinical relationship. It can be introduced when a boundary has been crossed or preventatively after a clinician has assessed a client’s technology use (after Activity 1). The levels of boundary violations are provided below as a brief framework to introduce a sample framework to a client. Level 1: Curiosity. This level encapsulates an appropri­ ate search for a clinician using a search engine (Zur, 2008). This search may produce information about the clinician’s professional life (including training, professional memberships, highest degree obtained, and the clinician’s professional website). Level 2: Thorough search/due diligence. This level includes a simple search (producing results similar

to Level 1) as well as contacting the state licensing board, inquiring after ethical investigations, or reading information provided about the clinician written by former clients or professional colleagues (Zur, 2008). Level 3: Intrusive search. This level includes seeking out a clinician’s personal information, such as inves­ tigating public records (e.g., marriage certificates, divorce proceedings, personal address), joining social media networks under a disguised name, and paying for a service that would conduct a legal investigation into a clinician’s life (Zur, 2008). Level 4: Illegal search/cyberstalking. At this juncture, a clinician should consider consulting an attorney and/or law enforcement. Cyberstalking, as defined by the National Institute of Justice, is defined as “the use of technology to stalk victims” and “involves the pur­ suit, harassment, or contact of others in an unsolic­ ited fashion . . . via the Internet or e-mail” (National Institute of Justice, 2007). This can include gathering information such as credit reports, banking informa­ tion, cell phone records, tax records, and other highly private information through illegal means (Zur, 2008). Brief Vignette

You are a therapist working in a small, communitybased nonprofit that provides after-school program­ ming (including clinical services) for self-identified SGMY and allies in a major urban area. NG is a six­ teen-year-old African American, gay-identified, cisgender male (using he, him, and his pronouns) with whom you have been working for four sessions. He presented to treatment reporting wanting to build a more supportive peer network and to address symp­ toms of anxiety and depression. At the start of your fifth session, he shares the facts that he uses Instagram and that he has been experiencing online bullying from peers at his school. He reports that peers have been leaving derogatory and hate-filled comments on his pictures. He is very tearful and reports that he is angry. He reports that Instagram was a safe space for him and that he could make meaningful connec­ tions with people outside his immediate peer group at school. He does not want to leave Instagram because it provides him a sense of community outside his school-based environment. Using the worksheets pro­

vided in this chapter, you help NG clarify that he wants to continue to maintain his safe space and that he can change his privacy settings to “private” on Instagram so that he can avoid receiving derogatory comments in the future. In completing the activity, he begins to ask you about your own Instagram profile. He admits that he looked for you on Instagram and found a profile that seemed to be yours. You know that your privacy set­ tings were on “private” and that you maintain an Instagram profile to stay connected to a group of friends. You navigate a conversation where you assess his level of interest as being developmentally appro­ priate and you his acknowledge his desire to be con­ nected, but you clarify that you cannot accept his request to be connected on Instagram because you want to maintain a professional relationship. He expresses understanding. Your session continues to address his ability to develop satisfying relationships with age-appropriate peers. Suggestions for Follow-up

As clients continue in treatment and as they age, it is suggested that clinicians continually assess a client’s involvement in ICT use and continue to assess for cyberbullying. Consider following up at various, clin­ ically appropriate junctures—for example, when a client transitions to a new school environment or when a client meets a new partner (GLSEN et al., 2013). Contraindications for Use

The information available about ICT use in nonurban areas is comparatively nascent (Craig & McInroy, 2014; Ybarra et al., 2015). Available research acknowl­ edges that ICT use is necessarily bounded by region, socioeconomic status (SES), and associated class or wealth privilege, despite the growing use of ICTs and improved availability of the necessary technologies (smartphones, computers, the Internet) in locations where ICT and necessary technologies were not avail­ able (Mustanski, Lyons, & Garcia, 2011). Clinicians in rural areas and clinicians working with clients who might not have access to the latest technologies should take caution when implementing the activities to anticipate and respond to microaggressions related to regional, class, and wealth privileges (Craig & McIn-

Negotiating Information and Communication Technologies 227

roy, 2014; Mustanski et al., 2011; Ybarra et al., 2015). Clinicians should also pay close attention to the ways in which access to and use of ICTs might differ across racial and ethnic boundaries as they intersect with a client’s stated gender and sexual orientation identity (Craig & McInroy, 2014; Mustanski et al., 2011; Ybar­ ra et al., 2015). The activities in this chapter were designed for clients who are within the specified age range of fifteen to twenty-four. However, the activities are assessment-based and thus not necessarily limited to that specific age range. The activities were designed in service of empowering a client demographic that is arguably more at risk for cyber-victimization than clients who might be outside that specific age range (GLSEN et al., 2013; Hillier & Harrison, 2007; Kosciw et al., 2012; Tao, 2014). Finally, the activities are con­ traindicated for clients who may have learning dif­ ferences or who might be experiencing symptoms of psychosis, as their involvement with ICT may be influenced by differences in perception and/or reality testing (GLSEN et al., 2013; Lenhart, 2015). Professional Resources Anti-Defamation League. (2012). What to do if your child exhibits bullying behavior. https://www.adl.org/assets/ pdf/education-outreach/What-to-Do-if-Your-Child-Ex hibits-Bullying-Behavior.pdf. Centers for Disease Control and Prevention. (2016). Technol­ ogy and youth: Protecting your child from electronic aggression. https://www.cdc.gov/violenceprevention/ pdf/ea-tipsheet-a.pdf. Edgington, S. M. (2011). The parent’s guide to texting, Facebook, and social media. Dallas: Brown Books. GLSEN, CiPHR, & CCRC. (2013). Out online: The experiences of lesbian, gay, bisexual and transgender youth on the Internet. New York: GLSEN. https://www.glsen.org/sites/ default/files/Out Online FINAL.pdf. Lenhart, A. (2015). Teens, social media, and technology over­ view 2015. Pew Research Center. www.pewinternet. org/2015/04/09/teens-social-media-technology-2015/#.

Client Resources Human Rights Campaign. (2017). Resources on cyber-bully­ ing. https://www.hrc.org/resources/resources-on-cyber­ bullying. i-Safe Ventures Digital Learning. (2018). www.isafe.org/. Trevor Project. (2017). Saving young LGBTQ lives. https:// www.thetrevorproject.org/.

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US Department of Health and Human Services. (2017). What is cyberbullying. https://www.stopbullying.gov/cyber­ bullying/index.html.

References American Counseling Association (ACA). 2014. ACA code of ethics. https://www.counseling.org/resources/aca-code­ of-ethics.pdf. American Psychological Association (APA). 2017. Ethical prin­ ciples of psychologists and code of conduct. https://www. apa.org/ethics/code/. Behnke, S. (2008). Ethics in the age of the Internet. Monitor on Psychology, 39 (7), 74. Brown, J. D., & Bobkowski, P. S. (2011). Older and newer media: Patterns of use and effects on adolescents’ health and well-being. Journal of Research on Adolescence, 21 (1), 95–113. Craig, S. L., & McInroy, L. (2014). You can form a part of your­ self online: The influence of new media on identity devel­ opment and coming out for LGBTQ youth. Journal of Gay and Lesbian Mental Health, 18 (1), 95–109. Craig, S. L., McInroy, L., McCready, L. T., Di Cesare, D. M., & Pettaway, L. D. (2015). Connecting without fear: Clinician implications of the consumption of information and communication technologies by sexual minority youth and young adults. Clinical Social Work Journal, 43, 159–168. Duncan-Daston, R., Hunter-Sloan, M., & Fullmer, E. (2013). Considering the ethical implications of social media in social work education. Ethics Information Technology, 15, 35–43. Garner, J., & O’Sullivan, H. (2010). Facebook and the profes­ sional behaviours of undergraduate medical students. Clinical Teacher, 7, 112–115. Giffords, E. D. (2009). The Internet and social work: The next generation. Families in Society, 90 (4), 413–418. GLSEN, CiPHR, & CCRC. (2013). Out online: The experiences of lesbian, gay, bisexual, and transgender youth on the Internet. New York: GLSEN. https://www.glsen.org/sites/ default/files/Out Online FINAL.pdf. Guan, S. A., & Subrahmanyam, K. (2009). Youth Internet use: Risks and opportunities. Current Opinion in Psychiatry, 22, 351–356. Halabuza, D. (2014). Guidelines for social workers’ use of social networking websites. Journal of Social Work Values and Ethics, 11 (1), 23–32. Hillier, L., & Harrison, L. (2007). Building realities less limited than their own: Young people practising same-sex attrac­ tion on the Internet. Sexualities, 10 (1), 82–100. Jones, L. M., Mitchell, K. J., & Finkelhor, D. (2012). Trends in youth Internet victimization: Findings from three youth Internet safety surveys, 2000–2010. Journal of Adolescent Health, 50, 179–186.

Judd, R. G., & Johnston, L. B. (2012). Ethical consequences of using social network sites for students in professional social work programs. Journal of Social Work Values and Ethics, 9 (1), 5–11. Kays, L. (2011, July 4). Must I un-friend Facebook? Exploring the ethics of social media. New Social Worker. https:// www.socialworker.com/feature_articles/ethics-articles/ Must_I_Un-Friend_Facebook%3F_Exploring_the_ Ethics_of_Social_Media/. Kolmes, K., & Taube, D.O. (2016). Client discovery of psycho­ therapist personal information online. Professional Psy­ chology: Research and Practice, 47 (2), 147–154. Kosciw, J. G., Greytak, E. A., Bartkiewicz, M. J., Boesen, M. J., & Palmer, N. A. (2012). The 2011 National School Climate Survey: The experiences of lesbian, gay, bisexual and transgender youth in our nation’s schools. New York: GLSEN. https://glsen.org/sites/default/files/2011%20National%20 School%20Climate%20Survey%20Full%20Report.pdf. Lenhart, A. (2015). Teens, social media, and technology over­ view 2015. Pew Research Center. www.pewinternet. org/2015/04/09/teens-social-media-technology-2015/#. Lusk, B. (2010). Digital natives and social media behaviors: An overview. Prevention Researcher, 17, 3–6. Mitchell, K. J., Finkelhor, D., Wolak, J., Ybarra, M., and Turner, H. (2011). Youth Internet victimization in a broader vic­ timization context. Journal of Adolescent Health, 48 (2), 128–134. Mustanski, B., Lyons, T., & Garcia, S. C. (2011). Internet use and sexual health of young men who have sex with men: A mixed-methods study. Archives of Sexual Behavior, 40, 289–300. National Association of Social Workers (NASW). (2017). Code of ethics. Washington, DC: Author. https://www.social workers.org/About/Ethics/Code-of-Ethics/Code-of­ Ethics-English.

National Institute of Justice. (2007). Stalking. https://www. nij.gov/topics/crime/stalking/pages/welcome.aspx. Rietmeijer, C., Bull, S., McFarlane, M., Patnaik, J., & Douglas, J. (2003). Risks and benefits of the Internet for populations at risk for sexually transmitted infections (STIs): Results of an STI clinic survey. Sexually Transmitted Diseases, 30, 15–19. Subrahmanyam, K., & Greenfield, P. M. (2008). Communicat­ ing online: Adolescent relationships and the media. Future of Children, 18 (1), 119–146. Tao, K. (2014). Too close and too far: Counseling emerging adults in a technological age. Psychotherapy, 51 (1), 123–127. Taylor, L., McMinn, M. R., Bufford, R. K., & Chang, K. B. T. (2010). Psychologists’ attitudes and ethical concerns regarding the use of social networking web sites. Profes­ sional Psychology: Research and Practice, 41, 153–159. Tunick, R. A., Mednick, L., & Conroy, C. (2011). A snapshot of child psychologists’ social media activity: Professional and ethical practice implications and recommendations. Professional Psychology: Research and Practice, 42 (6), 440–447. United Nations. (n.d.). Definition of youth. https://www. un.org/esa/socdev/documents/youth/fact-sheets/youth­ definition.pdf. Ybarra, M. L., Mitchell, K. J., Palmer, N. A., & Reisner, S. L. (2015). Online social support as a buffer against online and offline peer and sexual victimization among US LGBT and non-LGBT youth. Child Abuse and Neglect, 39, 123–136. Zur, O. (2008). The Google factor: Therapists’ unwitting selfdisclosure on the net. New Therapist, 57, 16–22. Zur, O., & Zur, A. (2011). The Facebook dilemma: To accept or not accept? Responding to clients’ “friend requests” on psychotherapists’ social networking sites. Independent Practitioner, 31 (1), 12–17.

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ACT IVIT Y 1 WO RKS H EET

Demographics Client Name: ________________________________________ Date of Birth: _______________ Pronouns: ___________________________ Do you have a cell phone? n Yes n No If yes: Is it a smartphone? n Yes n No

Do you text? n Yes n No

Whom do you text? Please list: __________________________________________________

Do you have access to a computer at home?

n Yes n No

Do you have access to an Internet connection at home?

n Yes n No

Do you have access to a computer at school?

n Yes n No

Do you have access to an Internet connection at school?

n Yes n No

Do you use any electronic video game consoles?

n Yes n No

If yes:

Is it a portable game console? n Yes n No Do you participate in any community-based or multiplayer games that use an Internet

connection? n Yes n No If yes, please list: _______________________________________________________________

For which of the following activities do you use the Internet? n Schoolwork

n Social media

n Romantic/sexual connections

n Browsing n Online communities

n Sexual health research n Activism participation

n Other: _____________________________________________________________________ If you participate in social media, which social media platforms do you participate in? n Facebook

n Twitter

n Instagram

n Snapchat

n Tumblr

n Dating applications (please list): ______________________________________________

How often do you participate in activities involving technology (including texting, the Internet,

and social media)? Circle the most accurate frequency.

Less than 1 hour

1–3 hours/day

9–15 hours/day

15+ hours/day

4–8 hours/day

PAGE 1

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ACT IVIT Y 1 WO RKS H EET

Are you aware of the privacy settings on your social media accounts? n Yes n No Have you ever Googled yourself? n Yes n No If yes, did you find anything surprising? n Yes n No If yes, please describe: _______________________________________________________________________________ _______________________________________________________________________________ If you participate in online communities (including social media), can you describe the quality of those communities? _______________________________________________________________________________ _______________________________________________________________________________ If you participate in online communities (including social media), what do you like about those communities? _______________________________________________________________________________ _______________________________________________________________________________ If you participate in online communities (including social media), what do you dislike about those communities?_________________________________________________________ _________________________________________________________________________________ Have you ever been a target of cyberbullying? n Yes n No If yes, please describe: _________________________________________________________________________________ _________________________________________________________________________________ Have you ever targeted anyone else as an act of cyberbullying?

n Yes n No

If yes, please describe: _______________________________________________________________________________ _______________________________________________________________________________ How do you keep yourself safe online? _______________________________________________________________________________ _______________________________________________________________________________

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ACT IVIT Y 2 WO RKS H EET

Are you aware of the HIPAA policies governing electronic communication? n Yes n No Do you have a cellphone? n Yes n No If yes: Is it a smartphone?

n Yes n No

Do you text?

n Yes n No

Whom do you text? Please list: __________________________________________________ Do you have access to a computer at home?

n Yes n No

Do you have access to an Internet connection at home?

n Yes n No

Do you have access to a computer at work?

n Yes n No

Do you have access to an Internet connection at work?

n Yes n No

Do you communicate with clients via email or text?

n Yes n No

Do you use any electronic video game consoles?

n Yes n No

If yes: Is it a portable game console? n Yes n No Do you participate in any community-based or multiplayer games that use an Internet connection ? n Yes n No.

If yes, please list: _________________________________________

For which of the following activities do you use the Internet? n Professional activities

n Social media

n Browsing

n Sexual health research

n Romantic/sexual connections

n Online communities

n Activism participation

n Other: ______________________________________________________________________

If you participate in social media, which social media platforms do you participate in? n Facebook

n Twitter

n Instagram

n Snapchat

n Tumblr

n Dating applications (please list): _______________________________________________

How often do you participate in activities involving technology (including texting, the

Internet, and social media)? Circle the most accurate frequency

Less than 1 hour

1–3 hours/day

9–15 hours/day

15+ hours/day

4–8 hours/day

Are you aware of the privacy settings on your social media accounts? n Yes n No Have you ever Googled yourself? n Yes n No If yes, did you find anything surprising? n Yes n No If yes, please describe: __________________________________________________________

_______________________________________________________________________________

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27 BDSM EXPLORATION AND COMMUNICATION WITHIN LGBT RELATIONSHIPS Kandice H. van Beerschoten Suggested Uses: Homework, activity Objective

The objective of this activity is to facilitate or increase open, healthy, and positive communication within relational constellations (monogamous, nonmonoga­ mous, polyamorous relationships) wherein individuals wish to consensually participate in bondage and disci­ pline/dominance and submission/sadism and masoch­ ism, or BDSM. It may also be used with individuals who are curious to explore BDSM activities but are unsure about their interests and limits. This question­ naire serves as a starting point for both therapeutic and relational dialogue about safe, healthy exploration. Rationale for Use

As both populations may be judged as nonnormative within our heteronormative society, the LGBT and BDSM communities alike struggle for acceptance (Freeburg & McNaughton, 2017). When these sexual identifications overlap within an individual, clients may face additional difficulties, both internally and within their respective sexuality peer group (Goldberg, 2016). Also, clients may fear being judged by their therapist when disclosing their interest in or curios­ ity about BDSM (Kolmes, Stock, & Moser, 2006; Nichols, 2006). With the recent introduction of BDSM-themed books and movies, there has been an increase in peo­ ple expressing their curiosity about BDSM and explor­ ing some of those activities in the privacy of their homes (Berrill, 2012). The Fifty Shades trilogy was “credited with spurring a rise in sales of furry hand­

cuffs and wooden paddles” (Deller & Smith, 2013, p. 934). Additionally, in a small survey of fifty-one women who read the Fifty Shades books, 86 percent said that the books had influenced their sexual attitudes (Del­ ler & Smith, 2013). However, there may be confusion about how to get started, the wide range of activities, and the depth of communication that is necessary for successful BDSM play. It is important that quality conversations take place before play in order to ensure safety (Williams et al., 2017; Williams, Thomas, Prior, & Christensen, 2014). It is also inevitable that some of this material will make its way into the therapeutic space. However, for the therapist who is unfamiliar with the intricacies of BDSM, power dynamics, and the various activities that take place in these relationships, the prospect of guiding clients through how to engage safely in these interactions may seem daunting (Cannon-Gibbs, 2016). Some therapists may feel uncertain or insecure about BDSM because of a lack of education and infor­ mation about the subject (Cannon-Gibbs, 2016), but others may cross the line, causing their clients to have a negative experience (Kolmes et al., 2006; Nichols, 2006; Wright, 2008). When a survey of kink-identi­ fied people explored discrimination by professionals, 39.3 percent of respondents reported feeling discrimi­ nated against by mental health professionals (Wright, 2008). Additionally, some BDSM practitioners have had negative experiences in which they felt their ther­ apist judged them on the basis of their kinky identifi­ cation (Kolmes et al., 2006; Nichols, 2006). Not only do these experiences contradict the core of affirmative practice, but they also present an ethical

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issue. The National Association of Social Workers (NASW) “Code of Ethics,” as well as the ethical codes of other major mental health organizations, specifi­ cally address the issue of discriminating against clients on the basis of sexual orientation (NASW, 2017; see also AAMFT, 2015; ACA, 2014; AMHCA, 2015; APA, 2013; American Psychological Association, 2017). There is an emerging belief that kink within the LGB community may also be seen through the lens of sexual orientation (Gemberling, Cramer, & Miller, 2015). According to Gemberling and colleagues (2015), sexual orientation is composed of sexual behavior, sexual attraction, and sexual identity (among other components), and those who identify as kinky close­ ly resemble people with an LGB orientation. Each group has a specific set of behaviors it prefers, peo­ ple to whom they are attracted, and an identity that they feel represents their true self (Gemberling et al., 2015). Within BDSM, people are viewed as being oriented toward the power exchange that occurs between partners (Gemberling et al., 2015). Thus, the NASW Code of Ethics advises that “social workers treat each person in a caring and respectful fashion, mindful of individual differences and cultural and ethnic diversity. Social workers promote clients’ socially responsible self-determination” (NASW, 2017, 3.4). Whether clients view their participation in BDSM as their orientation, one of many sexual practices, or a form of sexual leisure (Williams & Prior, 2015), therapists have the ethical responsibility to work in their clients’ best interests, withhold judg­ ment, and be respectful of them as unique individuals. The intersection between BDSM and other minority identifications can contribute to further stig­ matization. A 2008 study of BDSM participants found that 22 percent of respondents identified as gay or lesbian, 35 percent as bisexual, and 7 percent as “other.” Additionally, 5 percent identified as transgender and 1 percent as intersex (Wright, 2008). A person identi­ fying as LGBT or polyamorous “would be more likely to experience stigma and pathologisation for being kinky than someone who is cisgender, monogamous, and heterosexual” (Richards & Barker, 2013, p. 92). Particularly because this dual identification may put clients at risk of being additionally stigmatized, it is important that therapists practice with them in an

affirmative manner. This requires not only valuing the kinky LGBT client as much as the nonkinky hetero­ sexual cisgender client, but also working to “counter the effects of heterosexism” (British Psychological Society, 2012, p. 70). Williams et al. (2014) outlined the most important elements in establishing a healthy BDSM dynamic, called the Four Cs. These are identified as caring, con­ sent, caution, and communication. It is this model that I considered in the formulation of the BDSM Commu­ nication Tool (page 239), rather than the more out­ dated Safe, Sane, and Consensual (SSC) or Risk-Aware Consensual Kink (RACK). These two acronyms have historically been used by the BDSM community as guidelines for behavior within play and interactions, the goals ultimately being safety and accountability (Williams et al., 2014). The BDSM Communication Tool encourages individuality, self-expression, and assertiveness, and it gives clients an avenue for sharing information with their partner that may be challeng­ ing to broach in conversation. By using the BDSM Communication Tool with a person who wants to explore kink, the therapist is actively validating the cli­ ent as a whole person while also being sensitive to the sexual culture. Most important, the client’s gender and sexual identity, sexual and psychological limits, and consent are also clearly addressed with the aim of establishing a healthy communication foundation. Instructions

The BDSM Communication Tool should be used when clients appear to be stuck or uncertain regarding their specific interests in or the practical application of kink, as well as how to proceed with a partner. By asking directly, the therapist should ascertain if cli­ ents know which activities interest them, how to safely engage in those activities, and how to have discus­ sions with new or current partners about the aspects of BDSM relevant to them. For example, when some­ one is new to BDSM experimentation, do they know specifically what they want to try? Has the couple established a safe word, which is used to bring a halt to all activity if needed? Have medical conditions been discussed, as well as what to do if an emergency occurs? These are all questions the therapist should ask and areas that should be explored for those new BDSM Exploration and Communication 235

to this type of sexual experimentation. If clients appear confused, hesitant, or overwhelmed, or expresses uncertainty regarding how to broach the subject with their partner, this is a good indication that the BDSM Communication Tool would serve as a valuable source of assistance. Explain to clients that the tool may help them define their interests, boundaries, needs, and expectations for healthy kinky sexuality. Clients in individual therapy should be instructed to fill out the BDSM Communication Tool and bring it with them to the next session for review. If clients plan to share their BDSM exploration with a partner outside therapy, each person should complete the questionnaire individually and then exchange forms. After reviewing their partner’s form, both members of the couple should thoroughly discuss the answers provided. Ideally, this conversation will allow the cou­ ple to begin exploring BDSM in a healthy manner. Likewise, if the tool is being used within couples coun­ seling, each person should fill out a questionnaire, exchange and discuss the forms with the other, and then bring the completed questionnaires with them to the next session for processing. When discussing the results with clients, it is important to talk about each aspect of the form. What is appealing about the desired activities? Why are oth­ ers designated as hard limits? Is the hard limit attached to a trigger of which the client and partner need to be aware? Have adverse life events been properly pro­ cessed, and how might these affect desired types of play? Does the client, or the partner, have concerns about any types of activities? Do couples seem comfort­ able and respectful talking to each other? Are each person’s needs and expectations realistic? It is impor­ tant for the therapist to be supportive and nonjudg­ mental, yet also to challenge issues that could prove problematic. To assist clients and partners with con­ tinuing to learn and be prepared to explore sexually, therapists should recommend books that place empha­ sis on beginner protocol and safety (see Resources for Clients). Brief Vignette

