Scientific, social or legal redefinition is only slowly reflected in changed practitioners and practices. It is not surprising that surveys continue to report high levels of ignorance and prejudice encountered by homosexuals in their contacts with health care providers. This also contributes to a negative feedback loop in which many homosexuals are reluctant to utilize, inform or confront their care providers, impairing collaboration in treatment.
Arriving in Orlando, Fla., for the 10th Annual U. S. Psychiatric & Mental Health Congress, I felt a familiar surge of excitement about seeing colleagues, attending seminars for my own continuing education, and my presentation of "The Role of Shame and Idealization in Homosexual Identity Formation," as well as the follow-up Ask-the-Expert session on psychotherapy with gay and lesbian clients.
I was unprepared for the large audience and the level of energy and interest its members sustained throughout these presentations, which enlivened the question and answer periods. The high interest level revealed the clinicians' need for specific information and consultation to facilitate their work with a group of patients who are becoming increasingly visible within our culture.
Fortunately, the body of relevant knowledge is growing, and clinicians who have experience in working with this population are available for supervision and consultation. I hope in this article to summarize some of the clinical information that therapists need to master in order to work responsibly with their gay and lesbian clients.
A basic understanding of the social context in which and by which lesbians and gay men have been defined is important. Definitions and understanding of homosexuality and homosexuals have changed radically in this century. Seen as criminal by the law and evil by the church early in the century, we were "rescued" by the medical establishment and redefined as having a pathologic condition. Beginning in the 1950s, a convergence of scientific and political forces led to increased awareness of the realities of homosexuals' lives and relationships, and efforts to depathologize us as a group of people. Continuing work in that direction is reflected in the recent resolution by the American Psychological Association, which insists that patients exposed to the so-called "change therapies" be given information which validates homosexuality as a normal variant of human sexuality and recognizes the therapies available to support homosexual identity formation. It is an unfortunate reality that negative definition and stigmatization continue to some degree in the social environment of most homosexuals.
Scientific, social or legal redefinition is only slowly reflected in changed practitioners and practices. It is not surprising that surveys (Garnets and others, 1991) continue to report high levels of ignorance and prejudice encountered by homosexuals in their contacts with health care providers. This also contributes to a negative feedback loop in which many homosexuals are reluctant to utilize, inform or confront their care providers, impairing collaboration in treatment.
The category "homosexual," is now understood to include many different kinds of people and many varieties of self and relational expression. Homosexuality is not just a sexual act, but a sexual, affectional and relational preference. Gay men are more like other men, and lesbians more like other women, than they are similar to each other. The "problem" of homosexuality is not that these variations of human sexuality exist, but that the achievement of a healthy adult sexual identity is impeded, and the stress of daily living increased, by the social conditions of stigmatization and prejudice in which homosexuals must develop their identities and conduct their lives.
The process of "coming out" was originally thought of as an event, the moment of one's debut or first appearance at an openly homosexual social event. Now we understand that it is a prolonged process of identity formation and realization that extends over a lifetime and can be manifest in various ways.
My experience of psychotherapy with lesbians and gay men is derived from several sources. I am a psychiatrist in private practice with four other therapists, and our group sees somewhat more than a usual percentage of homosexual clients, either in individual and/or group therapy, or in relational therapy (couples and families). My ongoing experiential training groups in psychodynamic group psychotherapy are all of mixed gender and orientation, with approximately 20% gay or lesbian membership. I also travel to conduct three- and five-day self-awareness and intimacy-enhancing workshops for gay men. In the remainder of this article, I will discuss what I have learned in these venues about areas in which treatment of homosexual clients calls for particular knowledge and focus from the therapist.
The concept of one stage building upon the work of the previous stages has been used throughout the literature on biological and psychological developmental, but was particularly well described in Erik Erikson's (1997) writing on human development. In his later years, he expressed concern that the stages he had delineated were being thought of only in relation to early development, and that the ongoing process of adult and later life, which involves revisiting many of the tasks of early life, was not well enough understood and described.
Because the work of homosexual identity formation involves effort against the constraining forces of "heterosexism" at every stage, it is particularly important that therapists understand how addressing significant unfinished business can free psychological energy to improve self-esteem and enrich relational capacity. I have encountered many instances of gay and lesbian clients presenting themselves to other group members as "having already dealt with coming out," only to be stirred by the catalytic activity of group processes to experience long-avoided painful memories and powerful healing experiences.
Much of the homosexual's developmental work may have been done in relative social isolation due to such factors as the need to hide or camouflage the self in a "heterosexist" world; difficulty in finding and entering the homosexual subculture, which is frequently invisible; and a lack of positive role models like those available to the developing heterosexual. The power and necessity of validating and normalizing interpersonal experiences cannot be underestimated, and facilitating such experiences must be given prominence in the therapeutic strategy. For this reason, a knowledge of gay-affirmative therapists and of appropriate therapy, support and social groups in one's area is very useful. For example, there is Parents, Families and Friends of Lesbians and Gays (PFLAG), and OUTRIGHT for gay, lesbian, bisexual and transgender youth.
The therapist must understand the usual trajectory of the coming out process and be familiar with the internal struggles, stigma management strategies and social conflicts that accompany each stage (Troiden, 1989). Too many therapists naively expect the patient to inform them about a process for which the patient may be lacking language and concepts.
Speaking the Language of Shame
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.
Alonso A, Rutan JS (1988), The experience of shame and the restoration of self-respect in group therapy. Int J Group Psychother 38(1):3-27.
Davis M, Wallbridge D (1981), Boundary and Space: An Introduction to the Work of D.W. Winnicott. New York: Brunner/Mazel.
Erikson E (1997), The Life Cycle Completed. New York: W.W. Norton.
Garnets L, Hancock KA, Cochran SD et al. (1991), Issues in psychotherapy with lesbians and gay men. A survey of psychologists. Am Psychol 46(9):964-972.
Hanley-Hackenbruck P (1988), "Coming out" and psychotherapy. Psychiatr Ann 18(1):29-32.
Troiden RR (1989), The formation of homosexual identities. J Homosex 17(1-2):43-73.