The growing body of literature on shame, its role in men's and women's development and the treatment of shame-based conditions (Alonso and Rutan, 1988) has been a tremendous help to therapists working with homosexual clients. For many patients, assistance in recognizing the physiologic experience of shame and giving that experience a name provides healing normalization and an important conceptual tool for further work. The interpersonal process of shame is of projection and disconnection. Consciously reexperiencing shame in a context of identification and connection with therapist or therapy group and learning to maintain interpersonal contact through that experience is the ideal antidote to the emotional and social isolation in which many homosexuals live.
The therapist learning to work in the language of shame must trace its origins to before the finger-pointing, scowling and verbal blaming, which we all readily recognize as shaming, and encounter the more subtle world of early object relations. In that world, smell, touch, facial expression and body language convey approval and disapproval. Even more significantly, they express connection and disconnection. Winnicott (Davis and Wallbridge, 1981) has eloquently described early development in which the parent's facilitation of the child's spontaneous gesture results in expression of meaning, an experience of mastery and the formation of a piece of true self. When the parent fails to recognize the gesture, misinterprets it or replaces it with one of the parent's own, the child has an experience of shame, and a piece of false self is put into place as a defense. The foundation of self-esteem and of interpersonal grace and confidence is constructed from these experiences. Our success in sustaining intimate relationships depends on our capacity to experience our true self and to bring that self into connection with the true self of the other.
We know that homosexual preference begins early in life, often experienced as a sense of difference from like-gender peers. We also know that children understand that there is a category of people who differ from the heterosexual norm and are negatively defined. This knowledge precedes awareness of their own difference and may occur long before they consider putting themselves in that category. The personal histories of my homosexual patients are filled with examples of early recognition of the need to be careful expressing themselves, to hide the potentially betraying spontaneous gesture. The pre-homosexual child, then, may have had more than her or his share of disconnecting, shame-inducing events connected to self-expression, and is likely to have constructed a defensive false self that maintains painful personal constriction, unsatisfying interpersonal distance and prohibits healing underlying shame.Living in a Multicultural World
Our lesbian and gay patients live in at least a bicultural social system. The beginning of coming out occurs in the predominant heterosexual culture where they must realize and accept their difference. Then they must find a satisfactory way of entering the homosexual culture, establishing a sense of place among peers and developing intimate relationships. Any problems with shame or idealization in their culture of origin are magnified as they encounter shamed and idealized subgroups within the new culture. Although this is quite similar to any adolescent establishing peer relations in a social system with hierarchies and cliques, a therapist who is not familiar or comfortable with the homosexual culture and its mores may have trouble supporting and normalizing the patient's efforts, especially when the patient may be long past adolescence in chronological age.
Being homosexual is not a choice, but deciding how to live one's social and sexual adult life is. The therapist for lesbian and gay clients must be supportive to their exploring the necessary choices and grieving the attendant losses that are inevitable when one has connections to at least two cultures. These choices and losses are even more complicated when patients have gone a long way down the road of heterosexual socialization before accepting and pursuing their homosexual lives.
Shame resulting from countertransference reactions or empathic failure is a fairly common occurrence to which the therapist must be alert. Peggy Hanley-Hackenbruck, (1988) has divided therapist countertransference into stages of "must not" (negatively predisposed toward homosexual patients), "must" (feeling a political urgency to push the coming out process), and "can" (able to assist patients at various stages of self-acceptance from a therapeutically neutral position).
As an example of "must not" countertransference, questioning the origins of a patient's homosexual desire may not only be inappropriate (how often is heterosexuality questioned?), but can undermine the patient's self-confidence by adding to "heterosexist" stigmatization and seriously impair the therapeutic alliance. The number of times that my seminar participants have discussed their discomfort and confusion about acknowledging a patient's homosexual identity, exploring the patient's satisfaction with it, and investigating any relationship between that and their presenting symptoms indicates an important ongoing need for sensitization and education.
It is incumbent upon us as therapists to assess our levels of comfort and expertise with this varied population and augment our skills via the excellent literature available and through collegial contact at our professional meetings. The Association of Gay and Lesbian Psychiatrists in the American Psychiatric Association, a similar group in the American Psychological Association, and the Special Interest Group for Gay, Lesbian and Bisexual Issues in the American Group Psychotherapy Association present informative workshops and panels at their annual meetings that are superb resources for clinicians.