Mike is forty-two years old and Caucasian. He iden­ tifies as a gay cisgender male. He began therapy after ending a long-term relationship in which there had 236 Beerschoten

been little sex. Mike expressed the desire for a fully satisfying sex life, which he felt probably included some aspect of BDSM. However, having never exper­ imented with BDSM before, he could not identify his specific interests, nor did he know the range of options. Mike was given the BDSM Communication Tool to fill out as homework, and then several sessions were dedicated to processing his responses. Mike dated occasionally, though he did not feel comfortable enough to experiment with BDSM. How­ ever, approximately eighteen months into treatment, he began a serious relationship. Mike’s new partner was also interested in sexual exploration and had some limited experience with BDSM. Once they were far enough into the relationship that trust was estab­ lished, Mike used the BDSM Communication Tool by asking his partner to fill it out as well. Mike then brought his partner into a session, and we explored their similar interests together. For exam­ ple, flogging was a shared curiosity. We discussed spe­ cifically both persons’ thoughts and feelings, what they hoped to gain from the experience, what their fanta­ sies about flogging entailed, how they each expected to feel from flogging and being flogged, and how they hoped the other person would feel. Also, safety was discussed, which included the need to learn about proper technique, as well as communication during the scene. The couple had established a safe word that they each would remember and recognize, if used. Recommendations for both books and online resources were provided for Mike and his partner to use as addi­ tional preparation tools. Each person seemed comfort­ able in his respective role as dominant or submissive, and the couple as a unit appeared to be excited about introducing this new aspect into their intimate life. Suggestions for Follow-up

Once clients fill out the BDSM Communication Tool, they should bring their answers into session for pro­ cessing. Given that the questionnaire asks about trauma, fears, and other issues that may present chal­ lenges within BDSM, therapists should continuously evaluate to ensure that a healthy dynamic has, in fact, been established. This can be accomplished by asking questions that explore the quality of the dynamic, such as:

1. Has a safe word been established? If not, why? 2. Have limits been established and discussed? If not, why not? If the client is a dominant, how will the submissive partner be kept safe if the dominant is unaware of the submissive’s limits? If the client is a submissive, why has this information not been communicated to the partner? For both, how can this communication be improved? Are there other areas in which communication is an issue? 3. How do they feel during the scene? Negative emotions, such as guilt and shame, will need to be processed. 4. Do they feel safe before, during, and after playing? 5. Do they feel free to stop, if necessary? Able to say no? 6. Is the right amount of aftercare being provided? 7. Is BDSM adding to the client’s sexuality in the desired way? Contraindications for Use

This tool would be neither helpful nor necessary for individuals who have identified as kinky for a long time, are comfortable with this part of their sexuality, and know what their interests are. However, when entering a new relationship, it could be useful to com­ municate desires, limits, and needs, particularly if the client’s partner has relatively little experience with BDSM. This tool is not meant to be used in relationships where there is any history, suspicion, or disclosure of domestic violence or other types of relational abuse. In these situations, enthusiastic consent cannot be guaranteed, and the practice of BDSM would be a safety concern. Additionally, those who have experi­ enced a recent trauma may not be able to engage com­ fortably and safely in many BDSM activities. Professional Resources Goldberg, A. (2016). The Sage encyclopedia of LGBTQ studies. Los Angeles: Sage. Kleinplatz, P. J., & Moser, C. (2006). Sadomasochism: Powerful pleasures. Binghamton, NY: Harrington Park Press. Langdridge, D., & Barker, M. (2007). Safe, sane and consensual: Contemporary perspectives on sadomasochism. New York: Palgrave Macmillan.

National Coalition for Sexual Freedom. (2017). www. ncsfreedom.org. Weinberg, T. S. (1995). S&M: Studies in dominance and sub­ mission. Amherst, NY: Prometheus. Wright, S. (2008). 2008 Survey of Violence and Discrimina­ tion against Sexual Minorities fast facts. http://www. ncsfreedom.org/resources/bdsm-survey/2008-bdsm-survey­ fast-facts.

Resources for Clients Andrews, V. (2012). The complete leatherboy handbook. Day­ tona Beach, FL: Adynaton Publishing. Bean, J. (1994). Leathersex: A guide for the curious outsider and the serious player. Los Angeles: Daedalus Publishing. Califia, P. (1988). The lesbian S/M safety manual: Basic health and safety for woman-to-woman S/M (Lady Winston Series). Boston: Lace Publications. Eulenspiegel Society. (2017). www.tes.org. Miller, P., & Devon, M. (1995). Screw the roses, send me the thorns: The romance and sexual sorcery of sadomasoch­ ism. Fairfield, CT: Mystic Rose Books. National Coalition for Sexual Freedom. (2017). www. ncsfreedom.org National Leather Association International. (2017). www.nlainternational.com/. Rinella, J. (1994). The master’s manual: A handbook of erotic dominance. Los Angeles: Daedalus Publishing. Society of Janus. (2017). https://soj.org/. Stein, D. (2013, September 27). How to do the right kinky thing—Ethical principles for BDSM. Leatherati. https:// leatherati.com/how-to-do-the-right-kinky-thing-ethical­ principles-for-bdsm-c9a781f44a06. Warren, J. (2000). The loving dominant. Emeryville, CA: Greenery Press. Wiseman, J. (1996). SM 101: A realistic introduction. Emeryville, CA: Greenery Press.

References American Association for Marriage and Family Therapy (AAMFT). (2015). Code of ethics. http://www.aamft. org/Legal_Ethics/Code_of_Ethics.aspx. American Counseling Association (ACA). (2014). ACA code of ethics. https://www.counseling.org/docs/default-source/ ethics/2014-aca-code-of-ethics.pdf?sfvrsn=fde89426_5. American Mental Health Counselors Association (AMHCA). (2015). AMHCA code of ethics. http://connections.amhca. org/HigherLogic/System/DownloadDocumentFile.ashx? DocumentFileKey=d4e10fcb-2f3c-c701-aa1d-5d0f53b 8bc14. American Psychiatric Association (APA). (2013.) The principles of medical ethics with annotations especially applicable to psychiatry. https://www.psychiatry.org/ psychiatrists/practice/ethics.

BDSM Exploration and Communication 237

American Psychological Association. (2017). Ethical princi­ ples of psychologists and code of conduct. https://www. apa.org/ethics/code/. Berrill, A. (2012, December 10). Fifty Shades phenomenon gives Ann Summers a boost as “mummy porn” trend sends sales of handcuffs and blindfolds soaring. Daily Mail. http:// www.dailymail.co.uk/femail/article-2245788/Fifty-Shadesphenomenon-gives-Ann-Summers-boost-Mummy-Porn­ trend-sends-sales-handcuffs-blindfolds-soaring. html. British Psychological Society. (2012). Guidelines and literature review for psychologists working therapeutically with sexual and gender minority clients. Retrieved from https:// www.bps.org.uk/sites/bps.org.uk/files/Policy/Policy%20 -%20Files/Guidelines%20and%20Literature%20Review %20for%20Psychologists%20Working%20Therapeutically %20with%20Sexual%20and%20Gender%20Minority% 20Clients%20%282012%29.pdf. Cannon-Gibbs, S. (2016). The dichotomy of “them and us” thinking in counselling psychology incorporating an empirical study on BDSM. DPsych thesis, City Univer­ sity of London. http://openaccess.city.ac.uk/16215. Deller, R. A., & Smith, C. (2013). Reading the BDSM romance: Reader responses to Fifty Shades. Sexualities, 16, 932–950. doi:10.1177/1363460713508882. Freeburg, M. N., & McNaughton, M. J. (2017). Fifty shades of grey: Implications for counseling BDSM clients. Faculty, Administrator & Staff Articles. Paper 23. https://vc. bridgew.edu/fac_articles/23. Gemberling, T., Cramer, R., & Miller, R. (2015). BDSM as a sexual orientation: A comparison to lesbian, gay, and bisexual identity. Journal of Positive Sexuality, 1 (3), 37–43. http://journalofpositivesexuality.org/archive/volume-1­ feb-nov-2015/. Goldberg, A. (2016). The Sage encyclopedia of LGBTQ studies. Los Angeles: Sage.

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Kolmes, K., Stock, W., & Moser, C. (2006). Investigating bias in psychotherapy with BDSM clients. In P. J. Kleinplatz & C. Moser (eds.), Sadomasochism: Powerful pleasures, 301–324. Binghamton, NY: Harrington Park Press. National Association of Social Workers (NASW). (2017). NASW code of ethics. https://www.socialworkers.org/ About/Ethics/Code-of-Ethics/Code-of-Ethics-English. Nichols, M. (2006). Psychotherapeutic issues with “kinky” cli­ ents: Clinical problems, yours and theirs. In P. J. Klein­ platz & C. Moser (eds.), Sadomasochism: Powerful plea­ sures, 281–300. Binghamton, NY: Harrington Park Press. Richards, C., & Barker, M. (2013). Sexuality and gender for mental health professionals: A practical guide. Los Ange­ les: Sage. Williams, D. J., & Prior, E. E. (2015). “Wait, go back, I might miss something important!” Applying Leisure 101 to sim­ plify and complicate BDSM. Journal of Positive Sexuality, 1 (3), 63–69. http://journalofpositivesex uality.org/. Williams, D. J., Thomas, J. N., Prior, E. E., Amezquita, C., & Hall, D. (2017). Social work practice with clients that enjoy participation in consensual BDSM: Identifying and apply­ ing strengths. Journal of Positive Sexuality, 3 (1), 12–20. http://journalofpositivesexuality.org/wp-content/uploads/ 2017/03/Social-Work-Practice-and-Consensual-BDSM­ Applying-Strengths-Williams-Thomas-Prior-Amezquita­ Hall.pdf. Williams, D. J., Thomas, J. N., Prior, E. E., & Christensen, M. C. (2014). From “SSC” and “RACK” to the “4Cs”: Introduc­ ing a new framework for negotiating BDSM participation. Electronic Journal of Human Sexuality, 17. http://www. ejhs.org/volume17/BDSM.html. Wright, S. (2008). 2008 Survey of Violence and Discrimination against Sexual Minorities fast facts. http://www.ncsfree dom.org/resources/bdsm-survey/2008-bdsm-survey­ fast-facts.

BDSM COMMUNICATION TOOL Directions: Each person in the relationship is to fill out this form openly and honestly. Once

completed, forms are to be exchanged and discussed. Be sure to ask for clarity where needed.

This form does not constitute consent. Consent must be obtained for each activity and anew

during each encounter.

Preferred name during play:

Preferred pronouns:

Relationship status:

Preferred method of being addressed during play (title):

BDSM role identification, if known:

My definition of this is:

My safe word is:

Previous trauma(s) (including abuse, sexual violence, military experiences, motor vehicle accidents, etc.):

Health issues:

Potential trigger(s):

Hard limits (things I absolutely do not want to try):

Soft limits (things I may be willing to explore at a later time but not now):

Current areas I would like to explore:

BDSM fantasies that I have:

Pain level:

n None

Pain frequency: n Never

n Only as an accent n Occasional

n Significant pain

n About half the time

n Sadist/masochist n Most of the time

n All of the time

Circle one: I DO or DO NOT enjoy leaving/having temporary marks or bruises resulting from play. I DO or DO NOT seek to engage in a power exchange. Fears I have about BDSM are:

Questions I have about BDSM are:

1.

1.

2.

2.

3.

3.

It is important for me to give my partner and to receive from them

Aftercare needs:

Other specific needs I have:

Kandice H. van Beerschoten

239

AC TI V I TIES Instructions: Check the appropriate box that reflects your level of interest in exploring each activity. If you have already experienced the activity, indicate your preference for it.

Yes, I like this

Want to try

ANAL PLAY Anal intercourse Fisting Pegging Rimming Toys BREAST PLAY Breast binding Nipple clamps BONDAGE Blindfold Cock and ball torture (CBT) Cross Gags Handcuffs Rope Spreader bar CONTROL/RESTRAINT Chastity devices Denied masturbation Denied orgasm Forced celibacy Forced masturbation Forced orgasm Orgasm on command EDGE PLAY Choking/breath play Consensual nonconsent Scat Water sports GENERAL SEX Multiple simultaneous partners Partner exchange HUMILIATION Verbal Physical

240

Kandice H. van Beerschoten

Curious but cautious

Hard limit NO

Yes, I like this

Want to try

Curious but cautious

Hard limit NO

Sexual objectification Public IMPACT PLAY Back Breasts/chest Buttocks Feet Genitals Legs Cane Face slapping Belt Flogger Hand/spanking Paddle Riding crop Whip LEATHER MEDICAL PLAY Gynecological exam Sounding POWER EXCHANGE ROLE - PLAY SENSATION PLAY Electrical play Fire play Hot wax Ice Needle play SERVICE Cleaning Cooking Crawling Kneeling Massage VAGINAL PLAY Fisting Oral sex Toys Vaginal penetration WRESTLING

Kandice H. van Beerschoten

241

SECTION IV

HOMEWORK, HANDOUTS,

AND ACTIVITIES FOR

LGBTQ PARENTING AND

FAMILY THERAPY

running foot 243

In the chapters that this section comprises, the con­ tributors share interventions to enhance familial sup­ port and work through painful family dynamics with LGBTQ clients. The authors address affirmative par­ enting approaches, transform conventional geno­ grams to be inclusive of family of choice and other family structures, and provide activities to facilitate better understanding and communication among fam­ ily members. It is exceedingly important for LGBTQ individuals, whether they are children or parents, to be validated and respected by family members. For example, studies have demonstrated higher levels of self-esteem and less emotional distress in sexual and gender minorities who are raised in supportive envi­ ronments (Johnson, Sikorski, Savage, & Woitaszewski, 2014; Snapp et al., 2015). The chapters in this section are essential resources for helping clients get the sup­ port that they need. Transgender youth experience higher rates of abuse and discrimination than do other marginalized groups, even within their families (Grant et al., 2011). For this reason, several chapters in this section offer methods for assisting parents to validate their nonbi­ nary children’s gender identity. In Chapter 28, “Trans­ gender-Affirmative Parenting: Practicing Pronouns,” Jennifer M. Gess offers both psychoeducation and an exercise to assist parents in explicitly validating their trans or gender-nonconforming children by increas­ ing their facility with using their correct pronouns. Her innovative approach encourages parents to prac­ tice pronouns even with familiar household objects so that they can start to think outside the box in a nonshaming and effective way. Heather Kramer offers another effective strategy to help parents increase their comfort level with their children’s pronouns in Chapter 35, “An Informative Intervention for Parents and Caregivers of Transgen­ der and Gender-Nonbinary Children and Adoles­ cents.” This is a group intervention that is designed to increase the support and normalization that parents receive as they navigate this process. The activity is designed to ultimately promote the self-worth of chil­ dren and adolescents through a skillful balance of supporting and challenging their parents. Rebekah Byrd and Laura Boyd Farmer provide another activity for parents in Chapter 30, “Expanding 244

Binary Thinking: A Reflective Activity for Parents and Caregivers of Transgender and Gender-Expansive Youth.” Given that less than 43 percent of all transgender and gender-expansive (TGE) youth report having a supportive adult in their lives (Baum et al., 2014), they have created an activity that invites par­ ents to move beyond the gender binary in their think­ ing. They share a provocative worksheet to help par­ ents reflect honestly on the ways in which their more narrow views of gender may be negatively affecting their child or teen. Clients in LGBTQ-parented families too often do not see their particular family structures reflected in society. Two chapters provide therapists with geno­ gram exercises that can validate any family structure, social identity, and cultural context. Fiona Tasker, Maeve Malley, and Pedro Alexandre Costa share fam­ ily mapping exercises for adults and children to facili­ tate expression of their own definition of family in Chapter 29, “Family Mapping Exercises (FMEs) for Adults and Children in LGBTQ-Parented Families.” Anthony Zazzarino, Veronica M. Kirkland, and Jenae Thompson speak to the issues faced by parents who identify as sexual and gender minorities as well as trauma survivors through a genogram exercise in Chapter 34, “Addressing Blended Family and Trauma Issues with Sexual and Gender Minority Parents.” Both chapters incorporate elements of queer theory and intersectionality to help therapists explore the various systems of oppression and privilege experienced by the family members. In completing these activities, clients are guided to contextualize and explore their relation­ ships within their various sociocultural systems. Coming out as either a gender or a sexual minority can be fraught with pain and a range of reactions from family members. Three chapters provide excellent strategies to help families respond in supportive ways to the disclosure. In Chapter 31, “Parents of Transgender Teens and the Initial Disclosure Process,” Laura R. Haddock and Hilary Meier take a strengths-based approach to assist parents in regulating their affect and behavior toward their teens. They offer a thorough glossary of pertinent terms as a starting point for par­ ents in creating a shared vocabulary, and they pro­ vide parents with a wide range of reflective questions on all aspects of the process, including disclosure;

school, legal, and safety concerns; and physical tran­ sition. This chapter is an outstanding resource that helps transgender teens by ensuring that parents have the guidance and information that are essential for them to be affirming of their children. Taking a family therapy approach, Susannah C. Coaston, Patia Tabar, and Lori Barrett help youth mit­ igate the influence of negative family reactions to their coming-out disclosure in Chapter 32, “Maintaining the Family Unit When an Adolescent Family Mem­ ber Comes Out as a Sexual or Gender Minority.” Meet­ ing with the family as a whole allows the therapist to tailor the work to the family’s cultural background and worldviews in order to help the family respond in more adaptive ways. Using unexpected props to pro­ vide psychoeducation, their exercise also employs powerful symbolism. Another strategy to process the pain of parental rejection after coming out is outlined in Cara Herbitter and Heidi M. Levitt’s “Empty-Chair Work for Cop­ ing with Heterosexist and/or Transphobic Family Rejection” (Chapter 33). The authors guide thera­ pists to engage clients individually to empower them to appropriate assignation of blame for rejection to the parents, rather than its being internalized by the client. Effectively addressing varying levels of outness in couples can greatly enhance intimacy and reduce

tension in romantic relationships. In Chapter 36, “Cir­ cles of Outness: Systemic Exploration of Disclosure Decisions in Mixed-Orientation Relationships,” Mary R. Nedela, M. Evan Thomas, and Michelle M. Mur­ ray offer a narrative therapy approach to deepening communication and understanding regarding dis­ closure decisions in mixed-orientation couples. References Baum, J., Brill, S., Brown, J., Delpercio, A., Kahn, E., Kenney, L., & Nicoll, A. (2014). Supporting and caring for our gender expansive youth. http://hrc-assets.s3-website-us­ east-1.amazonaws.com//files/assets/resources/Genderexpansive-youth-report-final.pdf. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Kiesling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washing­ ton, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force. https://transequality. org/sites/default/files/docs/resources/NTDS_Report.pdf. Johnson, D., Sikorski, J., Savage, T. A., & Woitaszewski, S. A. (2014). Parents of youth who identify as transgender: An exploratory study. School Psychology Forum, 8 (1), 56. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low cost strategies for positive adjustment. Family Rela­ tions: An Interdisciplinary Journal of Applied Family Studies, 64 (3), 420–430.

245

28 TRANSGENDER-AFFIRMATIVE PARENTING: PRACTICING PRONOUNS Jennifer M. Gess Suggested Use: Homework Objective

This activity is for parents of transgender or genderdiverse children. The objective of the activity is to increase parents’ ability to use their child’s self-identi­ fied, gender-affirming pronoun. Rationale for Use

Transgender and gender-diverse individuals refer to those whose gender identity or expression does not align, according to Western societal standards, with their sex assigned at birth (Moe, Perera-Diltz, Sepul­ veda, & Finnerty, 2014). Transgender and genderdiverse youth often experience higher rates of harass­ ment, discrimination, and abuse in society and school and within their families than any other marginal­ ized group (Grant et al., 2011). At the societal level, many transgender and gender-diverse youth experi­ ence poverty, discrimination in health care, and barri­ ers to accessing identification documents aligning with their self-identified, affirming gender (Grant et al., 2011). According to the National Transgender Discrimination Survey, 78 percent of transgender and gender-diverse students between kindergarten and twelfth grade reported some form of harassment related to their gender identity and expression, 35 per­ cent reported incidences of physical violence, and 12 percent reported sexual violence (Grant et al., 2011). The harassment and bullying many transgender and gender-diverse youth experience are extremely severe, leading one in six students to drop out of school before the end of twelfth grade (Grant et al., 2011). Trans-

gender and gender-diverse youth of color experience greater harassment and violence (Koken, Bimbi, & Parsons, 2009; Singh, Hwahng, Chang, & White, 2017; Singh & McKleroy, 2011). Approximately 57 percent of transgender and gender-diverse individuals expe­ rience significant family rejection, which contributes to the 20–45 percent of homeless youth who identify as lesbian, gay, bisexual, transgender, queer, or other gender and sexual identities (LGBTQ+) (Grant et al., 2011; Keuroghlian, Shtasel, & Bassuk, 2014; National Alliance to End Homelessness, 2008). As a result of harassment, discrimination, and abuse in society and school and within their families, transgender and gender-diverse individuals have higher rates of negative mental health outcomes, lower academic results, and higher rates of substance abuse and suicidality than their cisgender peers (Grant et al., 2011; Grossman & D’Augelli, 2007; Singh, Hays, & Watson, 2011). Over half of transgender and gen­ der-diverse youth attempt suicide, a statistic that demonstrates the high risks vulnerable youth experi­ ence (Clements-Nolle, Marx, & Katz, 2006; Grant et al., 2011). The mistreatment many transgender and gender-diverse youth experience is highly correlated with negative outcomes, including mental health issues and suicide attempts, but these consequences can be reduced through social support. The negative outcomes dissipate when transgen­ der and gender-diverse youth are surrounded by social support (Mustanski & Liu, 2013). Transgender and gender-diverse youth in supportive environments report increased self-esteem, increased life satisfac­ tion, and higher rates of positive mental health (Sherer,

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

246

2016). Transgender and gender-diverse youth who have supportive environments have healthy development and higher self-esteem (Johnson, Sikorski, Savage, & Woitaszewski, 2014). Transgender and gender-diverse youth need social support to dissipate experiences of oppression, discrimination, and harassment. Specifically, family support has the largest posi­ tive effect on LGBTQ+ youth (Snapp et al., 2015). The psychological and emotional well-being of transgen­ der and gender-diverse youth increases with family support (Johnson et al., 2014). Family support of transgender children, including using the name and pronoun the children feel most comfortable with, leads to positive outcomes (McConnell, Birkett, & Mus­ tanski, 2016). The following activity demonstrates one method that counselors can use to help parents with a transgender or gender-diverse child show support for their child. Transgender and gender-diverse individuals often have names and pronouns assigned at birth that do not fit their identity. Many will change their assigned names and pronouns or have already done so (Deutsch & Buchholz, 2015; Thorpe, 2015). For many transgender and gender-diverse individuals, being called by their self-identified, gender-affirming names and pronouns is empowering (Denny, 2004). Transgen­ der and gender-diverse youth whose parents use their self-identified, gender-affirming pronoun experience affirmation and validation (McConnell et al., 2016). Parents and guardians have the opportunity to support their children by using their self-identified, genderaffirming names and pronouns. Counselors are ethically responsible for treating clients equitably and for honoring diversity. The Amer­ ican Counseling Association (ACA) Code of Ethics (2014) states the importance of social justice, diversity, and multiculturalism, specifically in the preamble and ethical principles. Specifically, the standard of non­ discrimination in the Code of Ethics states, “Counsel­ ors do not condone or engage in discrimination against prospective or current clients . . . based on . . . gen­ der identity, [and] sexual orientation” (p. 9). Further, the Code of Ethics requires multicultural counseling competence, defined as “counseling that recognizes diversity and embraces approaches that support the worth, dignity, potential, and uniqueness of individuals

within their historical, cultural, economic, political, and psychosocial contexts” (p. 20). Standards of the counseling profession include LGBTQ+ competency: counselors must support transgender and genderdiverse clients by using those clients’ self-identified, gender-affirming names and pronouns and helping support and facilitate families in using their children’s self-identified, gender-affirming names and pronouns (dickey & Singh, 2017). In 2009 the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC), a division of the ACA that promotes awareness and understanding of LGBTQ+ topics, published the ALGBTIC “Competencies for Counseling with Transgender Clients” (Burnes et al., 2010) to provide guide­ lines for counselors working with trans clients. The competencies provide an in-depth, affirmative framework for use by counselors, counseling students, and counselor educators. The competencies present guidelines for developing and maintaining safe and supportive counseling relationships with LGBTQ+ individuals. Specifically, the competencies state, “Com­ petent counselors will understand the importance of using appropriate language (e.g., correct name and pronouns)” (p. 8). The ALGBTIC competencies high­ light the importance of affirming clients by using their self-identified, gender-affirming names and pronouns. In 2015 the American Psychological Association (APA) published the “Guidelines for Psychological Practice with Transgender and Gender Nonconform­ ing People.” The guidelines classify “not using a per­ son’s preferred name or pronoun” as an example of discrimination (APA, 2015, p. 838). Counselors can affirm clients by using their self-identified, genderaffirming names and pronouns and educate parents on the importance of using their children’s self-iden­ tified, gender-affirming names and pronouns. Fur­ ther, the guidelines state, “Psychologists are encour­ aged to examine how their language (e.g., use of incorrect pronouns and names) may reinforce the gender binary in overt or subtle and unintentional ways” (p. 840). Counselors must be aware of the lan­ guage they use in order to use affirmative language to empower the client and educate the family. Using affirmative language is part of creating a safe, thera­ peutic space for the client. If the counselor does not Transgender-Affirming Parenting: Practicing Pronouns 247

use affirmative language and does not educate the family to use the transgender or gender-diverse child’s self-identified, gender-affirming name and pronoun, the counselor is not practicing ethical counseling. Instructions

The counseling session is a prime opportunity for fam­ ily members to begin or continue practicing their child’s self-identified, gender-affirming name and pro­ nouns. In the counseling session with the parents of the transgender or gender-diverse child, invite the parents to practice using their child’s self-identified, gender-affirming pronouns. Whether the child is pres­ ent depends on the family relationship and the child’s developmental level. Though transparency is impor­ tant, there might be situations in which, because the parents’ process takes time, hurtful discussion topics may arise. In these situations, provide an individual session exclusive to the parents. Provide a safe, nonjudgmental space for parents to practice using their child’s pronouns. Validate their experience of struggling with the new name and pro­ nouns. Many parents experience the loss of the dreams they held for their child, and it is important to acknowl­ edge the grief process (Phillips & Ancis, 2008; Saltz­ burg, 2004, 2009). Simultaneously, as an advocate for the transgender or gender-diverse child, it is just as important to correct the parents if they accidentally use their child’s old pronouns or old name (sometimes referred to as the child’s “deadname”). As appropri­ ate, it may be important to discuss the ramifications of using the child’s old name and pronouns, specifi­ cally the pain the child experiences when hearing the old name and pronouns. One suggestion to begin the session is to ask the parents to share a favorite memory of their child while using the child’s self-identified, gender-affirming pro­ nouns. Let them know you will correct them while they are sharing the memory to help them practice. Because parents may be tentative and uncomfortable using the child’s new name and pronouns, demon­ strate support through nodding, paraphrasing, and other supportive verbal and nonverbal techniques. To continue the progress, toward the end of the session invite the parents to engage in homework that will be due at the next session. The homework 248 Gess

appears at the end of the chapter, titled “TransgenderAffirming Parenting: Practicing Pronouns Homework” (page 253). The following is a detailed step-by-step process for the homework assignment. Step 1. Throughout the week, share stories out loud about your pet, car, holiday character, plants, and household objects using their pronouns. Post sticky labels around your home to remind you to engage in the activity. Verbally discussing and hearing the pro­ nouns is beneficial to this process. Invite your family to help you verbally practice sharing stories about your yellow Labrador retriever Luna (she/her), cele­ brating Santa Claus (he/him) during the Christmas holidays, and Jamie (she/her) the coffee machine. If you do not have safe people to share the activity with, verbally talk to your pet, plant, or yourself about Luna, Santa Claus, and Jamie. For example, when speaking with your spouse or partner, bring up the upcoming holidays: “Christmas is coming soon and Santa Claus is coming. He is going to fly to our home with his reindeer.” While you may feel silly during this activity, you will have the opportunity to become very proficient at changing names and pronouns. Step 2. Once you have practiced for a few days and are feeling proficient, switch pronouns for your pet, car, holiday character, plants, and household objects—but not the names. This step will help you with the pro­ cess of learning eventually to use different pronouns for your transgender or gender-diverse child. Con­ tinue referring to your Labrador retriever as Luna but begin using he/him pronouns; continue referring to Santa Claus as Santa Claus but use she/her pronouns. Again, keep sharing stories out loud to yourself, to your family, or to your pets or plants. This process pro­ vides you with the opportunity to become skillful at adapting to new pronouns while creating a supportive environment for the child. Many children use gender-neutral pronouns, such as they/them or ze/zir. Continue calling your coffee machine Jamie and use gender-neutral pronouns, such as they/them. Including nonbinary pronouns may make this activity more challenging. If your child iden­ tifies as nonbinary, this is a great place to start! Prac­ tice talking out loud about Jamie the coffee machine, who uses they/them pronouns.

Once this feels more comfortable, change the pro­ nouns again. Proceed at the pace that fits best for you, which varies from person to person. Pronouns can be difficult to change, so be gentle and kind with your­ self as you learn to use new pronouns. Recognize this as a big step that shows support for transgender or gender-diverse children, thereby reducing the nega­ tive effects of the oppression, discrimination, and harassment they experience. Step 3. The final step is changing the name. For some, changing the name is the most difficult. Some parents experience using a name different from the one they gave their child as painful and challenging. Again, making these imperative changes demonstrates sup­ port for the transgender or gender-diverse child, and support will lead to the child’s higher self-esteem and self-worth (Ryan, 2009). Brief Vignette

Thomas and Olivia Parker are parents of Zoe Parker, a twelve-year-old who was assigned female at birth. Thomas is a firefighter for the local fire department, and Olivia works part-time at a library. Thomas, a heterosexual, Caucasian cisgender man, grew up in a nonreligious household; Olivia, an African American, heterosexual cisgender woman, grew up in a Chris­ tian home. Thomas and Olivia take their daughter to church a few times a year and live in a middle-class, predominantly white neighborhood. Zoe plays for the school soccer team, and the Parkers spend their free time going to soccer games, camping, and attend­ ing events at the library where Olivia works. Thomas and Olivia describe Zoe as a playful, kind, spirited kid. When Zoe was three and four years old, she told people “My name is Ben” and “I’m a boy.” Thomas and Olivia would tell Zoe, “No, you’re a girl and your name is Zoe,” and laugh it off. Zoe would become infuri­ ated and scream whenever Thomas or Olivia would try to put a dress on her or put a hair clip in her hair. When Zoe was four years old, she found scissors in the kitchen and cut off her ponytail. Olivia was hor­ rified and yelled at Zoe for “ruining her hair.” Olivia rushed Zoe to a hairdresser to “fix” her hair. Zoe stopped telling people “My name is Ben and I’m a boy” around the age of five and began wearing dresses and hair clips. Thomas and Olivia felt relieved.

Around age ten, Zoe stopped wearing dresses and began wearing pants and baggy shirts. She became sullen and quiet. Thomas and Olivia became con­ cerned for their child. Given her previous experience at an earlier age, Zoe refused to talk to them about the change in appearance and behavior. By the time she was eleven, Thomas and Olivia decided to go to family counseling because of their concern for Zoe’s change in attitude and appearance. Audrey is a family counselor in private practice. The Parkers had a few sessions as a family with Audrey. Audrey soon discovered Zoe had seen the school counselor a few times and, after obtaining a release of information, she reached out to the school counselor. The school counselor stated that he had seen Zoe a few times over the past year, and Zoe had told him numerous times, “I’m not a girl. I’m a boy. A lot of my friends are already calling me ‘he’ and I love it.” Audrey asked to meet with Zoe individually. In the individual session, Zoe told Audrey, “I know I’m not a girl. I’ve always known I’m a boy. I’m too scared to say anything to my parents because they wouldn’t understand, but I can’t take this any longer. I need them to start calling me Ben and using he/him pro­ nouns.” After processing Zoe’s fears, Audrey and Zoe came up with a plan to come out as a transgender boy to Thomas and Olivia in the next family session. The following week, Audrey began the family ses­ sion by discussing gender as a spectrum and the oppression, discriminations, and harassment that transgender and gender-diverse individuals face. Audrey stated that the most important factor to reduce nega­ tive outcomes for transgender and gender-diverse youth is supportive family. Audrey emphasized that transgender and gender-diverse youth whose families support them have lower rates of suicide attempts, homelessness, depression, and substance abuse. If a family rejects their transgender or gender-diverse child, the child is eight times more likely to attempt suicide (Ryan, 2009). Audrey had several brochures, books, and websites to share with Thomas and Olivia on transgender and gender-diverse youth. Next, Zoe nervously stated, “I’m a boy,” and shared his story of gender, including how he never felt like a girl. Audrey supported him along the way and rec­ ommended that Thomas and Olivia listen and not Transgender-Affirming Parenting: Practicing Pronouns 249

interrupt Zoe. Thomas and Olivia appeared surprised, but they saw Zoe’s face light up with excitement and hope as their child talked about the future. Thomas and Olivia hadn’t seen their child exude happiness in years. Audrey recommended that Thomas and Olivia see another counselor who specializes in grief coun­ seling to process the potential ambiguous loss they might be experiencing. Audrey also provided educa­ tional materials for Thomas and Olivia to learn more about raising, supporting, and affirming their transgender child. After a few family sessions, Thomas and Olivia appeared ready to take the first step of the activity; therefore, Audrey discussed the importance of pro­ nouns. Audrey stated, “Using your child’s self-identi­ fied, gender-affirming name and pronouns is a way to show your child that you love and accept him. You’ve known your child for over eleven years; therefore, using his new name and pronouns can be a big change! One way to help practice using his new name and pro­ nouns is by practicing at home. For example, you have mentioned you have a family dog named Bear. Let’s try referring to Bear and Bear’s pronouns regu­ larly. Another idea is that Easter is coming up. You can try regularly referring to the Easter Bunny as he/him.” Audrey helped Thomas and Olivia come up with a few more examples. Thomas and Olivia agreed to put sticky notes around the house to remember to use their names and pronouns daily. The goal of the first part of the activity is to increase awareness of genderbinary pronouns. At the next family session, Audrey asked how the week using the names and different pronouns had gone for Thomas and Olivia. Thomas observed, “I’d never thought much about pronouns before, so this is the first time it’s really been on my mind.” Olivia noted that she was regularly discussing “the male Easter Bunny” and “our male dog, Bear” with Thomas. Thomas and Olivia demonstrated their desire to learn more about the power and influence of pronouns because of their desire to support and care for their child. Audrey decided Thomas and Olivia were ready for the second step: to switch pronouns. For the next week, Thomas and Olivia kept the same names for the dog and the Easter Bunny, but they switched the pronouns. For example, Bear, the previ­ 250 Gess

ously he/him dog, was now Bear, the she/her dog. The Easter Bunny now also had she/her pronouns. At the next family session, Thomas and Olivia reported that it was more difficult to call Bear and the Easter Bunny “she” and “her.” Thomas and Olivia kept practicing for another two weeks. The second step of the activity adds the component of increased awareness of genderbinary pronouns by forcing the participant to give careful consideration to gender and pronouns before referring to others. The third step to the activity is changing the names. Suddenly, Bear the dog became Carla (she/her) the dog and the Easter Bunny became the Leprechaun (he/him). While Thomas and Olivia reported they felt “a little silly” calling their dog Carla and the Easter Bunny “the Leprechaun,” they found the activity very helpful in making them aware of the power and sig­ nificance of names and pronouns. After the parents successfully completed the activ­ ity, Zoe felt supported and ready to share his self-iden­ tified new name, Ben, and his gender-affirming pro­ nouns, he, him, and his. After the period of practicing pronouns and names, Thomas and Olivia felt as though they understood the importance of using their child’s self-identified, gender-affirming name and pronouns to support his self-worth and identity. Thomas and Olivia were ready to begin actively calling their child Ben and using he/him pronouns. In session, Audrey gently corrected as needed, and Ben began to blossom as the kind, spirited kid he once had been. Suggestions for Follow-up

The initial process of changing pronouns and names can be a difficult one. For this reason, it is important for counselors to remain nonjudgmental when parents slip while simultaneously gently and firmly remind­ ing them to continue to use their child’s self-identified, gender-affirming pronouns. During counseling ses­ sions with parents, counselors should have parents continue practicing their child’s self-identified, genderaffirming pronouns and name. Contraindications for Use

Parents whose personal beliefs and values do not sup­ port transgender or gender-diverse people often have more difficulties supporting their transgender or gen­

der-diverse child. For example, parents who are deeply religious may struggle to accept their transgender or gender-diverse child (Higa et al., 2014). The conse­ quences for parents who do not support their transgender or gender-diverse child are the child’s higher risk for suicide attempts, higher rates of depression, and higher rates of substance abuse. Changing pro­ nouns and names may be a challenging and ongoing process. These parents may benefit from a slower, more in-depth family counseling process along with individual grief counseling. Professional Resources Brill, S. A., & Kenney, L. (2016). The transgender teen: A hand­ book for parents and professionals supporting transgender and non-binary teens. Jersey City, NJ: Cleis. Brill, S. A., & Pepper, R. (2008). The transgender child: A hand­ book for families and professionals. San Francisco: Cleis. Ginicola, M. M., Smith, C., & Filmore, J., eds. (2017). Affir­ mative counseling with LGBTQI+ People. Alexandria, VA: American Counseling Association. Kosciw, J. G., Diaz, E. M., & Gay, L. Y. (2008). Involved, invisi­ ble, ignored: The experiences of lesbian, gay, bisexual and transgender parents and their children in our nation’s K–12 schools. Gay, Lesbian and Straight Education Net­ work (GLSEN). Lev, A. I. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Press. Mustanski, B., & Liu, R. (2013). A longitudinal study of pre­ dictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Archives of Sexual Behavior, 42 (3), 437–448. Ryan, C. (2009). Supportive families, healthy children: Help­ ing families with lesbian, gay, bisexual, and transgender children. San Francisco: Family Acceptance Project, Marian Wright Edelman Institute, San Francisco State University. Saltzburg, S. (2009). Parents’ experience of feeling socially supported as adolescents come out as lesbian and gay: A phenomenological study. Journal of Family Social Work, 12 (4), 340–358.

Resources for Clients Brill, S. A., & Kenney, L. (2016). The transgender teen: A hand­ book for parents and professionals supporting transgender and non-binary teens. Jersey City, NJ: Cleis. Brill, S. A., & Pepper, R. (2008). The transgender child: A hand­ book for families and professionals. San Francisco: Cleis. Family Acceptance Project. (n.d.). http://familyproject.sfsu.edu/. Gender Spectrum. (n.d.). https://www.genderspectrum.org/.

Herdt, G., & Koff, B. (2000). Something to tell you: The road families travel when a child is gay. New York: Columbia University Press. Human Rights Campaign. (n.d.). Advocating for LGBTQ Equality | Human Rights Campaign. https://www.hrc.org/. Korell, S. C., & Lorah, P. (2007). An overview of affirmative psychotherapy and counseling with transgender clients. In K. J. Bieschke, R. M. Perez, & K. A. DeBord (eds.), Handbook of counseling and psychotherapy with lesbian, gay, bisexual, and transgender clients, chap. 11. Washing­ ton, DC: American Psychological Association. Kosciw, J. G., Diaz, E. M., & Gay, L. Y. (2008). Involved, invis­ ible, ignored: The experiences of lesbian, gay, bisexual and transgender parents and their children in our nation’s K–12 schools. Gay, Lesbian and Straight Education Net­ work (GLSEN). National Federation of Parents and Friends of Lesbian and Gays (PFLAG). (n.d.). https://www.pflag.org/. Pepper, R. (2012). Transitions of the heart: Stories of love, strug­ gle, and acceptance by mothers of transgender and gender variant children. San Francisco: Cleis.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association (APA). (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70, 832– 864. doi:10.1037/a0039906. Burnes, T. R., Singh, A. A., Harper, A., Pickering, D. L. Moun­ das, S., Scofield, T., Maxon, W., & Harper, B. (2010). ALGBTIC competencies for counseling with transgen­ der clients. https://www.counseling.org/resources/ competencies/algbtic_competencies.pdf. Clements-Nolle, K., Marx, R., & Katz, M. (2006). Attempted suicide among transgender persons: The influence of gender-based discrimination and victimization. Journal of Homosexuality, 51, 53–69. Denny, Dallas. (2004, November/December). Pronoun trouble. Transgender Tapestry, 104 (5). http://dallasdenny.com/ Writing/2013/10/06/pronoun-trouble-2004/. Deutsch, M., & Buchholz, D. (2015). Electronic health records and transgender patients—Practical recommendations for the collection of gender identity data. Journal of Gen­ eral Internal Medicine, 30 (6), 843–847. dickey, L. M., & Singh, A. A. (2017). Social justice and advo­ cacy for transgender and gender-diverse clients. Psychi­ atric Clinic, 40, 1–13. Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Keisling, M. (2011). Injustice at every turn: A report of the National Transgender Discrimination Survey. National Center for Transgender Equality and National Gay and Lesbian Task Force.

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Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life-Threaten­ ing Behavior, 37 (5), 527–537. doi:10.1521/suli.2007.37.5. 527. Haas, A. P., Rodgers, P. L., & Herman, J. L. (2014). Suicide attempts among transgender and gender non-conforming adults: Findings of the national transgender discrimina­ tion survey. American Foundation for Suicide Prevention. Herdt, G., & Koff, B. (2000). Something to tell you: The road families travel when a child is gay. New York: Columbia University Press. Herman, J. (2013). Gendered restrooms and minority stress: The public regulation of gender and its impact on transgender people’s lives. Journal of Public Management and Social Policy, 19 (1), 65–80. Higa, D., Hoppe, M. J., Lindhorst, T., Mincer, S., Beadnell, B., Morrison, D. M., Wells, E. A., Todd, A., & Mountz, S. (2014). Negative and positive factors associated with the well-being of lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQ) youth. Youth and Society, 46 (5), 663–687. Johnson, D., Sikorski, J., Savage, T. A., & Woitaszewski, S. A. (2014). Parents of youth who identify as transgender: An exploratory study. School Psychology Forum, 8 (1), 56–74. Keuroghlian, A. S., Shtasel, D., & Bassuk, E. L. (2014). Out on the street: A public health and policy agenda for lesbian, gay, bisexual, and transgender youth who are homeless. American Journal of Orthopsychiatry, 84 (1), 66–72. doi:10. 1037/h0098852. Koken, J. A., Bimbi, D. S., & Parsons, J. T. (2009). Experiences of familial acceptance-rejection among transwomen of color. Journal of Family Psychology, 23, 853–860. Kosciw, J. G., Diaz, E. M., & Gay, L. Y. (2008). Involved, invis­ ible, ignored: The experiences of lesbian, gay, bisexual and transgender parents and their children in our nation’s K–12 schools. Gay, Lesbian and Straight Education Net­ work (GLSEN). McConnell, E. A., Birkett, M., & Mustanski, B. (2016). Fami­ lies matter: Social support and mental health trajectories among lesbian, gay, bisexual, and transgender youth. Jour­ nal of Adolescent Health, 59 (6), 674–680. doi:10.1016/j. jadohealth.2016.07.026. Moe, J., Perera-Diltz, D., Sepulveda, V., & Finnerty, P. (2014). Salience, valence, context, and integration: Conceptual­ izing the needs of sexually and gender diverse youth in P–12 schools. Journal of Homosexuality, 61 (3), 435–451. Mustanski, B., & Liu, R. (2013). A longitudinal study of pre­ dictors of suicide attempts among lesbian, gay, bisexual, and transgender youth. Archives of Sexual Behavior, 42 (3), 437–448.

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National Alliance to End Homelessness. (2008, December 8). Incidence and vulnerability of LGBTQ homeless youth (Brief no. 2). Youth Homelessness Series. https://b.3cdn. net/naeh/1f4df9fc5fcad14d92_vim6ivd15.pdf. Phillips, M. J., & Ancis, J. R. (2008). The process of identity development as the parent of a lesbian or gay male. Jour­ nal of LGBT Issues in Counseling, 2 (2), 126–158. Ryan, C. (2009). Supportive families, healthy children: Helping families with lesbian, gay, bisexual, and transgender children. San Francisco: Family Acceptance Project, Marian Wright Edelman Institute, San Francisco State University. Saltzburg, S. (2004). Learning that an adolescent child is gay or lesbian: The parent experience. Social Work, 49 (1), 109. Saltzburg, S. (2009). Parents’ experience of feeling socially supported as adolescents come out as lesbian and gay: A phenomenological study. Journal of Family Social Work, 12 (4), 340–358. Sherer, I. (2016). Social transition: Supporting our youngest transgender children. Pediatrics, 137 (3), 1–2. doi:10. 1542/peds.2015-4358. Singh, A. A., Hays, D. G., & Watson, L. S. (2011). Strength in the face of adversity: Resilience strategies of transgender individuals. Journal of Counseling and Development: JCD, 89 (1), 20. doi:10.1002/j.1556-6678.2011.tb00057.x. Singh, A. A., Hwahng, S. J., Chang, S. C., & White, B. (2017). Affirmative counseling with trans/gender-variant people of color. In A. A. Singh & l. m. dickey (eds.), Affirmative counseling and psychological practice with transgender and gender nonconforming clients, 41–68. Washington, DC: American Psychological Association. Singh, A. A., & McKleroy, V. S. (2011). “Just getting out of bed is a revolutionary act”: The resilience of transgender peo­ ple of color who have survived traumatic life events. Traumatology, 17 (2), 34–44. Singh, A. A., Meng, S. E., & Hansen, A. W. (2014). “I am my own gender”: Resilience strategies of trans youth. Journal of Counseling and Development, 92 (2), 208–218. doi:10.1002/j.1556-6676.2014.00150.x. Snapp, S. D., Watson, R. J., Russell, S. T., Diaz, R. M., & Ryan, C. (2015). Social support networks for LGBT young adults: Low cost strategies for positive adjustment. Family Rela­ tions: An Interdisciplinary Journal of Applied Family Stud­ ies, 64 (3), 420–430. Thorpe, A. (2015). Towards the inclusion of trans* identities: The language of gender identity in postsecondary student documentation. Antistasis, 5 (2), 81–89. Zalaznick, M. (2015). Creating inclusive climates. District Administration, 51 (7), 35–38.

TRANSGENDER-AFFIRMING PARENTING: PRACTICING PRONOUNS HOMEWORK Do you have a pet?

n Yes n No

If yes, what is your pet’s name? _________________________________

Do you have a car?

n Yes n No

If yes, do you have a name for your car? _________________________

What is a character that represents an upcoming holiday you celebrate (e.g., Santa, Easter Bunny, leprechauns) ?_________________________________ Do you have a plant?

n Yes n No If yes, do you have a name for your plant? ________________________

In addition to the above or if none of the above fit, provide a name for a household or inanimate object you use daily (e.g., the television or refrigerator): ________________________________________ Next, what is the assigned gender for the above: Pet: _____________________

Car: ______________________

Holiday character: _____________________

Plant: _____________________

Household object: _____________________

STEP 1. Post sticky labels to remind yourself to share stories out loud about your pet, car, holiday character, plant, and household objects using their pronouns.

STEP 2. Once you have practiced for a few days and are feeling proficient, switch pronouns for your pet, car, holiday character, plant, and household objects—but not their names. Once this feels more comfortable, change the pronouns again.

STEP 3. Change the names of your pet, car, holiday character, plant, and household objects.

Jennifer M. Gess

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29 FAMILY MAPPING EXERCISES (FMES) FOR ADULTS AND CHILDREN IN LGBTQ-PARENTED FAMILIES Fiona Tasker, Maeve Malley, and Pedro Alexandre Costa Suggested Use: Activity Objective

The aim of the family mapping exercises (FMEs) is to explore and then chart clients’ self-definition of their family and the strength of their emotional, social, and practical connections with others in their family network. LGBTQ-parented families are frequently complex and rarely defined simply by biological or legal parenting. Thus, mapping family connections is often a useful exercise in beginning to understand a client’s relationship context and definition of family. Two different FMEs are available, one for adults (the Family Map for adults) and one for children (the Apple Tree Family). Rationale for Use

Visual depictions of family relationships, or drawn genograms, are established techniques in the clinical assessment of individuals or families (McGoldrick, Gerson, & Petry, 2008). Genograms enable the ther­ apist to easily view family membership and the rela­ tionship between family members in a family-tree formation over three or more generations. In provid­ ing an intergenerational view of the family, the gen­ ogram connects both family of origin and families led or formed by LGBTQ clients, prompting valu­ able insights into how past family events might affect current relationship concerns. Traditional genograms, however, often have presented a view of the family bound by biological and marital connections, bypass­ ing family-of-choice connections that feature in the family formations created by LGBTQ individuals (Weston, 1997). Traditional genogram nomenclature

has been expanded to include symbols for LGBTQ individuals (McGoldrick, Garcia Preto, & Carter, 2015), but standard notation lacks the flexibility of self-cho­ sen symbols that can depict cherished and changing identifications (Callis, 2014). As FMEs do not use a standard notation for denoting identities, these provide a visual way of affirming all the family relationships of LGBTQ people and identifying supportive family connections and social resources for LGBTQ people. Genograms have spawned a number of offshoots that have widened the consideration of family relation­ ships. Socially constructed genograms have been used by Milewski-Hertlein (2001) to give greater freedom to clients to draw twenty-first-century family forms. Ecomaps, or ecograms, also have been developed to help clients place their current family relationships in relation to the major systems that contextualize them (Hartman, 1995; Limb & Hodge, 2011). Ecomaps emphasize the presence or absence of resources for clients and their families at a systemic level. The Fam­ ily Map for adults (page 258) combines both the genogram focus on family and the ecomap freedom to depict systems and resources. FMEs evolved specifically in relation to working with members of LGBTQ-led families and are parti­ cularly useful for working with LGBTQ clients because they do not necessarily constrain family relationships into heteronormative structures. For example, draw­ ing and then redrawing genograms as family maps has highlighted the importance of acceptance and affir­ mation versus heterosexism and sexual prejudice for lesbian couples when constructing a joint family map (Swainson & Tasker, 2005). The special features and complexity of the family networks created by bisexual

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mothers also have been emphasized by family map­ ping (Tasker & Delvoye, 2018). In families with donorconceived children, both the similarities and differ­ ences in the family networks of lesbian mothers and their children were highlighted in a study using the Apple Tree Family activity for children (Tasker & Granville, 2011). FMEs enable the therapist and the client to think about the family system surrounding the client and may visually emphasize on a single page previously unacknowledged relationship connections and resources that could be further explored in therapy. Visual depiction and the associated conversation prompted by the FMEs enable the therapist to high­ light salient parenting contexts and identify relation­ ships that are important in different ways to the indi­ vidual and collective well-being of different family members. For example, different FME depictions may be produced by LGBTQ parents that depend on whether they became a parent within their current same-gender relationship or within a previous or ongoing different-gender relationship (Tasker & Malley, 2012). Furthermore, a child’s FME may rep­ resent one, two, or more parental figures (Tasker & Granville, 2010, 2011). From FMEs therapists may also learn about their clients’ chosen family relation­ ships (family of choice) as well as those based on biological or legal ties (Weston, 1997). FMEs are useful in considering the effects of changing family relationships through various pro­ cesses such as coming out, partnership, birth of chil­ dren, relationship dissolution, death, migration, and poverty. LGBTQ clients’ unique intersection of their multiple social identities will probably influence their family networks and the sources of support and resources they can draw on within their networks as depicted in FMEs (Swainson & Tasker, 2005). Moore and Brainer (2013) have considered how race and ethnicity matter in the lives of African Americans, Hispanics, and Asian and Pacific Islander (API) Americans and how these crucially intersect with experiences of sexual-minority parents and their children. For example, compared to European American same-gender couples, both African Amer­ ican and Hispanic same-gender couples are more likely to experience economic disadvantage, whereas

both API American and Hispanic same-gender cou­ ples are more likely than other groups to be affected by issues connected with immigration. Added com­ plexity is introduced in LGBTQ relationships and families when differences of power or visibility in class, culture, nationality, education, or ability com­ pete for attention in particular situations (Singh & Harper, 2012). In providing a map of family relation­ ships and allegiances that can be viewed as a whole, FMEs can help clients explore assumptions about which identity is foregrounded within a particular context or relationship, while helping family mem­ bers retain a sense of family connection. According to the American Association for Marriage and Family Therapy (AAMFT) code of ethics, therapists must provide professional service free of prejudice and discrimination and adopt a culturally sensitive stance (2015). Consent and con­ fidentiality issues of adults, vulnerable adults, and children must be appropriately addressed by the therapist in relation to family work—for example, through working within the guidelines of relevant professional bodies. The British professional body— the Association for Family Therapy (AFT)—states: “When faced with an ethical dilemma members should adopt the course of action which ‘maximises the good’ and does the ‘least harm.’ They should attach particular weight to the rights of the vulnera­ ble and those with least power” (2015, p. 2). The American Psychological Association (APA) has stated that the delivery of professional services to lesbian, gay, bisexual, and transgender clients must be built on the principle that “same-sex sexual and romantic attractions, feelings, and behaviors are normal and positive variations of human sexuality regardless of sexual orientation identity” (2009, p. 121). Specifically in regard to LGBTQ families, APA (2012) further states that LGBTQ people may recog­ nize friends and other nonbiologically related peo­ ple as part of their family of choice. For many LGBTQ people, the family of origin may be rejecting of their sexual identity, and other networks of morethan-friends can provide familial and supportive relationships that their biological family may not. These support networks can be revealed by a family mapping exercise. Family Mapping Exercises for LGBTQ-Parented Families 255

Instructions

Family Map (FM) for Adults Adult clients are asked to take part in an interview con­ versation about who is in their family and their fam­ ily relationships. Key interview questions for use with the Family Map (FM) for adults are available below and at the Family Mapping Exercises website (Tasker, 2017). As part of the interview, clients are asked to draw a map or to help the therapist draw a map of their family relationships. Clients are asked to come up with their own symbols for themselves and their sexual identity. A blank sheet of white 8.5- × 11-inch paper and a selection of lead and colored pencils are made available for the activity. If an audio recording is not made, then the therapist should note the client’s description of the relationships depicted on the FM as a future memory aid. The FM can usually be adapted for use with clients with special needs and disabilities: the therapist can assist with drawing or offer (as appro­ priate) computer help, a trained assistant, or a transla­ tor. For example, for a client with visual impairment, blocks of different shapes and sizes could be posi­ tioned and a range of textural fabrics used to provide rich description. Therapist instructions to client: I’d like you to draw, or help me draw, a map of your family. Please put a mark or a symbol or a drawing (use whatever symbols you like) on the blank sheet of paper for each mem­ ber of your family, so that all these relationships and the connections between them are shown on the paper. Remember, everybody’s family is different, and some­ times it’s not easy to draw, so you’re welcome to have another go at drawing your family map if you need to. Apple Tree Family (ATF) for Children The FME for children involves children constructing a picture of their family by placing a paper apple on an apple tree to represent each member of their fam­ ily —the Apple Tree Family (ATF). The ATF was devel­ oped as an enjoyable activity for preschool and ele­ mentary-school children. The materials needed for the Apple Tree Family are a standard picture of a green tree (the Apple Tree) in the center of a plain white sheet of 8.5- × 11-inch paper and a pile of red paper apples, available below or from the FME website (Tasker, 2017). The ATF, like the FM for adults, can 256 Tasker, Malley, & Costa

often be adapted for use by children and adolescents with special needs. The therapist puts the blank Apple Tree out on a table or the floor for the child and puts a few paper apples next to the tree ready for the child to pick up and place on the tree to represent family members. A pile of individual apples can be copied from the apple under the tree, reproduced, cut out, and placed in a pile at the foot of the apple tree on the sheet of paper. A pen or a pencil is needed for nam­ ing each apple (either for the therapist or the child to write the name on), as is glue suitable for children’s use. To avoid any suggestion of the “correct” family size expected on the apple tree, the therapist makes it clear that more apples are available for the child to use if these are needed. The interview questions for use with the ATF are available from the FME website (Tasker, 2017). If an audio recording is not made, the therapist should note the child’s description of each family relationship as the child places each apple on the tree. Therapist instructions to child: We all come from different sorts of families—some are very big, and some are very small and have different people in them. I’d like you to help me find out who is in your family by putting a red apple on this green apple tree for yourself and for anybody who is in your family. Then we can see your Apple Tree Family. Would you like to do that for me? So that I can remember whose apple is whose, would you like to write a name on each apple, or would you like me to write for you? Brief Vignette

When they arrived for a therapy session, Arlette and Cathleen (a white, middle-class, able-bodied, cisgen­ der lesbian couple, ages thirty-eight and thirty, respec­ tively) had been in a monogamous relationship for two years (living together for twelve months) and resided in New Zealand. Both Arlette and Cathleen had been traveling in New Zealand when they met, although they were both U.S. citizens originally from Arizona. Arlette brought her young son, Jamie, with her from Arizona to New Zealand. Arlette and Jamie’s father (Arlette’s ex-partner) had separated acrimoniously three years before. Jamie was now five years old. The issue that brought the family into therapy was the couple’s decision to move back to Arizona. Back

in Arizona, Arlette’s mother (age sixty-five) recently had had a major operation, and so Arlette felt that she needed to return home to support her mother, her father (seventy-four years old), and her younger sister, Susan (twenty-eight years old and living at home with her parents after being diagnosed with autism as a teenager). No other members of Arlette’s family of origin were mentioned as available to help out. Arlette’s brother and his wife (both thirty-two years old) were described by Arlette as “useless.” Arlette considered herself to be “first-generation” middle class, having been the first of her family to go to college, and she was aware of how her family and siblings felt a degree of alienation in response to what they perceived as her “abandonment” of some familial norms and values. Also, Arlette was anxious about how her family would regard Cathleen and her family, who were more estab­ lished in their middle-class circumstances, but who came from a second-generation Irish American Cath­ olic background. Arlette’s family identifies as Baptists, though Arlette herself espoused no religious identity. As a consequence of these interrelated issues, histories, and identifications, Arlette had apprehensions about moving back to Arizona. In contrast to Arlette, Cathleen was an only child whose parents had been “fine about it” when she came out to them while in college in her home state. At this time Cathleen and her parents occasionally contacted each other over Skype, and she also regularly Skyped her best friend and ex-lover Phyllis (Phyl), who lived with Nino and JJ (identified as a trans man and a gender-nonconforming person, respectively) in the United States. Cathleen saw her family of origin as less crucial to her than her family of choice. Further­ more, most of Cathleen’s family-of-choice connections were now in New Zealand, including Lucille (Cath­ leen’s ex and now her best friend) and Tanya (also from the United States; she recently had settled in New Zealand with Tui, a Maori woman). Nonetheless, Cathleen felt a great longing to be regularly back in touch with Phyl and rekindle other LGBTQ contacts. This was a factor in Cathleen’s decision to return to Arizona with Arlette and Jamie, to whom she said she was attached. With the couple’s agreement, the Family Map was introduced as an activity in this initial session, as many

of the difficulties that Arlette and Cathleen identified involved their very different pattern of close relation­ ships and the potential misunderstandings or clashes they could foresee in incorporating these relation­ ships into their life together. In the first half of the session, Jamie sat quietly, saying very little, and was keen to explore the toy box in the adjacent therapy room when invited to do so. While Jamie played with some toy cars he found, Arlette and Cathleen together constructed and talked about their family map (see Figure 1). Arlette and Cathleen subsequently brought Jamie back into the room, and they stayed with him for a more child-focused session in which Jamie con­ structed his Apple Tree Family (see Figure 2). The family was encouraged to think about the FMEs they produced as preparation for the next session, but the therapist asked them not to get into heavy discussion about the FMEs with one another. At a subsequent session Arlette, Cathleen, and the therapist together identified themes that were evident to them in Figures 1 and 2 while Jamie listened, chim­ ing in occasionally, as he played again with the cars in the toy box. In Figure 1, the family connections high­ lighted by Arlette seemed very different from those highlighted by Cathleen. Each attached different mean­ ings to the biological and chosen relationships included on the map, as highlighted by several contextual fea­ tures that the therapist encouraged the clients to draw or represent. For example, Arlette drew the distance between Arlette’s parental home in Arizona and her heartfelt family with Cathleen and Jamie in New Zealand. Cathleen added the flags. Arlette gave sup­ port to a number of people but indicated a mutually supportive relationship only with Cathleen. Arlette also said the distance (represented by her as a sea of waves) meant that she avoided conflict with Jamie’s father. Cathleen gave stars to family-of-choice mem­ bers who she said had “always been there for her.” Arlette then added Nina to the Family Map and gave her a star. Arlette spoke of Nina as her best friend through school and college, although they had not been in contact for a while. In Figure 2 Jamie first put his mom’s apple on the tree and then his dad’s. After that, Jamie put an apple for himself on the tree, situated below but between these two. He seemed eager to do the activity and Family Mapping Exercises for LGBTQ-Parented Families 257

Figure 1. Arlette and Catheen’s Family Map

258

Cathleen

Granny Auntie Susan

Mom Snoopy Dog

Dad Jamie

Name

Figure 2. Jamie’s Apple Tree Family

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Name

Figure 3. Apple Tree Family activity for children (blank) Source: Fiona Tasker and Julia Granville. (2011). Children’s views of family relationships in lesbian-led families, Journal of GLBT Family Studies, 7 (1–2), 182–199. Reprinted by permission of Taylor and Francis Group, LLC (www.tandfonline.com). First published in Fiona Tasker and Julia Granville. (2010). Die Perspektive des Kindes in lesbischen Familien. In Dorett Funcke and Petra Thorn (eds.), Die gleichgeschlechtliche Familie mit Kindern. Interdisziplinäre Beiträge zu einer neuen Lebensform. Reprinted by permission of Transkript Verlag.

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quickly added further apples for his granny and Aun­ tie Susan, whom he said he spoke to when they were on the phone with Mom. After this Jamie paused, and the therapist asked him if there was anyone else in his family who could go on the tree. Jamie then put on an apple for Cathleen, who he said helped him brush his teeth and took him to his preschool. After another pause, and a similar prompt, Jamie mentioned Tanya and Tui, who had two dogs, but he then said they were not in his family. He then decided, however, to add an apple for Auntie Susan’s dog, Snoopy, next to his apple on the tree. After completion of both FMEs, the following issues were identified as potential topics for discus­ sion in a subsequent session: Were there differences in hierarchies of closeness or obligation experienced by the couple? Whom did Jamie want in his family and in what ways could this be organized in the family? Who had rights and responsibilities (legal, financial, practical, and emotional) as a parent, grandparent, aunt, uncle, family friend, or supporter for Jamie? Were these rights and responsibilities reserved for family of origin, or could these roles be filled by family of choice? How did each partner experience the incorporation, or exclusion, of various ex-partners into a shared relational network? Suggestions for Follow-up

The FMEs were initially developed as assessment tech­ niques for examining family relationships. Addition­ ally, the FMEs can be used as follow-up exercises— either in the session or as a homework activity—as a way of evaluating the effectiveness of an interven­ tion designed to combat isolation by increasing social support networks or deepen existing involvements. Contraindications for Use

Many different and difficult issues can be raised for LGBTQ clients in talking about family in terms of past experiences, current predicaments, and future hopes. Simply being presented with a blank piece of paper, or a blank apple tree, and instructions to display your family can be daunting, particularly for those with perfectionist tendencies. Furthermore, the fact of “mapping,” or indeed producing any visual depiction, can be an emotional experience even though it may

be a gateway to addressing deficits or reshaping patterns of relationship. Knowing something can be a very different experience from actually seeing it. For instance, a very sparse relational map can feel like a painful failure. Further, particular sensitivity is needed when considering how people who have died are included in the map, or in pointing out a similar patterning of difficulties across or within generations of the family, especially if clients have not noticed this before. For these reasons, we strong­ ly advise that therapists first administer FMEs within a session with the client and ensure that enough time is allowed for the activity in the session. Once the client is familiar with the FME technique, a subse­ quent administration can be either session-based or used as a homework activity. Professional Resources Ariel, J., & McPherson, D. W. (2000). Therapy with lesbian and gay parents and their children. Journal of Marital and Family Therapy, 26, 421–432. doi:10.1111/j.17520606.2000.tb00313.x. Brodzinsky, D. M., & Pertman, A. (eds.). (2012). Adoption by lesbians and gay men: A new dimension in family diversity. New York: Oxford University Press. Freeman, T., Graham, S., Ebtehaj, F., & Richards, M. (eds.). (2014). Relatedness in assisted reproduction: Families, origins, and identities. Cambridge: Cambridge University Press. Goldberg, A. E. (2010). Lesbian and gay parents and their children. Washington, DC: American Psychological Association. Goldberg, A. E., & Allen, K. R. (eds.). (2013). LGBT-parent families: Innovations in research and implications for practice. New York: Springer. Golombok, S. (2015). Modern families: Parents and children in new family forms. Cambridge: Cambridge University Press. Hicks, S. (2011). Lesbian, gay, and queer parenting: Families, intimacies, genealogies. Basingstoke, UK: Palgrave Macmillan. Tasker, F. (2017). Family mapping exercises. https://family mappingexercises.wordpress.com/. Weston, K. (1997). Families we choose: Lesbians, gays, kinship. New York: Columbia University Press.

Resources for Clients Dunne, G. A. (ed.). (1998) Living “difference”: Lesbian perspec­ tives on work and family life. Binghamton, NY: Haworth Press. Garner, A. (2004). Families like mine: Children of gay parents tell it like it is. New York: HarperCollins. Family Mapping Exercises for LGBTQ-Parented Families 261

Goldberg, A. E., Gartrell, N. K., & Gates, G. (2014). Research report on LGB-parent families. Los Angeles: Williams Institute, UCLA School of Law. http://williamsinstitute. law.ucla.edu/wp-content/uploads/lgb-parent-familiesjuly-2014.pdf. Gottlieb, A. R. (2003). Sons talk about their gay fathers: Life curves. Binghamton, NY: Harrington Park Press. Howey, N., & Samuel, E. (eds.). (2000). Out of the ordinary: Essays on growing up with gay, lesbian, and transgender parents. New York: St. Martin’s Press. Lehr, V. (1999). Queer family values: Debunking the myth of the nuclear family. Philadelphia: Temple University Press. Sarles, P. A. Gay-themed picture books for children. http:// booksforkidsingayfamilies.blogspot.co.uk/. Strah, D., & Margolis, S. (2003). Gay dads: A celebration of fatherhood. New York: Putnam. Weston, K. (1997). Families we choose: Lesbians, gays, kinship. New York: Columbia University Press.

References American Association for Marriage and Family Therapy (AAMFT). (2015). Code of ethics. https://www.aamft.org/ Documents/ Legal Ethics/AAMFT-code-of-ethics.pdf. American Psychological Association (APA). (2009). Report of the APA Task Force on Appropriate Therapeutic Responses to Sexual Orientation. https://www.apa.org/pi/lgbt/ resources/therapeutic-response.pdf. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual Clients. American Psychologist, 67, 10–42. doi:10. 1037/a0024659. Association for Family Therapy (AFT). (2015). AFT code of ethics and practice. http://www.aft.org.uk/Springboard­ WebApp/userfiles/aft/file/Ethics/Code%20of%20 Ethics%20September%202015.pdf. Callis, A. S. (2014). Bisexual, pansexual, queer: Non-binary identities and the sexual borderlands. Sexualities, 17, 63–80. doi:10.1177/1363460713511094. Hartman, A. (1995). Diagrammatic assessment of family rela­ tionships. Families in Society: The Journal of Contemporary Human Services, 76 (2), 111–122. Limb, G. E., & Hodge, D. R. (2011). Utilizing spiritual eco­ grams with Native American families and children to promote cultural competence in family therapy. Journal

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of Marital and Family Therapy, 37, 81–94. doi:10.1111/j. 1752-0606.2009.00163.x. McGoldrick, M., Garcia Preto, N., & Carter, B. (2015). The expanding family life cycle: Individual, family, and social perspectives. London: Pearson. McGoldrick, M., Gerson, R., & Petry, S. S. (2008). Genograms: Assessment and intervention, 3rd edition. New York: W. W. Norton. Milewski-Hertlein, K. A. (2001). The use of a socially con­ structed genogram in clinical practice. American Journal of Family Therapy, 29, 23–38. doi:10.1080/019261801 25996. Moore, M. R., & Brainer, A. (2013). Race and ethnicity in the lives of sexual minority parents and their children. In A. E. Goldberg & K. R. Allen (eds.), LGBT-parent families: Innovations for research and for practice, 133–148. New York: Springer. doi:10.1007/978-I-4614-4556-2_9. Singh, A. A., & Harper, A. (2012). Intercultural issues in LGBTQQ couple and family therapy. In J. J. Bigner & J. L. Wetchler (eds.), Handbook of LGBT-affirmative couple and family therapy, 283–298. New York: Routledge. Swainson, M., & Tasker, F. (2005). Genograms redrawn: Les­ bian couples define their families. Journal of GLBT Family Studies, 1 (2), 3–27. doi:10.1300/J461v01n02_02. Tasker, F. (2017). Family mapping exercises. https://family­ mappingexercises.wordpress.com/. Tasker, F., & Delvoye, M. (2018). Maps of family relations drawn by women engaged in bisexual motherhood: Defining family membership. Journal of Family Issues, 39 (18), 4248–4274. doi:10.1177/0192513X18810958. Tasker, F., & Granville, J. (2010). Die Perspektive des Kindes in lesbischen Familien. In D. Funcke & P. Thorn (eds.), Die gleichgeschlechtliche Familie mit Kindern. Inter­ disziplinäre Beiträge zu einer neuen Lebensform, 429– 454. Frankfurt: Transkript Verlag. Tasker, F., & Granville, J. (2011). Children’s views of family relationships in lesbian-led families. Journal of GLBT Family Studies, 7, 182–199. doi:10.1080/15504 28X.2011.540201. Tasker, F., & Malley, M. (2012). Working with LGBT parents. In J. J. Bigner & J. L. Wetchler (eds.), Handbook of LGBTaffirmative couple and family therapy, 149–165. New York: Routledge. Weston, K. (1997). Families we choose: Lesbians, gays, kinship. New York: Columbia University Press.

ACTIVITIES: FAMILY MAP (FM) FOR ADULTS

Suggested Additional Interview Questions Sometimes there might be additional people who are important to you in a way a family member might be, although other people in your family would not always include them in their family definition. These might be people with whom you previously had or currently have an intimate connection in an emotional, sexual, or practical way. Do you want to include anyone like this on your map? Sometimes other aspects of your life are very much connected to the way you think about your family— for example, being part of an LGBTQ group or your local community or neighborhood. Or it may be that your home, or any animals you have living with you, are connected with your family. Would you like to include these or anything else that’s important on your family map? For additional questions, see https://familymappingexercises.wordpress.com.

ACTIVITIES: APPLE TREE FAMILY (ATF) FOR CHILDREN Suggested Additional Interview Questions Sometimes everybody in a family lives together and sometimes they don’t. Sometimes lots of different people can be like a parent to you or part of your family in different ways. Does that happen in your family? Some children have just one parent; others have two moms or two dads or a mom and a dad. Some children have more than two parents, and all of them are so special in their very own way that it might be difficult to tell other people about. What’s your family like? For additional questions, see https://familymappingexercises.wordpress.com.

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30 EXPANDING BINARY THINKING: A REFLECTIVE ACTIVITY FOR PARENTS AND CAREGIVERS OF TRANSGENDER AND GENDER-EXPANSIVE YOUTH Rebekah Byrd and Laura Boyd Farmer Suggested Uses: Activity, homework Objective

The objective of this activity is to assist parents and caregivers of transgender and gender-expansive (TGE) youth in questioning and elaborating on binary ideas of gender. This activity is intended to develop greater awareness for parents and caregivers in supporting TGE youth while also strengthening resources for advocat­ ing against oppression that stems from genderism. Rationale for Use

This activity is designed to help parents and caregivers of TGE youth understand that binary conceptualiza­ tions of gender have been used to oppress and discrim­ inate against sexual- and gender-identity diverse indi­ viduals (Farmer & Byrd, 2015). Increasingly, alarming rates of suicidal ideation specifically attributed to how one identifies is a significant risk factor for TGE youth (Grossman & D’Augelli, 2007). Support from parents and caregivers for TGE youth is essential to develop a positive self-image, to increase self-esteem, and to foster thriving (Orr & Baum, 2015), but fewer than half (43 percent) of TGE youth report having a supportive adult in their family (Baum et al., 2014). It is important to assist parents and caregivers in chal­ lenging biased thinking so that they may in turn assist their youth in combating internalized stigma related to gender identity. Understanding genderism is a key component of this task. In short, genderism is “the belief that gender is binary, and that only two gen­ ders—male and female—exist” (Sampson, 2014, p. 35).

In a much greater context, genderism affects myriad aspects of one’s life. Airton (2009) conceptualizes gen­ derism quite vividly: “Because of the reality of gender binary socialization, then, genderism not only rein­ forces the negative evaluation of gender non-confor­ mity or an incongruence between sex and gender. Genderism is more pervasively manifested as the fear­ ful anticipation of non-conformity and any incon­ gruence between biological sex, and the way these are lived and expressed through gender” (p. 230). Binary thinking may limit parents and caregivers in their ability to understand, accept, and support their child. Reflecting on the binary paradigm and questioning the subsequent genderism that pervades Western culture is an essential place to start. Though this activity focuses on expanding binary thinking, it is necessary for counselors to acknowledge the intersectionality of identities. Gender, gender iden­ tity, and gender expression intersect with many identi­ ties, including socioeconomic status, race, ethnicity, ability status, sexual or affectional orientation, religious or spiritual affiliation, and age (Parent, Deblaere & Moradi, 2013). Therefore, counselors seek to understand the multiple systems of oppression affecting each client. Because each client and each counseling situation are unique, ethical and multiculturally competent counsel­ ors think critically about the intersections present. Sexual minority and TGE youth may face signif­ icant challenges well into adulthood (Toomey et al., 2010). Some challenges may include school victimiza­ tion, depression, and poor self-concept (Toomey et al., 2010). Therefore, clinical interventions are recom-

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mended to support TGE youth as well as their parents and caregivers (Grossman & D’Augelli, 2007). Affirming TGE individuals is a legal and ethical obligation for counselors. The American Counseling Association Code of Ethics (ACA, 2014) states that ethical counselors do not discriminate “based on . . . gender, gender identity, sexual orientation . . . or any basis proscribed by law” (p. 9). Further, the code is clear that our primary role as counselors is to affirm, respect, and promote client welfare. According to the ALGBTIC “Competencies for Counseling Transgender Clients,” counselors will “affirm that all per­ sons have the potential to live full functioning and emotionally healthy lives throughout their lifespan while embracing the full spectrum of gender identity expression, gender presentation, and gender diversity beyond the male-female binary” (2009, p. 4). Support­ ing and responding in an affirming manner are imperative when clients are questioning, disclosing, and processing their identities (ALGBTIC Transgen­ der Committee, 2010; Harper et al., 2013). School counselors are uniquely positioned to pro­ vide support to TGE students. The American School Counselor Association’s (ASCA’s) ethical standards emphasize a school counselor’s role to advocate for and affirm “all students from diverse populations including but not limited to . . . gender, gender iden­ tity/expression” (2016, p. 1). Legally, federal Title IX law prohibits discrimination in schools on the basis of sex and has been applied by the U.S. Justice and Edu­ cation Departments as well as courts to include dis­ crimination of youth who identify as TGE (National Center for Transgender Equality, 2016). State and local laws protecting TGE individuals do exist (American Civil Liberties Union, 2016) but vary from state to state. Counselors should stay apprised of the laws that apply in their respective states. In sum, counselors, whether working in schools, agencies, or private prac­ tices, seek to affirm all clients in a supportive and compassionate manner. Counselors who adopt fluid, multifaceted conceptualizations of gender and affec­ tional identities are best prepared to meet the needs of TGE youth (Farmer & Byrd, 2015). Instructions

When working with families, couples, children, or adolescents, this activity may be used to assist the par­

ents and caregivers of TGE youth in questioning and expanding on binary ideas of gender. Questions for initial reflection are derived from Garfinkel’s (1967) ethnomethodological studies describing the character­ ization of gender as it is generally understood and acknowledge that viewing gender as binary, rigid, and fixed is manifest in many ways. Statements 1 through 8 in the activity are derived from Kessler and McKenna (1978, pp. 113–114), as they offer genderbinary assumptions that may be chosen, depending on presenting concerns, as a self-reflective exercise for parents and caregivers to examine and challenge their own binary beliefs. The authors have expanded on this list and added follow-up questions. The vignette below illustrates how the activity can be used in an initial session; however, this activity may be appropriate at any time during the counseling process when binary thinking emerges as a barrier in the parent-child relationship. As is true of any activ­ ity that encourages self-reflection, counselors should take care to build rapport with clients and present information in a thoughtful and compassionate man­ ner. Further, counselor self-awareness is key, and coun­ selors are asked to consider the following concepts: • In what ways could the client’s experience with racism affect the experience of genderism? • In what ways could the client’s experience with poverty affect the experience of genderism? • In what ways could the client’s experience with pov­ erty, racism, and sexual or affectional orientation affect the experience of genderism? • In what ways could the client’s experience with heterosexism affect the experience of genderism? • In what ways could experiences with multiple iden­ tities affect the client’s internalization of these “isms”? • In what ways have multiple systems of oppression affected the client? The activity could also be used in an individual session with a TGE youth to examine internalized genderism. Further, the activity is not limited to counseling sessions and can also be applied in the context of training. Counselors, teachers, administrators, and staff members could benefit from an activity that enhances understanding of TGE individuals. Expanding Binary Thinking: A Reflective Activity 265

When parents and caregivers discuss thoughts reflecting a binary view of gender, gender expression, and/or identity, the counselor can provide the parents and caregivers with a handout of this activity (see page 269). In session, the counselor can introduce specific statements related to the discussion at hand. Therefore, it would be helpful for counselors to be familiar enough with the activity that they can offer the statements that are most applicable to each unique situation. For example, if parents or caregivers are reflecting on how their child or adolescent needs to “figure out if he is a boy or a girl,” the counselor could offer mul­ tiple challenging statements from the activity for exploration. The counselor could start with the first statement, asking the parents or caregivers to con­ sider their ideas and beliefs on the following: “There are two, and only two, genders (male and female).” An attuned, nonjudgmental, and patient counselor understands that the parent or caregiver may in fact believe this statement. Depending on where the parents or caregivers are in their own process, it may be helpful to offer a sec­ ond statement for contemplation, such as, “Any excep­ tions to the two genders are not to be taken seriously. (They must be jokes, pathology, etc.)” The parents or caregivers are invited to consider their level of agree­ ment with this idea. With each step, the parents are also invited to consider the unique characteristics of their own child and contrast this knowledge of their child with the binary ideas represented in the state­ ments. The counselor understands that this is a pro­ cess that takes time and is dependent on each individ­ ual and the unique needs presented. Parents and caregivers will present at different places in their own process of understanding. This will determine how the counselor is able to move through the statements for consideration. It may be unclear where the parents and caregivers are in their own awareness until the statements and subsequent reflective questions are offered. The parent or care­ giver may be able to process only a few statements in one session; alternatively, multiple sessions may be needed to process and evaluate beliefs on a single statement. The counselor works with the parents and caregivers to meet them where they are and does not push them through the activity at a rapid pace. 266 Byrd & Farmer

Brief Vignette

You are conducting an initial session with a thirteen­ year-old child, Emma, who was referred by Emma’s parents because of recent moodiness, withdrawal, and family conflict. Emma’s gender assignment at birth was female; however, Emma does not identify as female or male. Emma prefers to be called Em and uses the pronouns they, them, and their. Em likes to wear baggy clothes, has short hair, and sometimes uses chest bind­ ing to flatten their breasts. Em is outspoken about their identity with their parents, rejecting both male and female labels. During the appointment, Em’s mother states, “I just can’t take it. You’re either a he or a she . . . but there is no such thing as an ‘it.’ If you’re an ‘it,’ you are nobody. You don’t exist.” As the counselor facilitating the session, you quickly realize that you will need to separate Em and her mother to continue gathering information. You decide to invite Em’s mother for an individual session the following week. After building rapport with Em’s mother and validating her confusion about Em’s iden­ tity, you introduce the activity as a way to explore ideas about gender. You also acknowledge that perhaps our beliefs about gender are socialized; in other words, some beliefs we develop on our own through our lived experiences, and others are handed to us and rein­ forced from a very early age. In these cases, it can be difficult to tease apart what is true for us, what is true for others, and what is true in society. This activity is thus offered as an exercise to explore assumptions about gender, sexuality, and identity. As the counselor working with Em’s mother, you begin by saying, “I would like to invite you to consider some ideas about gender. For each of the following statements, consider how much you agree or disagree with the idea presented.” Then the first binary state­ ment in the activity is offered for reflection: There are two, and only two, genders (male and female). Em’s mother considers her own beliefs associated with this statement and seems pensive. You gently facilitate a discussion with the mother about her personal beliefs and values using prompts such as: What is your ini­ tial reaction to this statement? What thoughts are coming up for you? If you agree with this statement, what if there is a possibility that more genders exist? How might this relate to Em?

Em’s mother seems to be thinking critically about the previous questions. You notice that her shoulders drop, her posture softens, and her tone lowers as she expresses a desire to be close with Em. She also states that while she does not understand, she also does not want to be disconnected from her daughter. She tells you, “I just don’t know how to understand, but I want to try.” As the counselor, you present her with the following question from the activity, asking her to consider her beliefs associated with the following: One’s gender is invariant. (If you are female/male, you always were female/male and you always will be female/male.) She reflects on this statement and how it is some­ thing she has certainly believed in the past but is not sure how it fits with Em. She notes that society, com­ munity, school, and other systems may view Em in a negative light, and she does not want that for Em. You discuss ways to affirm and support Em, and their mother seems interested in this conversation, while noting, “I have never thought of that before!” Because Em’s mother made the statement above (“You’re either a he or a she”), you decide to discuss the fourth statement in the activity: Any exceptions to the two genders are not to be taken seriously. (They must be jokes, pathology, etc.) Together, you discuss the challenges and benefits of taking Em seriously and confirming their identity. You further discuss, if there are beliefs or values that Em’s mother personally stands firm on, how might she avoid imposing them on Em and thus convey love and support. You assist Em’s mother in role-playing affirming messages and using Em’s personal pronouns. You acknowledge Em’s mother and support her in this process while noting that this will take time. You give Em’s mother a copy of the self-reflective activity for her to continue thinking about until your next session. Suggestions for Follow-up

In the sessions following distribution and facilitation of the self-reflective activity, counselors can follow up with parents and caregivers to inquire about new realizations and integration of ideas. Ideally, the activ­ ity will open the door for an ongoing dialogue between counselors and the parents and caregivers of TGE youth to increase self-awareness of biases related to gender-binary thinking. By doing their own work, parents and caregivers are better equipped to support

youth when they face challenges on their own path toward self-discovery and self-acceptance. It is possi­ ble that the process of challenging such ingrained ideas about gender may take weeks or months. To address the issue from multiple angles, counselors may question how these binaries have influenced parents and caregivers in their own lives and, in turn, how they may be affecting their child. Having a safe, sup­ portive space for such dialogue will help facilitate further growth and understanding. Contraindications for Use

This activity should not be used with parents and caregiv­ ers while youth are present in the session. It is best prac­ tice for parents and caregivers to be separated from youth while parents work through their own process of coming to understand their child’s identity, particularly in cases where the parent is experiencing emotional distress. By working with counselors separately, parents are free to do their own work and exploration without unintended, negative effects on the child. Professional Resources Budge, S. L., Rossman, H. K., & Howard, K. A. S. (2014). Cop­ ing and psychological distress among genderqueer indi­ viduals: The moderating effect of social support. Journal of LGBT Issues in Counseling, 8 (1), 95–117. doi:10.1080/155 38605.2014.853641. Davis, K. (2008). Intersectionality as a buzzword. Feminist The­ ory, 9 (1), 67–85. Elizabeth, A. (2013). Challenging the binary: Sexual identity that is not duality. Journal of Bisexuality, 13 (3), 329–337. Entrup, L., & Firestein, B. A. (2007). Developmental and spiri­ tual issues of young people and bisexuals of the next gener­ ation. In B. A. Firestein (ed.), Becoming visible: Counseling bisexuals across the lifespan, 89–107. New York: Columbia University Press. Galupo, M. P., Davis, K. S., Grynkiewicz, A. L., & Mitchell, R. C. (2014). Conceptualization of sexual orientation identity among sexual minorities: Patterns across sexual and gender identity. Journal of Bisexuality, 14 (3–4), 433– 456. doi:10.1080/15299716.2014.933466. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . Kocet, M. (2013). Association for Les­ bian, Gay, Bisexual, and Transgender Issues in Counseling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:1080/15538 605.2013.755444. McDonald, M. (2006). An other space: Between and beyond lesbian-normativity and trans-normativity. Journal of Les­ bian Studies, 10 (1), 201–214. Expanding Binary Thinking: A Reflective Activity 267

Nadal, K. L., Rivera, D. P., & Corpus, M. J. (2010). Sexual ori­ entation and transgender microaggressions: Implications for mental health and counseling. In D. W. Sue (ed.), Microaggressions and marginality: Manifestation, dynamics, and impact, 217–240. Hoboken, NJ: John Wiley & Sons. Nadal, K. L., Skolnik, A., & Wong, T. (2012). Interpersonal and systemic microaggressions toward transgender people: Implications for counseling. Journal of LGBT Issues in Counseling, 6 (1), 55–82. doi:10.1080/15538605.2012.648583. Preves, S. E. (2000). Negotiating the constraints of gender bina­ rism: Intersexuals’ challenge to gender categorization. Current Sociology, 48 (3), 27–50. Tebbe, E. A., Moradi, E., & Ege, B. (2014). Revised and abbre­ viated forms of the genderism and transphobia scale: Tools for assessing anti-trans* prejudice. Journal of Coun­ seling Psychology, 6 (4), 581–592. doi:10.1037/cou0000043.

Resources for Clients Baum, J., Brill, S., Brown, J., Delpercio, A., Kahn, E., Kenney, L., & Nicoll, A. (2014). Supporting and caring for our gen­ der expansive youth. http://hrc-assets.s3-website-us-east­ 1.amazonaws.com//files/assets/resources/Gender-expan sive-youth-report-final.pdf. GLSEN. (2017). Championing LGBTQ issues in K–12 educa­ tion since 1990. www.glsen.org. Human Rights Campaign. (2017). Explore: Transgender chil­ dren and youth. https://www.hrc.org/explore/topic/ transgender-children-youth. National Center for Transgender Equality. (2019). Know your rights: Schools. https://transequality.org/know-your-rights/ schools. Orr, A., & Baum, J. (2015). Schools in transition: A guide for supporting transgender students in K–12 schools. http:// hrc-assets.s3-website-us-east-1.amazonaws.com//files/ assets/resources/Schools-In-Transition.pdf. Sylvia Rivera Law Project. (2017). Fact sheet: Transgender & gender non-conforming youth in school. http://srlp.org/ resources/fact-sheet-transgender-gender-nonconforming­ youth-school/.

References Airton, L. (2009). Untangling “gender diversity”: Genderism and its discontents (i.e., everyone). In S. R. Steinberg (ed.), Diversity and multiculturalism: A reader, 223–246. New York: Peter Lang. ALGBTIC Transgender Committee. (2010). American Coun­ seling Association: Competencies for counseling with transgender clients. Journal of LGBT Issues in Counsel­ ing, 4 (3–4), 135–159. doi:10.1080/15538605.2010.524839. American Civil Liberties Union. (2016). Know your rights: Transgender people and the law. https://www.aclu.org/ know-your-rights/transgender-people-and-law. American Counseling Association (ACA). (2014). Code of ethics and standards of practice. Alexandria, VA: Ameri­ can Counseling Association. 268 Byrd & Farmer

American School Counselor Association. (2016). Ethical stan­ dards for school counselors. https://www.schoolcounselor. org/asca/media/asca/Ethics/EthicalStandards2016.pdf. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. Baum, J., Brill, S., Brown, J., Delpercio, A., Kahn, E., Kenney, L., & Nicoll, A. (2014). Supporting and caring for our gender expansive youth. http://hrc-assets.s3-website-us­ east-1.amazonaws.com//files/assets/resources/Genderexpansive-youth-report-final.pdf. Farmer, L. B., & Byrd, R. (2015). Genderism in the LGBTQQIA community: An interpretative phenomenological analysis. Journal of Lesbian, Gay, Bisexual, and Transgender Issues in Counseling, 9 (4), 288–310. doi:10.1080/15538605.201 5.1103679. Garfinkel, H. (1967). Studies in ethnometholology. Englewood Cliffs, NJ: Prentice-Hall. Grossman, A. H., & D’Augelli, A. R. (2007). Transgender youth and life-threatening behaviors. Suicide and Life-Threatening Behavior, 37 (5), 527–537. doi:10.1521/suli.2007.37.5.527. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . Kocet, M. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling com­ petencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:1080/15538605.20 13.755444. Kessler, S. J., & McKenna, W. (1978). Gender: An ethnometh­ odological approach. Chicago: John Wiley & Sons. National Center for Transgender Equality. (2019). Know your rights: Schools. https://transequality.org/know-your-rights/ schools. Orr, A., & Baum, J. (2015). Schools in transition: A guide for supporting transgender students in K–12 schools. http:// hrc-assets.s3-website-us-east-1.amazonaws.com//files/ assets/resources/Schools-In-Transition.pdf. Parent, M. C., Deblaere, C., & Moradi, B. (2013). Approaches to research on intersectionality: Perspectives on gender, LGBT, and racial/ethnic identities. Sex Roles, 68 (11–12), 639–645. doi:http://dx.doi.org.iris.etsu.edu:2048/ 10.1007/s11199-013-0283-2. Sampson, I. (2014). Gender: The infinite ocean. Communities, 162, 35–38. Stone, C. (2015). Transgender and gender nonconforming students: Advocate for best practice. https://www.school counselor.org/magazine/blogs/september-october-2015/ transgender-and-gender-nonconforming-students-adv. Toomey, R. B., Ryan, C., Diaz, R. M., Card, N. A., & Russell, S. T. (2010). Gender-nonconforming lesbian, gay, bisex­ ual, and transgender youth: School victimization and young adult psychosocial adjustment. Developmental Psychology, 46 (6), 1580–1589. doi:10.1037/a0020705.

EXPANDING BINARY THINKING: A REFLECTIVE ACTIVITY FOR PARENTS AND CAREGIVERS OF TRANSGENDER AND GENDER-EXPANSIVE YOUTH 1. There are two, and only two, genders (male and female). 2. One’s gender is invariant. (If you are female/male, you always were female/male and you always will be female/male.) 3. Genitals are the essential sign of gender. (A female is a person with a vagina; a male is a person with a penis.) 4. Any exceptions to the two genders are not to be taken seriously. (They must be jokes, pathology, etc.) 5. There are no transfers from one gender to another except ceremonial ones (masquerades). 6. Everyone must be classified as a member of one gender or the other. (There are no cases where gender is not attributed.) 7. The female-male dichotomy is a “natural” one. (Males and females exist independently of scientists’ —or anyone else’s—criteria for being male or female.) 8. Membership in one gender or the other is “natural.” (Being female or male is not dependent on anyone’s deciding what you are.) 9. Gender expression should always match gender identity. Any incongruence between gender expression and gender identity should not be taken seriously and must be for entertainment purposes only. 10. There is only one sexual orientation: heterosexual. Any other sexual orientation that does not fit into this category (gay, lesbian, bisexual) should not be taken seriously and shall be considered immoral. 11. There are two and only two sexual orientations (gay/lesbian and heterosexual). Any other sexual orientation that does not fit into these two categories should not be taken seriously, shall be considered a phase, or may be understood as sexual identity confusion. 12. There are two and only two types of relationship status (single or married/partnered). A person who identifies as engaging romantically or sexually in anything other than a monogamous, committed relationship will not find true happiness in life and shall not be considered moral. After reflecting on the statements above, consider the following questions: a. Did you become aware of any personal beliefs or values that you were unaware of previously? b. What is the potential effect of your beliefs on your child? c. Would you consider expanding your views to include multiple understandings of human sexuality, affectional attraction, gender, and relationships? d. If there are beliefs or values you personally stand firmly on, how might you avoid imposing them on your child and convey love and support?

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31 PARENTS OF TRANSGENDER TEENS AND THE INITIAL DISCLOSURE PROCESS Laura R. Haddock and Hilary Meier Suggested Uses: Handout, homework Objective

The goal of this exercise is to educate caregivers on facts related to gender identity. An additional goal is to encourage caregivers to initiate an honest reflection of their own experience after their child discloses as transgender. Rationale for Use

The disclosure process for transgender adolescents can be terrifying, not only for the teenager, but also for their family and friends. It is often a time of high emo­ tions that move along a continuum from confusion, shock, disbelief, rejection, anger, and grief to accep­ tance, peace, understanding, and concern (Field & Mattson, 2016). Researchers examining the disclosure experiences of transgender teens report that the pro­ cess of coming out is frequently mediated by factors that are unique to each individual, such as fear, safety, and personal circumstances (Klein, Holtby, Cook, & Travers, 2015). For some youth, despite the potential for negative consequences, disclosing their gender identity is “pure necessity” (Klein et al., 2015, p. 308). Transgender youth who feel a sense of family acceptance report better physical, mental, and educa­ tional outcomes all around (Hunt & Moodie-Mills, 2012). Until parents understand the concept of gender identity, they may question their relationship with their children and the home environment that they fostered (Gross, 2013). Parents may grieve the loss of their expectations and the future that they imagined for themselves and their child (Field & Mattson, 2016).

This exercise is designed to help parents gain clarity, answer questions, and raise self-awareness related to gender identity. It is important at this potentially frag­ ile time for parents to be well informed and educated about gender identity, as well as to have the opportu­ nity to process their own thoughts, feelings, and beliefs related to gender identity. Therapists can provide a compassionate environment to support parents whose teens are moving through the disclosure process. These resources may be used to facilitate greater under­ standing and increased self-awareness with parents in a neutral and affirming way. Studies show that many children and adolescents from diverse backgrounds identify as transgender at an earlier age than historically recorded (Svab & Kuhar, 2014). This means that youth often disclose their identity and come out while still living with their parents (D’Augelli, Grossman, Starks, & Sinclair, 2010). Research tells us that many adolescents dis­ close gender disparity to a friend or other person close to them before coming out to their parents and family (Beals & Peplau, 2006), that motivation for coming out varies from individual to individual and by ethno­ cultural background, and that many youth long to be close to their families (Svab & Kuhar, 2014). Of impor­ tance is the reality that when youth disclose their gender identity to parents, they face both the imme­ diate and long-term reactions of their parents. For example, if a teen’s disclosure results in parental rejec­ tion, that rejection can leave the youth emotionally and physically vulnerable, particularly if they find themselves cast onto the streets with nowhere to turn for support (Hunt & Moodie-Mills, 2012). Managing

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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the transition into the awareness of a gender-minority status is stressful for both teens and caregivers as it may change the significant family relationships that structure their lives, in addition to their relationships with friends and other significant adults (Ryan et al., 2010). While it would be ideal for every parent to receive a teen’s disclosure of transgender identity with open arms and an attitude of loving acceptance, this is often not the case (Pyne, 2016). Parents may exhibit a series of hostile attitudes and feelings against transgender people, grounded in their own cultural iden­ tity (American Psychological Association, 2011). Being insulted by a parent can be hurtful to a child, and those with nonconforming gender identities are at great risk of experiencing oppression (Hebard & Hebard, 2015). Throughout history, many thriving cultures have recognized and integrated gender variance (Brill & Pepper, 2008; McKitrick, 2015). Being mindful of the cultural identity of the family system and honoring the variety of potential cultural and racial contexts of parents are critical. Therapists should orient them­ selves beyond the Western tradition of a binary percep­ tion of gender (Dea, 2016). For example, the Navajo culture recognizes an identity that integrates identity of boy and girl (“A Map of Gender Diverse Cultures,” 2015). Another example is Hawaiian culture, which recognizes a gender identity that embraces the inter­ section of both the male and female spirit (“A Map of Gender Diverse Cultures,” 2015). The therapist can use a wellness- and strengthsbased approach that employs the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC) (2009) competencies for counseling with transgender clients. Creating a friendly, supportive environment that affirms people who identify as transgender will set a tone of respect in accordance with ALGBTIC competency C.9 (ALGBTIC, 2009). For all interactions that involve the family of a transgender teen, competency C.7. (ALGBTIC, 2009, p. 7) advises the therapist to “acknowledge that physical (e.g., access to health care, HIV, and other health issues), social (e.g., fam­ ily/partner relationships), emotional (e.g., anxiety, depression, substance abuse), cultural (e.g., lack of support from others in their racial/ethnic group),

spiritual (e.g., possible conflict between their spiritual values and those of their family’s), and/or other stress­ ors (e.g., financial problems as a result of employ­ ment discrimination) often interfere with transgen­ der people’s ability to achieve their goals.” Therefore, taking a proactive approach to assisting parents in regulating their affect, thoughts, and behav­ ior throughout this disclosure process ultimately has the potential to help both the transgender youth and the caregivers navigate a very complex process and, ideally, strengthen the adult-child relationship. Stud­ ies of parents of LGBT youth following the comingout process have shown that parental reactions range from feelings of cognitive dissonance related to a lack of understanding to intense love and protectiveness for their child (Conley, 2011). Cognitive-emotional dissonance causes many caregivers to disengage from routine parenting functions and to withdraw socially (Pallotta-Chiarolli, 2005). Thus, as the youth discloses a nonconforming gender identity, the parents often shut down (Svab & Kuhar, 2014) as they face learn­ ing to adapt to the new identity of being a parent of a child who belongs to a stigmatized minority group (Grafsky, 2014). This can be especially important for the adoles­ cent, as perceived caregiver attitudes toward the youth’s identity have been found to have a significant rela­ tionship to the teen’s emotional adjustment following the disclosure process (Darby-Mullins & Murdock, 2007). The perceived acceptance and support from parents has been associated with better mental, emo­ tional, and behavioral health (D’Augelli, 2003; Ryan et al., 2010). Conversely, perceived negative parental reactions have been associated with increased psy­ chological symptoms, depression, suicide attempts, illegal drug use, and sexually risky behaviors (D’Am­ ico, Julien, Tremblay, & Chartrand, 2015; Willoughby, Doty, & Malik, 2010). By guiding caregivers toward valuing their children and supporting their choice to live authentically, parents can be assisted through emotional uncertainty into a position of advocacy. Through affirmative practice, caregivers may feel that their parental rights are legitimized, gain the safety of sharing authentic feelings, and learn to be a resource and lifelong advocate for their progeny.

Parents of Transgender Teens and the Disclosure Process 271

Instructions

The glossary of terms (see page 276) is intended to be a starting point for discussion related to gender identity, and it is designed to serve as a psychoeduca­ tional resource. This handout includes definitions of a variety of terms related to gender identity, and it may be shared with parents as appropriate. It is important to remain cognizant that terms are ever-changing and that clinicians should research the most current terms, as well as terms that are familiar and used by the cli­ ent, before handing out the glossary. Therapists may choose to dedicate an entire session to reviewing the glossary and answering caregiver questions or use the glossary review as an introduction to the reflective exercise. Once the therapist is satisfied that the care­ givers have working knowledge of the glossary’s terms, they may initiate the reflective exercise. The reflec­ tive exercise can be conducted in one or multiple ses­ sions, depending on each caregiver’s individual needs, emotional state, and developmental process. This exercise can be deeply emotional, and ther­ apists should be prepared to fully support and medi­ ate parental reactions. Thus, the therapist may choose to give the caregiver the self-reflection sections one at a time or all at once. When executing the exercise, the caregiver should be provided with the questions and allowed some quiet time to complete the answers. Because most sessions are limited to roughly an hour, that is probably not enough time to fully answer and explore all sections of the exercise. Thus, the thera­ pist may opt to use one session to have the caregiver draft the answers and another session (or sessions) to explore the content. Alternatively, the therapist can administer the exercise in sections over the course of multiple sessions. There is no identified benefit to offering the questions in a particular order, and it is recommended that therapists tailor the selection of items to meet the needs of each particular client. Brief Vignette

Paul and Keisha are the biological grandparents of Misha, a fifteen-year-old who was assigned female at birth and who has recently come out as transgender and uses he, him, and his pronouns. Paul and Keisha are the legal guardians and primary caregivers for Misha and are a working-class couple who identify as 272 Haddock & Meier

African American and Seventh-Day Adventist. There are no reported physical health problems within the family. Misha was initially enrolled in therapy by his grandparents to address self-injurious behavior, and sessions have included both individual and family appointments in conjunction with Paul and Keisha. Misha, who has asked to be called Mike, expressed gender dysphoria and ultimately disclosed a transgen­ der identity to his therapist. He recently disclosed being transgender to his caregivers by writing a letter. Following the receipt of the letter, Paul and Keisha requested an appointment to meet with the therapist without Mike. Mike fully supports the therapist’s meet­ ing with his grandparents and is relieved that they are willing to discuss his disclosure as transgender. Paul and Keisha arrive for the first counseling ses­ sion independent of Mike, presenting as distraught and angry. The therapist indicates that the goal for the session is to process Keisha’s and Paul’s thoughts and feelings after receiving Mike’s disclosure letter. The therapist expresses empathy for their experience and the challenge of understanding what has happened. Keisha angrily states, “She is not a boy. She is messed up and needs help.” Paul is initially very quiet. He does not verbalize that he agrees with Keisha’s position but does not offer an alternative perspective either. The therapist initiates an inquiry to assess Paul’s and Kei­ sha’s level of understanding of the concepts of gender identity. At this point, Paul speaks up and asks if this means that Misha is gay. Keisha, maintaining her defensive position, bitterly comments that “Misha has always been a tomboy and she is just confused.” It becomes clear that education is a good starting point. Providing Keisha and Paul each a copy of the glossary of terms, the therapist asks them to review the information and to feel free to ask questions. They are gently encouraged to open themselves up to learn­ ing more about what it means to be trans or genderqueer and to gain understanding of what Mike may be going through. Paul and Keisha both articulate a desire to maintain a relationship with Mike and agree to learn more about what it means to be trans or gen­ derqueer. The remainder of the session is dedicated to answering Paul’s and Keisha’s questions related to sex­ ual and gender identity because they conflate the two concepts. The session concludes with both guardians

expressing greater understanding of gender identity and how it is separate from sexual orientation. They both present as more calm, and each actively partici­ pate in discussion. The therapist encourages Paul and Keisha to write down any questions that come up for them after the review of the glossary and asks them to bring those questions to their next session. Each expresses a willingness to assume a neutral position and an understanding of their role in preserving their relationship with Mike. They are encouraged to affirm their love and commitment to Mike, and it is deter­ mined that they will participate in a few independent sessions with the therapist to complete the reflective exercise and process their thoughts, feelings, and questions. Upon completion of the reflective exercise and any subsequent follow-up, they will reconvene for a family session.

identity. One contraindication of the reflective exercise is the potential for disrupted parent-child communi­ cation if caregivers become triggered with intense emotions or the relationship between parents and youth is particularly fragile. It may be best not to use this activity if the risk of a period of decreased com­ munication between caregiver and child outweighs the benefits of heightened self-awareness for parents. Therapists are cautioned against using the reflec­ tive exercise with caregivers who demonstrate a partic­ ularly unstable emotional state. Though it is common for parents to make comments like “it feels like my world has been flipped upside-down” and “it feels like a death in the family,” this activity requires a capacity for logic and insight, and it should not be used with caregivers who demonstrate a pervasive pattern of maladaptive cognitions or behavior.

Suggestions for Follow-up

Professional Resources

The exercise of the glossary of terms may introduce caregivers to a great deal of new information. Follow­ ing an initial review of the glossary, the therapist may want to follow up by verifying that the information is clear and that there are no questions. The therapist may choose to encourage caregivers to write down questions and bring them to the follow-up appoint­ ment to help ensure that all concerns are addressed. After completing the self-reflective exercise, an additional follow-up could include preparing the care­ givers for a family session together with the child or teen. Topics for follow-up with the teen could include a response to the disclosure about gender identity, exploration of the implications of the disclosure on the caregivers and teen’s relationship, or perceptions about what challenges the future may hold for the youth, the caregiver, or both. Remember that cultural norms inform belief systems, frames, perceptions, understandings, and behaviors. Ideally, the follow-up will facilitate affirmative exchanges between caregivers and teens. Contraindications for Use

Therapists should use the glossary of terms as needed depending on caregiver knowledge. The glossary is not necessary to use with caregivers who demonstrate working knowledge of concepts related to gender

Dea, S. (2016). Beyond the binary: Thinking about sex and gender. Peterborough, Ont.: Broadview Press. dickey, l., Singh, A., Chang, S., & Rehrig, M. (2017). Advocacy and social justice: The next generation of counseling and psychological practice with transgender and gender non­ conforming clients. In A. Singh & l. dickey (eds.), Affir­ mative counseling and psychological practice with transgender and gender nonconforming clients. Washington, DC: American Psychological Association. Dispenza, F., & O’Hara, C. (2016). Correlates of transgender and gender nonconforming counseling competencies among psychologists and mental health practitioners. Psychology of Sexual Orientation and Gender Identity, 3 (2), 156–194. doi:10.1037/sgd0000151. Erickson-Schroth, L. (ed.). (2014). Trans bodies, trans selves. New York: Oxford University Press. Gender Spectrum. (2017). Gender Spectrum helps to create gender sensitive and inclusive environments for all chil­ dren and teens. https://www.genderspectrum.org/. Lev, A. (2004). Transgender emergence: Therapeutic guidelines for working with gender-variant people and their families. Binghamton, NY: Haworth Press. National Center for Transgender Equality. (2017). About us. https://www.transequality.org/about. The National Cen­ ter for Transgender Equality is the nation’s leading social justice advocacy organization winning lifesaving change for transgender people. PFLAG New York City. (2016). Questions parents ask about transgender people. www.pflagnyc.org/support/trans genderquestions. PFLAG NYC is a partnership of par­ ents, allies, and LBGT people working to make a better future for LBGT youth and adults. Parents of Transgender Teens and the Disclosure Process 273

Winch, G. (2014). Emotional first aid: Healing rejection, guilt, failure, and other everyday hurts. New York: Hudson Street Press.

Resources for Clients Brill, S., & Pepper, R. (2008). The transgender child: A handbook for parents and professionals. San Francisco: Cleis Press. Brown, M. (2003). True selves: Understanding transsexualism —For families, friends, coworkers, and helping profession­ als. San Francisco: Jossey-Bass. Evelyn, J. (2007). Mom, I need to be a girl. Longmont, CO: Just Evelyn. Herman, J. (2009). Transgender explained for those who are not. Bloomington, IN: AuthorHouse. Krieger, E. (2011). Helping your transgender teen: A guide for parents. New Haven, CT: Genderwise Press. Kuklin, S. (2014). Beyond magenta: Transgender teens speak out. Somerville, MA: Candlewick Press. Tando, D. (2016). The conscious parent’s guide to gender iden­ tity: A mindful approach to embracing your child’s authentic self. Avon, MA: Adams Media. Transparenthood. (2016). Experiences raising a transgender child. https://transparenthood.net. TransPulse. (2017). TransPulse transgender resources. https:// transgenderpulse.com/. TransPulse is a support and research site for those on the transgender spectrum and their friends, family, and support system. Trans Youth Equality Foundation. (n.d.). Education, advocacy, and support for transgender youth and their families. www.transyouthequality.org. Wipe Out Transphobia. (2015). Activism, education, sup­ port, understanding. www.wipeouttransphobia.com/.

References American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author. American Psychological Association. (2011). Answers to your questions about transgender people, gender identity, and gender expression. https://www.apa.org/topics/lgbt/ transgender.pdf. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC). (2009). Competencies for coun­ seling with transgender clients. Alexandria, VA: Author. Beals, K. P., & Peplau, L. A. (2006). Disclosure patterns within social networks of gay men and lesbians. Journal of Homo­ sexuality, 51, 101–120. doi:10.1300/J082v51n02_06. Bregman, H. R., Malik, N. M., Page, M. J. L., Makynen, E., & Lindahl, K. M. (2013). Identity profiles in lesbian, gay, and bisexual youth: The role of family influences. Journal of Youth and Adolescence, 42, 417–430. doi:10.1007/ s10964-012-9798-z. Brill, S., & Pepper, R. (2008). The transgender child: A handbook for families and professionals. San Francisco: Cleis Press.

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Conley, C. (2011). Learning about a child’s gay or lesbian sex­ ual orientation: Parental concerns about societal rejection, loss of loved ones, and child well-being. Journal of Homo­ sexuality, 58, 1022–1040. doi:10.1080/00918369.2011.59 8409. D’Amico, E., Julien, D., Tremblay, N., & Chartrand, E. (2015). Gay, lesbian, and bisexual youths coming out to their par­ ents: Parental reactions and youths’ outcomes. Journal of GLBT Family Studies, 11 (5), 411–437. doi:10.1080/1550 428X.2014.981627. Darby-Mullins, P., & Murdock, T. B. (2007). The influence of family environment factors on self-acceptance and emo­ tional adjustment among gay, lesbian, and bisexual ado­ lescents. Journal of GLBT Family Studies, 3, 75–91. doi:10.1300/J461v03n01_04. D’Augelli, A. R. (2003). Lesbian and bisexual female youths aged 14 to 21: Developmental challenges and victimiza­ tion experiences. Journal of Lesbian Studies, 7, 9–29. doi:10.1300/J155v07n04_02. D’Augelli, A. R., Grossman, A. H., Starks, M. T., & Sinclair, K. O. (2010). Factors associated with parents’ knowledge of lesbian, gay, and bisexual youths’ sexual orientation. Journal of GLBT Family Studies, 6, 1–21. doi:10.1080/1550 4281003705410. Dea, S. (2016). Beyond the binary: Thinking about sex and gender. Peterborough, Ont.: Broadview Press. Field, T., & Mattson, G. (2016). Parenting transgender children in PFLAG. Journal of GLBT Family Studies, 12 (5), 413– 429. doi:10.1080/1550428X.2015.1099492. Grafsky, E. L. (2014). Becoming the parent of a GLB son or daughter. Journal of GLBT Family Studies, 10, 36–57. doi: 10.1080/1550428X.2014.857240. Gross, G. (2013, August 13). Parenting advice: When your gay child comes out (blog post). http://www.huffington post.com/dr-gail-gross/when-your-gay-child-comes­ out_b_3437051.html. Hebard, S., & Hebard, A. (2015, February 26). Beyond LGB. Counseling Today. https://ct.counseling.org/2015/02/ beyond-lgb/. Hunt, J., & Moodie-Mills, A. (2012, June 29). The unfair crim­ inalization of gay and transgender youth: An overview of the experiences of LGBT youth in the juvenile justice sys­ tem. Center for American Progress. https://www.ameri canprogress.org/issues/lgbt/reports/2012/06/29/11730/ the-unfair-criminalization-of-gay-and-transgender-youth/. Klein, K., Holtby, A., Cook, K., & Travers, R. (2015). Compli­ cating the coming out narrative: Becoming oneself in a heterosexist and cissexist world. Journal of Homosexual­ ity, 62, 297–326. doi:10.1080/00918369.2014.970829. A map of gender diverse cultures. (2015, August 11). Inde­ pendent Lens. www.pbs.org/independentlens/content/ two-spirits_map-html/.

McKitrick, J. (2015). A dispositional account of gender. Phil­ osophical Studies, 172 (10), 2575–2589. doi:10.1007/ s11098-014-0425-6. Mohr, J. J., & Fassinger, R. E. (2003). Self-acceptance and selfdisclosure of sexual orientation in lesbian, gay, and bisexual adults: An attachment perspective. Journal of Counseling Psychology, 50, 482–495. doi:10.1037/0022­ 0167.50.4.482. Pallotta-Chiarolli, M. (2005). When our children come out: How to support gay, lesbian, bisexual, and transgendered young people. Sidney, Australia: Finch Publishing. Pyne, J. (2016). Parenting is not a job . . . it’s a relationship: Recognition and relational knowledge among parents of gender non-conforming children. Journal of Progressive Human Services, 27 (1), 21–48. doi:10.1080/10428232.20 16.1108139.

Ryan, C., Russell, S. T., Huebner, D., Diaz, R. M., & Sanchez, J. (2010). Family acceptance in adolescence and the health of LGBT young adults. Journal of Child and Adolescent Psychiatric Nursing, 23, 205–213. doi:10.1542/peds.2007­ 3524. Svab, A., & Kuhar, R. (2014). The transparent and family clos­ ets: Gay men and lesbians and their families of origins. Journal of GLBT Family Studies, 10, 15–35. doi:10.1080/1 550428X.2014.857553. Willoughby, B. L., Doty, N. D., & Malik, N. M. (2010). Victim­ ization, family rejection, and outcomes of gay, lesbian, and bisexual young people: The role of negative GLB identity. Journal of GLBT Family Studies, 6, 403–424. doi :10.1080/1550428X.2010.511085.

Parents of Transgender Teens and the Disclosure Process 275

GENDER IDENTITY GLOSSARY OF TERMS Agender: A person whose identity is nonbinary or who may feel as though they are genderless or do not have a gender. Androgynous: Possessing both masculine and femi­ nine traits. Presenting in a way that appears not entirely masculine or entirely feminine. Androgyny can occur in regard to fashion, gender, physical characteristics, and so on. Bigender: A person who identifies as both masculine and feminine. They may feel that they shift between a distinct feminine identity and masculine identity, or as though their gender identity encompasses a combi­ nation of their feminine and masculine identities. Cisgender: A person who is not under the transgender umbrella. Demigirl/Demiboy: A demigirl is a person who feels their gender identity is partially feminine but is not wholly binary, regardless of their assigned gender. Like­ wise, a demiboy is a person who feels their gender identity is partially masculine but is not wholly binary. Like a demigirl, a demiboy may identify this way regardless of their assigned gender. Dysphoria: A state of feeling unhappy; discomfort with oneself emotionally, mentally, or physically. Some­ one with gender dysphoria experiences significant discontent with their sex assigned at birth. Gender: The state of being male, female, or however one defines oneself on the gender spectrum. Gender dysphoria: The formal diagnosis used by counselors, psychologists, and other providers for people with significant body dysphoria. Genderfluid: A person whose gender is fluid, mean­ ing their gender can shift and change from various points on the spectrum; they may feel as though their gender is in a constant state of motion and readily shifts from one state to another. Gender nonconforming: The behavior or expression of not conforming to society’s definitions of male and female. Genderqueer: A person who identifies as neither, both, or a combination of male and female genders. Gender transition: A period during which a transgen­ der person may decide to change their physical appear­ ance and body to match their internal gender identity. 276

Intersex: A general term used for a variety of condi­ tions in which a person is born with reproductive or sexual anatomy that doesn’t fit the typical definition of male or female. Neutrois: Another identity that falls under the umbrella of gender-neutral or transgender identities. In most cases, neutrois can be understood as inter­ changeable with gender neutral. There is, however, not one singular definition for neutrois because everyone experiences gender in a different way. Nonbinary: A person who feels their gender identity does not fall within the accepted gender binary of male or female and may feel as though they are both, neither, or a mixture of the two. Sex: The biological and physiological characteristics of male and female. Sexuality: A person’s sexual preference or orienta­ tion—for example, gay, straight, bisexual, pansexual, transsensual, and so on. Transgender: A person whose self-identity does not conform unambiguously to conventional notions of male or female gender. Transfeminine: Used to describe transgender people who were assigned male at birth but who identify with femininity to a greater extent than with masculinity. Transmasculine: Used to describe transgender people who were assigned female at birth but who identify with masculinity to a greater extent than with femininity. All the terms offered here are intended as flexible, working definitions. Cultural identity, socioeconomic background, region, race, and age may all influence the understanding and interpretation of these terms. Every effort was made to use the most inclusive lan­ guage possible while also offering useful descriptions. This information was adapted from the following sources: • http://genderqueerid.com/gq-terms • https://www.hrc.org/resources/sexual-orientation­ and-gender-identity-terminology-and-definitions • https://spectrumcenter.umich.edu • https://nonbinary.org/wiki/List_of_nonbinary_ identities • https://thesafezoneproject.com/

Laura R. Haddock and Hilary Meier

REFLECTIVE QUESTIONS FOR PARENTS OF TRANSGENDER TEENS Initial Disclosure 1. What does being transgender mean to me? 2. How is my child’s gender identity a reflection of me? 3. Does knowing my teen identifies as transgender change the way I feel about them? 4. Do I believe my teen is rebelling, experimenting, or going through a phase? 5. Why do I believe my child chose this time to tell me that they are transgender? 6. Does my teen’s being transgender leave me feeling as if I am losing the child I know? 7. What do I think my child needs from me to feel safe to talk to me about being transgender? 8. How will I feel if my child asks me to call them by a different name or use different pronouns? 9. How do I feel about connecting with other parents and youth going through this process? 10. What do I need to embrace my child who identifies as a new gender? Sexual Orientation 11. Do I associate transgender with being gay or lesbian? 12. How will I feel if my teen is sexually attracted to the gender they were assigned at birth? 13. How do I feel about having a child who is gay? 14. Would I rather my son or daughter be gay than transgender? Safety 15. How worried am I that my child will be discriminated against? 16. Am I afraid for my teen’s safety? 17. Do I worry that my family will be targeted for hate crimes or stereotyping? 18. How will I feel if my child is bullied because of their gender identity? School 19. What are my concerns about my teen’s returning to school after disclosing as transgender? 20. How do I feel about my teen’s using the restroom of the gender that they identify with, either in public or at school? 21. What responsibility do I feel my school has to support my child’s gender identity?

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Religious or Spiritual Beliefs 22. What are my religious beliefs in relation to transgender identities? 23. If my religious beliefs are not affirming toward my teen’s identity shift, what does that mean for me? 24. How will I deal with a conflict between my spiritual or religious beliefs and my teen’s identity? 25. If I take an affirmative position and support my child’s transition, how important is it to me for my place of worship to support that decision? Parental Uncertainty or Guilt 26. Do I believe there is something I could have done as a parent to prevent my teen from being transgender? 27. Am I worried that I did something as a parent to contribute to my child’s being transgender? 28. Am I concerned that my child is transgender because of something I or my spouse did during my pregnancy? 29. What will I do if my teen’s other caregiver(s) doesn’t feel the same way I do? Disclosing to Others 30. Am I worried about how I will tell other people my child is transitioning or transgender? 31. Am I worried that other people will judge me, my teen, or my family when they find out that my child identifies as transgender? 32. Would I prefer to keep this information private within our family? 33. Do I have concerns that our family will be treated differently after my teen comes out publicly? Puberty and Transitioning 34. How do I feel about allowing my child to take hormones or wear a binder? 35. How would I feel if my teen began to dress as the gender opposite the one they were assigned at birth? 36. Do I feel clearly informed and educated about hormone treatment or puberty-delaying interventions? 37. How will I find the information that I need to clearly understand the implications of using hormone therapy? Surgery and Body Modification

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38. How will I feel if my child wants gender-affirmation surgery? 39. Am I feeling overwhelmed by the idea of my child’s surgically altering their body? 40. Do I feel that I know where to get information and support for reassignment surgery? 41. What is my opinion about my teen’s permanently changing their body? 42. Do I clearly understand what happens during gender-affirmation surgery? Legal Issues 43. Am I concerned that there will be negative consequences for my child if they legally change their gender and name? 44. Do I believe my child will have difficulty finding a job or attending college? 45. What will it mean to me if my child asks to change a name or gender on legal documents?

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32 MAINTAINING THE FAMILY UNIT WHEN AN ADOLESCENT FAMILY MEMBER COMES OUT AS A SEXUAL OR GENDER MINORITY Susannah C. Coaston, Patia Tabar, and Lori Barrett Suggested Use: Activity Objective

The goal of this activity is to help the family under­ stand the possible consequences of rejecting or nonaffirming statements and behaviors for the adolescent client. This activity gives the client an opportunity to share the effect of these rejecting experiences with the family and to rebuild family cohesion. Acceptance by the family ensures the integrity of the family unit, allows the client to live without the fear of rejection, and increases the overall well-being of the adolescent client. Rationale for Use

Family therapy, when combined with experiential interactions, is helpful in creating meaningful com­ munication between family members, including adolescents and their caregivers (Thompson, Bender, Cardoso, & Flynn, 2011). Additionally, clients who feel engaged in the therapeutic process participate more and are more likely to support treatment goals (Broome, Joe, & Simpson, 2001). Participation in fam­ ily therapy can help develop a greater sense of belong­ ing and connection between parents and children, which in turn enhances engagement in the therapeutic process (Thompson, Bender, Lantry, & Flynn, 2007). For sexual orientation or gender identity (SOGI) minority youth, there exists a host of unique stressors. In the Gay, Lesbian, and Straight Education Network’s (GLSEN) 2015 National School Climate Survey, 85 per­

cent of students who responded to the survey reported verbal harassment, 27 percent reported physical harass­ ment, 13 percent reported physical assault, and, alarm­ ingly, nearly 60 percent reported sexual harassment in their school during the previous year (Kosciw et al., 2016). In an earlier study based on the 2009 GLSEN data, researchers found that victimization in the school environment can result in reduced self-esteem, as well as lower grade-point averages and more absences, par­ ticularly in schools with fewer supportive educators (Kosciw, Palmer, Kull, & Greytak, 2013). Approximately 42 percent of SOGI minority youth report online harassment or bullying, which is three times the rate of heterosexual or cisgender youth bullying (GLSEN, CiPHR, & CCRC, 2013). As a result of the stresses experienced by SOGI minority youth, the chance of depression, substance use, and risky sexual behaviors increases (Centers for Disease Control and Preven­ tion, 2014; Marshal et al., 2011). In terms of substance abuse, sexual minority youth are five times more likely to use illegal drugs (Kann et al., 2016). Gender-identity minorities also have increased risk of substance use (Reisner, Greytak, Parsons, & Ybarra, 2015). For ado­ lescents, suicide is the second most common cause of death (Heron, 2016); however, sexual minority youth are two to four times more likely to attempt suicide (CDC, 2014; Kann et al., 2016). Reisner, Vetters, and colleagues (2015) found rates of depression, anxiety, suicidal ideation, suicide attempts, self-harm, and inpatient and outpatient mental health use two to three times the rates of cisgender peers. SOGI minority

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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youth are also at a greater risk of both suicidal ideation and nonsuicidal self-harm as a result of victimization (Liu & Mustanski, 2012), including a heightened risk for rural versus urban youth both online and in per­ son (GLSEN et al., 2013; Kosciw, Palmer, & Kull, 2014). Coming out or disclosing one’s identity can be a challenging task for adolescents (Legate, Ryan, & Weinstein, 2012), the challenge often being related to a fear of rejection or of damaging the relationship with the family (Potoczniak, Crosbie-Burnett, & Saltzburg, 2009). These concerns can be compounded for SOGI minority youth who are also ethnic minorities (e.g., African American, Asian American, Latin American, or American Indian). Intersectionality refers to the awareness and experience of those with multiple cate­ gories of identities (e.g., race, class, gender, nationality) and how the overlay of these distinct identities can affect the experience of any one of these identities (Gibson, Alexander, & Meem, 2014). Viewed through this lens, SOGI minority youth who are ethnic minori­ ties may experience discrimination and lack of privi­ lege as a result of how our culture views race, sexuality, and gender identity. Limited literature exists that focuses on the challenges that can exist for these youth owing to racial, ethnic community, or family values; however, adherence to traditional values and level of acculturation may play a significant role (Potoczniak et al., 2009). Further, it is important to note that there exist significant within-group differences, along with similarities and differences between groups within each culture (Ratts et al., 2015). Cultures that have a collectivist orientation, such as Asian American, African American, and Latin Amer­ ican, tend to give priority to harmony in relationships with family members, and actions and decisions are determined by a sense of duty or obligation to the fam­ ily unit (Sauceda, Paul, Gregorich, & Choi, 2016). Such cultures tend to embed the self in the relation­ ship with family (Sauceda et al., 2016). For the SOGI youth from these backgrounds with particularly strong kinship ties, the fear of losing the support of family as a result of coming out can be overwhelming (LaSala, 2010). Overall, coming out for SOGI minority youth can have significant implications for the household, so ethnic minority youth are less likely to be out to their families (Grov, Bimbi, Nanín, & Par­

sons, 2006). Thus, some researchers have concluded that the factors that determine disclosure to family for ethnic minority youth warrant further research (Potoczniak et al., 2009). Unfortunately, there is a lack of empirical infor­ mation available that specifically speaks to how having a transgender family member affects the family unit (Whitley, 2013). As a whole, however, transgender youth face high levels of family rejection and home­ lessness, and transgender youth of color experience additional challenges because of racism (Bith-Melander et al., 2010). When a SOGI minority youth comes out, the entire family unit can be affected. Studies have shown that parental rejection can lead to a decrease in ado­ lescent self-esteem and emotional well-being (Shpigel, Belsky, & Diamond, 2015). Implicit or explicit criti­ cism, rejection, shaming, and other types of emotional and physical abuse increase an adolescent’s risk for depression and suicidal ideations (Shpigel et al., 2015). This lack of tolerance or acceptance demonstrated by parents shreds the basic attachment between the par­ ents and child, and it also has the capacity to destroy the child’s self-esteem (Gutierrez & Hagedorn, 2013). Parents whose views are based on the belief that their child is “choosing” to be gay in contravention of their closely held religious beliefs are more likely to resort to sexual-orientation change efforts (SOCE) to convert their child to heterosexuality, thereby driving a wedge between themselves and the child (Diamond & Shpigel, 2014). The more the child’s sexuality or gender identity is seen as controllable, the more negative the response toward the child becomes (Armesto & Weisman, 2001). When parental acceptance is present, however, it tends to result in lower depression scores and a reduced sensitivity to discrimination, rejection sensitivity, and internalized homophobia (Feinstein, Wadsworth, Davila, & Goldfried, 2014). Often, SOGI minority youth find themselves homeless as a result of family rejection. The Lesbian, Gay, Bisexual, and Transgender (LGBT) Homeless Youth Provider Survey indicated that the top two rea­ sons for homelessness were running away following family rejection because of sexual orientation or gen­ der identity and being forced out of the home as a result of the same (Durso & Gates, 2012). Approximately

Maintaining the Family Unit When an Adolescent Comes Out 281

40 percent of all homeless youth identify as LGBTQ, and 68 percent of those youth reported that being rejected by their families was the primary cause (Durso & Gates, 2012). Anecdotal evidence suggests that emo­ tional distress caused by family rejection can have disastrous consequences. For example, a Cincinnati transgender adolescent, Leelah Alcorn, reported that her parents responded to the disclosure of her gender identity by telling her, “God doesn’t make mistakes.” Additionally, they took her to Christian therapists who reinforced their opinion that being transgender is wrong. Leelah ultimately walked four miles from her house to Interstate 71, where she completed sui­ cide by deliberately walking into the path of an oncom­ ing tractor-trailer (Fox, 2015). In recognition of the challenges that SOGI minority youth face and the critical importance of parental acceptance, counselors should work to keep up-to-date with advances in the literature to provide culturally sensitive and appropriate care. Counselors must be careful to avoid imposing their own attitudes, values, and beliefs on clients, and they must be sensi­ tive to cultural differences regarding issues of sexual orientation and gender (American Counseling Asso­ ciation [ACA], 2014). Counselors should examine potential biases and heteronormative or transnegative assumptions or beliefs that could present a barrier to providing affirmative practice and gain cultural com­ petence regarding unique challenges and experiences of SOGI minority individuals (McGeorge & Carlson, 2011; Singh & dickey, 2016). For many counselors, it can be challenging to be supportive and understand­ ing of parents who behave in ways that can be hurt­ ful to their child; however, it is important for parents to have a safe environment in which they can feel free to work through their feelings without sensing judg­ ment from the counselor (Shpigel & Diamond, 2014). The Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling (ALGBTIC), a divi­ sion of the ACA, published a list of competencies for those working with sexual minorities (Harper et al., 2013) and competencies for counseling transgender clients (Burnes et al., 2010). Among the specific rec­ ommendations are several general suggestions for cre­ ating a safe environment in a counseling setting. Coun­ selors are encouraged to continue their education 282 Coaston, Tabar, & Barrett

through workshops and conferences, but also through dialogue with SOGI minority individuals, reading about life experiences that may be similar to or differ­ ent from their own, and educating themselves on the sociopolitical climate and how it influences laws and policies that affect their clients’ lives (Harper et al., 2013). Counselors should use respectful and inclusive language and client-identified, gender-affirming pro­ nouns or names when appropriate (Burnes et al., 2010; Harper et al., 2013). Doing so may involve a measure of flexibility and accommodation, as clients may ini­ tially express one preference but change as they explore their identity and identify another that fits better. Counselors should be careful not to misgender (i.e., use the wrong gender pronoun for) their clients; how­ ever, if misgendering occurs, counselors should cor­ rect themselves but avoid drawing excessive attention to the mistake (Stringer, 2011). It is important for counselors to recognize that coming out is an individ­ ual decision wherein SOGI minorities determine the process and extent to which they come out (Harper et al., 2013). Coming out has positive effects in terms of improved well-being; however, it can also increase the chances of victimization (Kosciw et al., 2014). Finally, the concept of family can refer to family of ori­ gin (whether biological or through adoption), for which this chapter is written. That said, counselors should honor a broader definition of family, or “family of choice,” that includes others defined by the SOGI individual (Burnes et al., 2010). When working with families from privileged and marginalized backgrounds, counselors should con­ sider the multicultural and social justice counseling competencies published by the Association for Mul­ ticultural Counseling and Development (AMCD), a division of the ACA (Ratts et al., 2015). As discussed above, family reactions to coming out vary across cultures; race and ethnicity can significantly affect the experience of coming out or be a causal factor in fami­ lies’ reactions (Potoczniak et al., 2009). Therefore, coun­ selors should seek to understand the family’s worldview on issues of sexual orientation or gender identity and how this influences their perspective on their SOGI minority youth’s identity. Further, counselors should consider how the SOGI minority youth view their own intersecting identities and how this affects their experiences.

TABLE 1. STATISTICAL RATES OF EXPERIENCES FOR SOGI MINORIT Y YOUTH

Kosciw et al. (2016)

Bullying

85% reported some form of bullying at school, including 60% reporting sexual harassment

GLSEN, CiPHR, & CCRC (2013)

Cyberbullying

3x more likely to experience online harassment or bullying than heterosexual peers

Kann et al. (2016)

Substance use/abuse

5x higher rates than heterosexual peers

Reisner, Greytak, et al. (2015)

Substance use/abuse

Increased odds over cisgender adolescents

Marshal et al. (2011)

Depression

2x higher rates than heterosexual peers

Reisner, Vetters, et al. (2015)

Anxiety, depression, self-harm

2–3x increased risk than cisgender youth

Liu & Mustanski (2012)

Self-harm

Higher rates than heterosexual or cisgender peers

Suicide/suicidal ideation

2–4x more likely than heterosexual peers to attempt suicide 3x increased risk of suicidal ideation and suicide attempts

CDC (2014); Kann et al. (2016); Reisner, Vetters, et al. (2015)

Instructions

This activity is designed for use in a family therapy session. Specifically, balloons are used to demonstrate the concept of familial unity and how that unity can be affected by the coming out of a teen or young adult member. The therapist provides balloons and a twelveinch length of string for each family member. Family members are instructed to blow up their balloons, and all but the client tie their balloons with a string. The client is instructed to hold their balloon firmly between their fingers to secure the opening, without letting air out. While standing in a circle, all members of the family unit hold their own balloons and press them carefully together in the center of the circle to demonstrate that the whole is greater than the individ­ ual parts. The therapist can comment on the strengths of the family unit on the basis of information gathered in previous sessions. Then the therapist asks the client to share a state­ ment that a family member has made to or about them that resulted in feelings of isolation or disconnection from the family unit because of their SOGI minority status. The client is then asked to move away from

the family unit with their balloon. This physical sep­ aration demonstrates the breakup of the integrity of the family unit in visual form. The counselor then begins to educate the family on the effect of rejection on SOGI minority adoles­ cents using the statistics stated above (Table 1) or newer statistics if available. Depending on the emo­ tional status of each member of the family unit, the counselor should determine which option of letting the air out of the balloon is appropriate: using a pin (concealed from the family) at the end of the exer­ cise or having the adolescent slowly release the air until the balloon is empty. As each statistic is stated, from least traumatic to most traumatic, the coun­ selor will ask the client to release just a little air from the balloon. When the counselor reveals the statistic regarding teen suicide for SOGI minority adoles­ cents, the counselor will reach for the client’s balloon and pop it with the pin. After allowing a moment of startled silence follow­ ing the popping of the balloon, the counselor will process the activity with the family. Processing should focus on reactions to the activity, the meaning of the

Maintaining the Family Unit When an Adolescent Comes Out 283

lost balloon to the sum of the balloons, and how this experience relates to life outside the family therapy sessions. For counselors who feel that the shock value of popping the balloon might be too intense for the cli­ ent and family, the client can slowly let the air out of the balloon while the counselor reads the statistics, demonstrating how the air will be let out of the fam­ ily members’ lives if they force the family member out. Alternatively, the client could be seated in an office chair on wheels. With the recitation of each fact, the client can be asked to move farther and farther toward the door until the client is outside the door to the coun­ seling office. Once the separation has been achieved, the client can be brought back in and the balloons can once again be used to demonstrate the interconnect­ edness of the family. It is important that the counselor provide a safe, open environment for discussions and respond in an empathetic and validating manner. All members of the family unit should be given the opportunity to pro­ cess their responses to the exercise, with the caveat that some responses might be embarrassing or emo­ tional, and therefore it might be appropriate to remind the members that respect should be shown at all times. To further illustrate the interconnection of the family unit, all members could be given a balloon and be asked to juggle their own balloon. All members should throw their balloon into the air and catch it several times. After reflection on the ease of juggling one balloon, each member of the family unit is asked to juggle all the balloons by themselves. The family unit can then process the difficulty of being respon­ sible for juggling all the balloons. After each mem­ ber has had the chance to juggle all the balloons, the family can juggle all the balloons together, demon­ strating that balancing their challenges together as an intact family unit makes the unit stronger, and each member has more support as a whole than individu­ ally. The family members can then process the differ­ ences and the value each member brings to the whole of the family unit. Brief Vignette

Elias is a fifteen-year-old Latino cisgender boy growing up in a conservative Texas town with strict Catholic 284 Coaston, Tabar, & Barrett

parents, Carlos and Belinda. The second of five chil­ dren, Elias is the oldest son, and his father hoped that he would become a football star at the local high school, following in his father’s footsteps. Elias did not share his father’s interest in sports, favoring more cere­ bral pursuits. Additionally, he found himself attracted to a classmate, Mark, who was not Hispanic. When Elias came out to his parents, Carlos became very angry, screaming that he wouldn’t have a “faggot” liv­ ing under his roof and threatening to kick Elias out of the house. Belinda, who was more embracing of her son’s sexuality, convinced his father to go to family coun­ seling to seek an alternative to kicking Elias out of the house. After several weeks building the therapeu­ tic alliance, the counselor completed the balloon exer­ cise and chose to pop Elias’s balloon. After a stunned silence lasting nearly a minute, Carlos revealed that suicide was one of his greatest fears for his children and explained that he had lost a cousin to suicide during his childhood. This session served as a turn­ ing point for the family: each member grew more committed to healing the rift that had formed since Elias disclosed his sexual orientation. Suggestions for Follow-up

Therapists should follow up during the next session to determine whether further processing of either exercise is needed. The following questions could be used as guides for processing the activity: • What were you feeling while participating in this activity? • What thoughts did you have while participating in this activity? • What have you learned as a result of this activity? • How might you use what you have learned here in your life? • How, if at all, has the information shared today influenced the way you see the family unit? Contraindications for Use

Because of the emotional nature of these issues and the possible negative responses to the disclosure made by family members to the adolescent client, it is rec­ ommended that a stable therapeutic alliance be devel­ oped before the activity is attempted. This activity is

appropriate for all backgrounds, as long as the thera­ peutic alliance is strong. No matter what therapeutic focus the provider attempts, Shpigel and colleagues (2015) recommend the provider first demonstrate to the non-SOGI minority family members that the therapist understands the distress the family members are feeling and is not allied with the SOGI minority member in any perceived adversarial position. This activity would not be recommended for any client or family member who is actively suicidal or who has a history of suicidality that could be retriggered thereby. Professional Resources American Psychological Association (APA). (2009). Report of the American Psychological Association Task Force on Appropriate Therapeutic Responses to Sexual Orientation. https://www. apa.org/pi/lgbc/publications/therapeutic­ resp.html. American Psychological Association (APA). (2012). Guide­ lines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10–42. doi:10.1037/a0024659. Armesto, J. C., & Weisman, A. G. (2001). Attribution and emo­ tional reactions to the identity disclosure (“coming-out”) of a homosexual child. Family Process, 40 (2), 145–161. doi:10.1111/j.1545-5300.2001.4020100145.x. Burnes, T. R., Singh, A. A., Harper, A. J., Harper, B., MaxonKann, W., Pickering, D. L., & Hosea, J. (2010). American Counseling Association: Competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3–4), 135–159. doi:10.1080/15538605.2010.524839. Diamond, G. M., & Shpigel, M. S. (2014). Attachment-based family therapy for lesbian and gay young adults and their persistently nonaccepting parents. Professional Psychol­ ogy: Research and Practice, 45 (4), 258–268. doi:10.1037/ a0035394. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . Kocet, M. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling com­ petencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individuals. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:10.1080/1553 8605.2013.755444. Knudson-Martin, C., & Laughlin, M. J. (2005). Gender and sexual orientation in family therapy: Toward a postgender approach. Family Relations, 54 (1), 101–115. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., McCullough, J. R., & Hipolito-Delgado, C. (2015). Multi­ cultural and social justice counseling competencies. Alex­ andria, VA: Association for Multicultural Counseling and Development.

Stone Fish, L., & Harvey, R. G. (2005). Nurturing queer youth: Family therapy transformed. New York: W. W. Norton.

Statistical References for the Professional Bullying statistics: Anti-bullying help, facts, and more. (n.d.). http://www.bullyingstatistics.org/content/gay-bullyingstatistics.html. Centers for Disease Control and Prevention (CDC). (n.d.). LGBT youth. https://www.cdc.gov/lgbthealth/youth.htm. GLSEN. (n.d.). https://www.glsen.org. PFLAG New York City. (n.d.). Statistics you should know about gay & transgender youth. http://www.pflagnyc.org/ safeschools/statistics. SPEAK: Suicide Prevention Education Awareness for Kids. (n.d.). Suicide facts. http://www.speakforthem.org/facts. html. Trevor Project. (n.d.). Preventing suicide: Facts about suicide. http://www.thetrevorproject.org/pages/facts-about-suicide.

Resources for Clients Holman, M. (2015). Mom and Dad, I’m gay: Coming out of the closet. CreateSpace Independent Publishing Platform. Human Rights Campaign. (n.d.). Resources: Coming out. https://www.hrc.org/resources/topic/coming-out. Jennings, K., & Shapiro, P. (2003). Always my child: A parent’s guide to understanding your gay, lesbian, bisexual, trans­ gendered, or questioning son or daughter. New York: Simon & Schuster. Pandora’s Project. (n.d.). Coming out to family and friends as being GLBT. https://www.pandys.org/articles/ comingout.html. Pew Research Center. (2013). Chapter 3: The coming out expe­ rience. www.pewsocialtrends.org/2013/06/13/chapter-3­ the-coming-out-experience/. PFLAG. (n.d.). https://www.pflag.org/. Ryan, C. (2009). Helping families support their lesbian, gay, bisexual, and transgender (LGBT) children. Washington, DC: National Center for Cultural Competence, George­ town University Center for Child and Human Develop­ ment. http://nccc.georgetown.edu/documents/LGBT_ Brief.pdf. Signorile, M. (1995). Outing yourself: How to come out as les­ bian or gay to your family, friends, and coworkers. New York: Random House. Stanford, J. C. (2015). Coming out: Gay, lesbian, bisexual, trans­ gendered: The complete guide to coming out of the closet, finding support, and thriving in your new life. Amazon Digital Services.

References American Counseling Association (ACA). (2014). ACA code of ethics. Alexandria, VA: Author.

Maintaining the Family Unit When an Adolescent Comes Out 285

Armesto, J. C., & Weisman, A. G. (2001). Attribution and emo­ tional reactions to the identity disclosure (“coming-out”) of a homosexual child. Family Process, 40 (2), 145–161. doi:10.1111/j.1545-5300.2001.4020100145.x. Bith-Melander, P., Sheoran, B., Sheth, L., Bermudez, C., Drone, J., Wood, W., & Schroeder, K. (2010). Understanding sociocultural and psychological factors affecting transgender people of color in San Francisco. Journal of the Association of Nurses in AIDS Care, 21 (3), 207–220. doi:10.1016/j.jana.2010.01.008. Broome, K. M., Joe, G. W., & Simpson, D. D. (2001). Engage­ ment models for adolescents in DATOS-A. Journal of Adolescent Research 16, 608–623. Burnes, T. R., Singh, A. A., Harper, A. J., Harper, B., MaxonKann, W., Pickering, D. L., & Hosea, J. (2010). American Counseling Association: Competencies for counseling with transgender clients. Journal of LGBT Issues in Counseling, 4 (3–4), 135–159. doi:10.1080/15538605.2010.524839. Centers for Disease Control and Prevention (CDC). (2014). LGBT youth. Retrieved from https://www.cdc.gov/lgb thealth/youth.htm. Diamond, G. M., & Shpigel, M. S. (2014). Attachment-based family therapy for lesbian and gay young adults and their persistently nonaccepting parents. Professional Psychol­ ogy: Research and Practice, 45 (4), 258–268. doi:10.1037/ a0035394. Durso, L. E., & Gates, G. J. (2012). Serving our youth: Findings from a national survey of service providers working with lesbian, gay, bisexual, and transgender youth who are home­ less or at risk of becoming homeless. Los Angeles: Williams Institute with True Colors Fund and the Palette Fund. Feinstein, B. A., Wadsworth, L. P., Davila, J., & Goldfried, M. R. (2014). Do parental acceptance and family sup­ port moderate associations between dimensions of minority stress and depressive symptoms among lesbi­ ans and gay men? Professional Psychology: Research and Practice, 45 (4), 239–246. doi:10.1037/a0035393. Fox, F. (2015, January 8). Leelah Alcorn’s suicide: Conversion therapy is child abuse. Time. http://time.com/3655718/ leelah-alcorn-suicide-transgender-therapy/. Gibson, M. A., Alexander, J., & Meem, D. T. (2014). Finding out: An introduction to LGBT studies, 2nd edition. Thou­ sand Oaks, CA: Sage. GLSEN, CiPHR, & CCRC. (2013). Out online: The experiences of lesbian, gay, bisexual, and transgender youth on the Internet. New York: GLSEN. https://www.glsen.org/sites/ default/files/Out Online FINAL.pdf. Grov, C., Bimbi, D. S., Nanín, J. E., & Parsons, J. T. (2006). Race, ethnicity, gender, and generational factors associated with the coming‐out process among gay, lesbian, and bisexual individuals. Journal of Sex Research, 43 (2), 115–121. doi:10. 1080/00224490609552306. Gutierrez, D., & Hagedorn, W. B. (2013). The toxicity of shame

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applications for acceptance and commitment therapy. Journal of Mental Health Counseling, 35 (1), 43–59. doi:10.17744/mehc.35.1.5n16p4x782601253. Harper, A., Finnerty, P., Martinez, M., Brace, A., Crethar, H. C., Loos, B., . . . & Kocet, M. (2013). Association for Lesbian, Gay, Bisexual, and Transgender Issues in Coun­ seling competencies for counseling with lesbian, gay, bisexual, queer, questioning, intersex, and ally individu­ als. Journal of LGBT Issues in Counseling, 7 (1), 2–43. doi:1080/15538605.2013.755444. Heron, M. (2016). Death: Leading causes for 2014. National Vital Statistics Report, 65 (5), 1–96. Kann, L., Olsen, E. O., McManus, T., Harris, W. A., Shanklin, S. L., Flint, K. H., . . . & Zaza, S. (2016). Sexual identity, sex of sexual contacts, and health-related behaviors among students in grades 9–12—United States and selected sites, 2015. MMWR Surveillance Summaries 65 (no. SS-9). doi:10.15585/mmwr.ss6509a1. Kosciw, J. G., Greytak, E. A., Giga, N. M., Villenas, C., & Dan­ ischewski, D. J. (2016). The 2015 National School Climate Survey: The experiences of lesbian, gay, bisexual, transgen­ der, and queer youth in our nation’s schools. New York: GLSEN. Kosciw, J. G., Palmer, N. A., & Kull, R. M. (2014). Reflecting resiliency: Openness about sexual orientation and/or gender identity and its relationship to well-being and edu­ cational outcomes for LGBT students. American Journal of Community Psychology, 55 (1–2), 167–178. doi:10.10 07/s10464-014-9642-6. Kosciw, J. G., Palmer, N. A., Kull, R. M., & Greytak, E. A. (2013). The effect of negative school climate on academic out­ comes for LGBT youth and the role of in-school supports. Journal of School Violence, 12 (1), 45–63. doi:10.1080/153 88220.2012.732546. LaSala, M. C. (2010). Coming out, coming come: Helping fami­ lies adjust to a gay or lesbian child. New York: Columbia University Press. Legate, N., Ryan, R. M., & Weinstein, N. (2012). Is coming out always a “good thing”? Exploring the relations of auton­ omy support, outness, and wellness for lesbian, gay, and bisexual individuals. Social Psychological and Personality Science, 3 (2), 145–152. doi:10.1177/1948550611411929. Liu, R. T., & Mustanski, B. (2012). Suicidal ideation and selfharm in lesbian, gay, bisexual, and transgender youth. American Journal of Preventive Medicine, 42 (3), 221–228. Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., . . . & Brent, D. A. (2011). Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. Journal of Adolescent Health, 49 (2), 115–123. doi:10.1016/j.jado health.2011.02.005. McGeorge, C. R., & Carlson, T. S. (2011). Deconstructing heterosexism: Becoming an LGB affirmative heterosexual

couple and family therapist. Journal of Marital and Family Therapy, 37 (1), 14–26. doi:10.1111/j.1752-06 06.2009.00149.x. Potoczniak, D., Crosbie-Burnett, M., & Saltzburg, N. (2009). Experiences regarding coming out to parents among Afri­ can American, Hispanic, and white gay, lesbian, bisex­ ual, transgender, and questioning adolescents. Journal of Gay and Lesbian Social Services, 21 (2–3), 189–205. doi:10.1080/10538720902772063. Ratts, M. J., Singh, A. A., Nassar-McMillan, S., Butler, S. K., McCullough, J. R., & Hipolito-Delgado, C. (2015). Mul­ ticultural and social justice counseling competencies. Alexandria, VA: Association for Multicultural Counsel­ ing and Development. Reisner, S. L., Greytak, E. A., Parsons, J. T., & Ybarra, M. L. (2015). Gender minority social stress in adolescence: Disparities in adolescent bullying and substance use by gender identity. Journal of Sex Research, 52 (3), 243–256. doi:10.1080/00224499.2014.886321. Reisner, S. L., Vetters, R., Leclerc, M., Zaslow, S., Wolfrum, S., Shumer, D., & Mimiaga, M. J. (2015). Mental health of transgender youth in care at an adolescent urban community health center: A matched retrospective cohort study. Journal of Adolescent Health, 56, 274–279. doi:10. 1016/j.jadohealth.2014.10.264. Sauceda, J. A., Paul, J. P., Gregorich, S. E., & Choi, K. H. (2016). Assessing collectivism in Latino, Asian/Pacific Islander, and African American men who have sex with men: A psychometric evaluation. AIDS Education and Prevention, 28 (1), 11–25. doi:10.1521/aeap.2016.28.1.11.

Shpigel, M. S., Belsky, Y., & Diamond, G. M. (2015). Clinical work with non-accepting parents of sexual minority chil­ dren: Addressing causal and controllability attributions. Professional Psychology: Research and Practice, 46 (1), 46–54. doi:10.1080/00918369.2015.1061364. Shpigel, M. S., & Diamond, G. M. (2014). Good versus poor therapeutic alliances with non-accepting parents of samesex oriented adolescents and young adults: A qualitative study. Psychotherapy Research, 24 (3), 376–391. doi:10.10 80/10503307.2013.856043. Singh, A. A., & dickey, l. m. (2016). Implementing the APA guidelines on psychological practice with transgender and gender nonconforming people: A call to action to the field of psychology. Psychology of Sexual Orientation and Gender Diversity, 3 (2), 195–200. doi:10.1037/sgd000 0179. Stringer, J. (2011). All about pronouns. http://transwellness. org/wp-content/uploads/2014/02/Pronouns-Handout.pdf. Thompson, S. J., Bender, K., Cardoso, J. B., & Flynn, P. M. (2011). Experiential activities in family therapy: Percep­ tions of caregivers and youth. Journal of Child and Fam­ ily Studies, 20, 560–568. doi:10.1007/s10826-010-9428-x. Thompson, S. J., Bender, K., Lantry, J., & Flynn, P. M. (2007). Treatment engagement: Building therapeutic alliance in home-based treatment with adolescents and their families. Contemporary Family Therapy, 29 (1–2), 39–55. doi:10. 1007/s10591-007-9030-6. Whitley, C. T. (2013). Trans-kin undoing and redoing gender negotiating relational identity among friends and family of transgender persons. Sociological Perspectives, 56 (4), 597–621.

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33 EMPTY-CHAIR WORK FOR COPING WITH HETEROSEXIST AND/OR TRANSPHOBIC FAMILY REJECTION Cara Herbitter and Heidi M. Levitt Suggested Use: Activity Objective

The objective of this exercise is to aid clients in pro­ cessing painful emotions related to heterosexist and/ or transphobic parental rejection. Additionally, it is intended to hold the parents accountable for their rejecting behavior in order to help in the child’s pro­ cess of recovering and developing resilience. Rationale for Use

Lesbian, gay, bisexual, transgender, and queer (LGBTQ) clients who experience parental rejection related to their sexual orientation and gender identity are at increased risk for negative mental health symptoms (Bouris et al., 2010; Rothman, Sullivan, Keyes, & Boeh­ mer, 2012; Simons et al., 2013). The rejection experi­ ence can linger in clients’ minds and influence their self-esteem, mood, substance use, and interpersonal connections (Herbitter & Levitt, 2019; Rothman et al., 2012). More broadly, decreased social support has been associated with a myriad of negative mental health risks among LGBTQ people (e.g., Fredriksen-Goldsen et al., 2014; Teasdale & Bradley-Engen, 2010; Williams, Connolly, Pepler, & Craig, 2005). The presence of social support also may be protective for LGBTQ per­ sons against other sexual and gender minority stress­ ors (e.g., Button, O’Connell, & Gealt, 2012; Eisenberg & Resnick, 2006; Graham & Barnow, 2013; Trujillo et al., 2017), and the lack of this support may render LGBTQ people more vulnerable to the negative con­ sequences of other stressors they are likely to encoun­ ter. Low parental support, in particular, has been

associated with negative mental health risks among LGBTQ youth (e.g., Bouris et al., 2010; Simons et al., 2013) and LGBQ adults (e.g., Rothman et al., 2012). In a systematic review of studies of LGB youth, Bouris and colleagues (2010) found that heterosexist rejec­ tion has been associated with increased risk of maladap­ tive behaviors, including substance use and self-harm. A study of transgender youth found that increased parental support was correlated with fewer depressive symptoms and greater life satisfaction (Simons et al., 2013). In a study of LGB adults ages eighteen to sixty, a history of poor reactions by parents to their com­ ing out was associated with mental health problems and behaviors, including depression and substance use (Rothman et al., 2012). Losing family support may pose additional challenges for ethnic minority indi­ viduals, for whom family involvement may be both an important cultural value and a way of connecting to the broader community (Potoczniak, CrosbieBurnett, & Saltzburg, 2009). The American Psychological Association (APA) guidelines for working with sexual minority clients has outlined how therapists should address the effects of heterosexism as follows: “Among the interventions psychologists are urged to consider are (a) increasing the client’s sense of safety and reducing stress, (b) developing personal and social resources, (c) resolv­ ing residual trauma, and (d) empowering the client to confront social stigma and discrimination, when appropriate” (APA, 2012, p. 13). The guidelines also identified difficulties with family of origin as an impor­ tant area for therapists to potentially address, while attending to intersectionality and how cultural factors

Whitman, Joy S., and Boyd, Cyndy J., Homework Assignments and Handouts for LGBTQ+ Clients © 2021 by Joy S. Whitman and Cyndy J. Boyd

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may come to bear on these relationships. Similarly, when working with transgender and gender-noncon­ forming (TGNC) clients, the APA has recognized the importance of addressing challenges that may develop with family of origin as clients explore their gender identity (APA, 2015). In this vein, the activity described here aims to help clients work toward resolution with their painful experiences of familial heterosexist and/ or transphobic parental rejection. Knowing how to assist clients as they work through heterosexist and/ or transphobic experiences is part of ethical practice with LGBTQ clients. Preliminary research on LGBQ people coping with heterosexist parental rejection has suggested that clients may be seeking more experiential modes of therapy to cope with the emotional challenges of this rejection (Herbitter & Levitt, 2019). Emotion-focused therapy (EFT), or process-experiential therapy, is a humanistic and constructivist psychotherapy orien­ tation that is based in both Gestalt and client-centered modalities. It is an empirically based approach that has demonstrated equivalence to other bona fide psy­ chotherapy orientations through meta-analyses (Elliott, Watson, Goldman, & Greenberg, 2004; Elliott et al., 2013). EFT can be adapted for use with diverse clients while attending to feminist-multicultural values (e.g., Levitt, Whelton, & Iwakabe, 2019). Clinicians have adapted these experiential approaches for use with sexual minority couples in particular (e.g., Hardtke, Armstrong, & Johnson, 2010), and we believe these approaches may be well suited for use in individual therapy with LGBTQ clients, as these approaches provide an opportunity to explore difficult emotions and relationships. Empty-chair work for unfinished business, an exercise introduced by EFT practitioners, may be a particularly powerful opportunity for LGBTQ clients to address heterosexist and/or transphobic rejection from parents. Our qualitative research on heterosexist parental rejection suggests that appropriately assign­ ing blame to rejecting parents and understanding the systemic roots of rejection may enable adaptive cop­ ing (Herbitter & Levitt, 2019). Our findings identify coping mechanisms for parental rejection as including acceptance of negative emotions, self-acceptance, seeking out affirmative support, and potentially deep­

ening understanding of parents. Engaging in this exer­ cise can assist clients in developing highly individu­ alized strategies that can support them in coping with rejection. Two-chair exercises are therapeutic activities that are based in Gestalt therapy and typically used to help clients integrate divided aspects of themselves or develop new responses to interpersonal experiences (see Elliott et al., 2004). They structure a role-played dialogue between either nonintegrated parts of the self or the self and a significant other who is imagined in an empty chair (Elliott et al., 2004). The emptychair exercise presented in this chapter is a type of twochair exercise that has been adapted from EFT and often is referred to as an exercise for unfinished busi­ ness (Greenberg, Rice, & Elliott, 1993). The current application of empty-chair work for unfinished busi­ ness is an opportunity to achieve some resolution with these painful, unresolved experiences in the absence of family acceptance, or in cases when family mem­ bers have become more accepting but discussing past rejection is not feasible or safe. These exercises can help clients separate their own self-assessment from that of critical others or to develop new perspectives on others’ intentions (Elliott et al., 2004; Greenberg & Malcolm, 2002). In this exercise we refer to the stages of resolution that often are used in teaching empty-chair work for unfinished business (Elliott et al., 2004), but we apply the exercise to addressing heterosexist and/or transphobic parental rejection. While this chapter tailors this exercise to the context of parental rejection, it can also be used to process heterosexist and/or transphobic rejection from other significant figures in cli­ ents’ lives. It can be used in the context of ongoing individual therapy. Instructions

In this exercise clients have the opportunity to claim and explore unresolved emotions, such as hurt and anger, toward the rejecting parents. Clients can then articulate their unmet needs for parental support and acceptance and work to find some resolution. Because the exercise is driven by client-centered theory, the way this resolution transpires is determined by the cli­ ents, which allows them to develop coping strategies Empty-Chair Work for Coping with Family Rejection 289

and resolutions that are appropriate for their own cul­ tural contexts, family dynamics, and personal needs. For instance, for some clients the process of holding the parents accountable for their rejecting behavior and recognizing that they, the LGBTQ children, are not to blame for the rejection or any negative family interactions that followed is empowering. For others, the process of understanding their rejecting parents’ behavior as evolving from a context of heterosexism and transphobia, rather than purely a character flaw, may lead to a sense of compassion without their nec­ essarily forgiving their parents. For other clients, the exercise provides space for them to forgive their par­ ents in order to move on, without condoning the rejecting behavior. Therapists can guide clients through this exercise repeatedly over a course of therapy, and resolutions may evolve across time. We recommend that therapists do not initiate this task with a certain outcome in mind, but rather permit their clients to arrive at their own solutions that emerge from the pro­ cess of exploration. Two-chair exercises may be an especially emo­ tional experience, and therapists should enter the exer­ cises willing to slow the stages down as needed to allow clients to engage safely and work through chal­ lenging emotions. If therapists are uncertain about how clients are feeling, they can ask clients if they feel able to continue or would like to take a break to pro­ cess what has happened so far. The clients’ pace should be respected, and empty-chair work can progress slowly. Although the complete task is described in this chapter, it may be that some clients move through only a few stages in initial sessions. If therapists need to end a session and clients are between stages of the task, therapists can simply ask clients to notice how they are feeling in that moment, and then ask them to come out of the exercise and consider what would be good to continue thinking about until the next session. I. Marker Confirmation Within EFT, therapists look for client signals that they are ready to work on a particular issue; these signals are referred to as markers. This exercise is initiated in response to a client’s raising issues of unresolved hurt, sadness, pain, or anger related to rejecting parents, particularly when the issue appears to be causing the 290 Herbitter & Levitt

client distress. The client’s emotional expression can appear either restrained or charged. II. Setting Up and Starting Because empty-chair work is a very emotionally charged process, therapists typically do not engage in these exercises until after they have had three sessions of therapy with a client, in which they can establish their alliance and develop a focus for their treatment. In the case where parental rejection appears as a marker, it can be useful to spend a session exploring a client’s emotional reaction to the rejection. This initial exploration can assist a client in connecting to the emotional response once the empty-chair exercise is begun. It can help to build clients’ investment in engaging in this focused exploration by allowing them to recognize the distressing emotions that they have been carrying. Once the marker has been expressed in session, the therapist begins by reflecting on the emotions that the client has expressed as a preliminary means of setting up the exercise. Then the therapist can intro­ duce the exercise as an opportunity to further explore the emotions by imaging the rejecting parents. It usu­ ally suffices to ask the client simply, “Would you like to engage in an exercise with me to explore your reac­ tion to your parents’ rejection and see if we can under­ stand it better?” The therapist should convey this sug­ gestion with confidence. (Tentatively suggesting having a conversation with an empty chair that represents a parent is often met with skepticism!) Simple assent that the issue is important to explore is enough. Once the client consents, the therapist can initiate the exercise in the same session. From a logistical perspective, the therapist can set up the empty-chair exercise by sitting next to the client and placing an empty chair across from the client, so that both are gazing at the empty chair, which will represent the rejecting parent or relative. The client should be asked first to imagine the other in the chair. This exploration can take some time. Clients can describe the other, in particular how the parent may be seated, the par­ ent’s facial expression, and whether the client imag­ ines the parent expressing the rejection through body language. This exploration of the nonspeaking parent allows the client to enter into emotional contact with

the imagined other and evokes powerful feelings and reactions. III. Differentiating Meaning and Expressing Primary Emotions (Deeper Emotions) To stimulate the client’s emotional response to the rejection, the therapist typically will ask the client to move into the parent’s chair. After the client is seated, the therapist will ask the client to pretend they are the parent and express the rejection to the client in just the way that the parent would. (“Be your parent.” “What would she say to really reject you?” “Do what he does to make you feel really rejected.”) While it might take clients some time to readjust, most clients are able to do this for a few minutes. If a client refuses to move into the parent’s chair, this is okay; the client can remain in the client chair and describe the parent’s expected rejection. Next, clients return to their own chair, and the therapist asks them to express their feelings in response to the parent’s rejection. (“What does it feel like to hear all this anger and outrage? Tell him.”) The ther­ apist can restate the most dramatic aspects of the parental rejection to help stimulate this response. (For instance, “Your father was saying to you, ‘I never wanted a lesbian daughter. You are not the daughter that I wanted.’ How does it feel to hear him say that? Tell him.”) By asking the client to reflect inward and then to communicate the emotion to the other chair directly, the therapist can maintain contact between the two chairs and help the client maintain access to deeper emotions. By using an evocative tone and language, the therapist aids the client in going deeper into their most basic, or primary, emotions, such as hurt and anger. The therapist helps the client explore the root of emotions by focusing the client on the newest or least well-integrated emotion and asking for further descrip­ tion and elaboration of that emotion. (For instance: “You feel angry. Really angry. What does that emotion feel like? Tell him!”) For example, a client who begins the exercise angry might come to identify sad emo­ tions that require integration. A client who begins the exercise in fear of a parent might get in touch with anger. Each time the therapist asks the client to stay with and describe a less well-integrated emotion, the

client can differentiate aspects of that newer emotion and better integrate them. After staying with and exploring the new emotion for some time, the thera­ pist will notice the same new emotions emerging, which is a cue to move on. The therapist then asks the client to change chairs and imagine how the parent might respond. The imagined parent might respond with understanding and with a softer affect. Parents might explain why they were unable to meet the clients’ needs or their wish that they could have done so. In this case, the therapist can guide parents to express the wish and articulate the apology implicit in the response. While the client is in the parent chair, the therapist will align with that chair and support the parent’s emo­ tional expression. Alternatively, the parent may respond with further rejection. This rejection can also be helpful, as it allows the client to realize that the parent is not soft­ ening and that boundaries may need to be established in order to provide protection from unyielding rejec­ tion. If the parent is still alive, it may not be as useful to explore the parents’ side too extensively (because the real parent might have a different response); it may be preferable to use this expression as a way to stim­ ulate change in the client when seated in the client chair. If the parent is deceased, however, the exercise can more extensively explore both sides to help the client reach some resolution. Clients are returned to the client chair and again directed to express their feelings to the parent. These switches might occur a few times as a client comes into contact with deeper emotions. Once the client appears to be in strong contact with multiple levels of feeling, the therapist can progress to the next stage. IV. Expressing and Validating Unmet Needs In this stage clients are encouraged to express what they would have liked the parent to give them, namely, acceptance of their sexual orientation and/or gender identity, or what they still need in order to cope with the distressing feelings. It is often useful to ask the client specifically what the less well-integrated emo­ tion that was discovered in the previous stage needed or still needs. (“So alongside of the feelings of being scared or small, there is also a feeling of anger. That Empty-Chair Work for Coping with Family Rejection 291

anger is important and real. What does that anger need to feel better? Tell him.”) Clients should be encour­ aged to express what they needed and how it felt to have this need unmet, while the therapist validates the client’s right to have this need met. Therapists can ask the client how that need might be met, regardless of whether the parent is capable of fulfilling it or if it needs to be fulfilled by the client. (“What might that scared part of you need in order to feel better?” “Is there anything that the sad part of you might want to ask of your parent?” “What might you remind your­ self or say to yourself when you are feeling angry?”) During this stage, clients may worry that therapists are expecting them to ask their real parent to fulfill this need, and so therapists may want to communi­ cate that this process is meant to help clients under­ stand themselves and decide later what, if anything, they wish to communicate to their real parent. V. Shift in Representation of the Other As clients become more confident in asserting their feelings and needs, they can better claim their right to be accepted by their parents. In this imagined inter­ action, a client’s perspective of the parent shifts from a purely threatening and judgmental figure to a less powerful person who may simply be acting on their own fears and internalized stigma. The loss of power may be due to the client’s realizing that the parent is either an imperfect but well-disposed person who is sorry to have been unable to meet the client’s needs or an imperfect and hostile person who is unable to stop being rejecting. There may be a sense of compas­ sion for the parent, but this is not necessary. What is most important in this stage is that the parent’s power is diminished and vulnerabilities are revealed. In response, the client becomes more empowered and able to make decisions about how to proceed with the relationship. VI. Self-Affirmation and Letting Go of Bad Feelings In this final stage, the resolution takes place in one of two ways: the client develops a deeper understand­ ing of the parent who was unable to provide support but is apologetic or holds the hostile parent account­ able. In the first scenario, the client may recognize that the parents were raised in a very religious envi­ 292 Herbitter & Levitt

ronment and probably had to constrain their own sexual desires and simply were repeating this pattern out of fear or habituated learning. A new, deeper understanding of the parent could lead to forgiving parents for their rejecting behavior as a limitation rather than as having arisen out of maliciousness. For­ giveness is not necessary, however, nor should it be pressured, as it may be experienced as invalidating the injustice of the rejection. In the absence of understanding or forgiveness, resolution occurs through holding the parent account­ able for the rejection. This is especially important for LGBTQ people, who may perceive themselves as at fault for the rejection and may have internalized this stigma. Thus, achieving this accountability is impor­ tant regardless of how the resolution takes place, and it should be coupled with understanding and for­ giveness even if it is pursued. Finally, there may be a grieving for the unmet need for acceptance from the parent as the client realizes that the need for accep­ tance may never be met. This acceptance can allow the client to move on and develop new resources and supports that foster self-acceptance. Brief Vignette

A trans male-identified, white, European American twenty-eight-year-old client, John, presented in ther­ apy expressing unresolved feelings about his parent: “Ever since I came out as trans to my dad, he can barely look at me. He still keeps up the old pictures of me with long hair, like, pretending that’s how I still look. I get so frustrated, but I guess it’s just how things are.” In this case, the client expressed frustration and com­ municated that his tense relationship with his par­ ents, especially his father, was a critical issue for him, but he did not appear to be in touch with emotions of anger or hurt. The identification of this marker pre­ sented an opening for engaging in empty-chair work to deepen contact with his emotions. Because the marker emerged after the therapy relationship had been well established and they had spent time discussing his family, the therapist decided to propose an emptychair exercise in this session (Setting Up and Start­ ing). After reflecting the client’s emotional expression, the therapist introduced the exercise.

T: It might be helpful to have you explore your reac­ tions to your father so we can better understand them. Would you be willing to engage in an exercise with me to do this? C: Okay. I would do that.

boy who I was—even if I didn’t have words to tell you then who I was. T: You are saying, “I feel sad, Dad, for you and for me too.” Can you tell him how that