Affirmative Psychotherapy Helps Patients Find Truth
Up until the early 1970s, the American Psychiatric Association included a diagnosis of "homosexuality" in its Diagnostic and Statistical Manual of Mental Disorders, or DSM, the handbook used by healthcare professionals in the United States as the authoritative guide to diagnosing mental disorders.
"In 1973, after much protesting and lobbying by psychotherapists, some of whom bravely came out as openly homosexual, the diagnosis of 'homosexuality' was officially removed from the DSM," according to Marston James, a licensed marriage and family therapist in California who offers gay-centered depth psychotherapy. "In 2000, the American Psychological Association presented its list of guidelines for practitioners working with self-identified gay, lesbian and bisexual individuals, in order to better support the psychological and emotional well-being of these clients by addressing the biases of and the need for affirming from practitioners."
However, James noted those APA guidelines from 2000 did not address affirmative treatment for transgender clients. Indeed, the APA guidelines that year omitted references to transgender people entirely, save for the title of one citation in the references list. The updated "Guidelines for Psychological Practice with Lesbian, Gay and Bisexual Clients," which the APA first adopted in 2011, replacing the earlier document, includes references to literature and resources available to psychologists working with transgender individuals who identify as lesbian, gay and/or bisexual.
"Affirmative psychotherapy has been developed from a foundation of these guidelines and includes the affirmative treatment of transgender clients, as well," James said.
As Jeffrey Chernin, Ph.D., emphasized, an affirmative approach doesn't require the use of specific techniques or even the adoption of a particular form of therapy.
"A therapist of any stripe can provide affirmative therapy because it has to do with the therapist's underlying assumptions," said Chernin, a licensed psychotherapist in Los Angeles.
Psychotherapy itself, James noted, has been around for about a century and takes various forms, from psychoanalysis and cognitive behavioral therapy (CBT) to family and group therapy to narrative and solution-focused approaches. While many psychotherapists assume a neutral posture to the extent possible in relation to clients and issues raised, James noted a "neutral" position can feel unsupportive or hostile to lesbian, gay, bi and transgender (LGBT) clients.
"One of the key differences distinguishing affirmative psychotherapy from other forms of psychotherapy is the need for practitioners to take a stand in affirming the sexual orientation and/or gender identity of their clients," James explained. "Affirmative psychotherapy also generally encourages the practitioner to self-disclose their sexual orientation and/or gender identity to their clients in order to enhance safety in the therapeutic relationship and as a positive modeling of openness and transparency."
According to the authors of a 2018 paper in the journal Psychotherapy, affirmative psychotherapy also refers to the addition of LGBT-affirmative attitudes, knowledge and skills to a therapist's existing therapeutic orientation.
Mary Read, Ph.D,, a clinical training director in the counseling department at California State University, Fullerton, explained that psychotherapy can help enhance self-awareness and increase a person's repertoire of coping skills, while affirmative psychotherapy goes beyond neutrality to help someone live within, accept and—with time and as needed—celebrate their identity.
Why LGBT-affirmative psychotherapy?
A review paper published in 2016 in the Annual Review of Clinical Psychology found LGBT youth reported greater emotional distress, mood and anxiety problems, self-harm and suicidal behaviors than straight peers. Authors of a 2016 paper in the journal Current Psychiatry Reports noted older LGBT adults are more likely than others to have experienced discrimination and mistreatment related to their identities, and that LGBT people have higher rates of anxiety, depression and substance use disorders.
Individuals with sexual minority status are more likely to experience psycho-emotional disorders than the general population, not owing to problematic identities, but attributable to "a social milieu that produces a unique set of stigma-related stressors," as authors of a chapter in the 2022 Comprehensive Clinical Psychology reference book explained. As Read put it, society "can be so punishing and so exclusionary."
Affirmative psychotherapy is intended to address those effects and assist in positive identity development.
Individuals with sexual minority status are more likely to experience psycho-emotional disorders than the general population.
Minority stress theory accounts for this higher incidence of psychological issues among LGBT people by acknowledging when someone lives with a marginalized or minority identity within a discriminatory and stigmatizing society—including one with homophobic and transphobic elements—the conflict between the individual and the dominant culture can trigger the aforementioned stressors and produce poor psycho-emotional health outcomes.
"Another important foundational principle of affirmative psychotherapy is that growing up LGBT in this homophobic, biphobic and transphobic world is traumatic in that LGBT persons are forced to live in a constantly hostile environment, even—and sometimes especially—in their own homes, as well as in their schools and surrounding communities," James said. "Inherent in that hostile environment is the idea that we are all raised within a heteronormative and cisgender-normative indoctrination that informs us all of what is expected in society from each of us. This indoctrination insidiously impacts our very thinking and feeling about ourselves and our place in the world, and that makes it especially destructive to LGBT persons' sense of self-worth, self-esteem and overall well-being."
LGBT-affirmative psychotherapy positions the social and cultural context as a problem, aiding clients in identifying, exploring, treating and healing from the trauma it causes.
What it can entail and what clients can expect
When someone attends the office of an LGBT-affirmative psychotherapist, as part of their standard of care, they fill out paperwork to establish informed consent. Such paperwork may include a range of options with regards to gender expression as well as questions about the age at which they became aware of having their unique sexual feelings and interests.
"The framing of the latter question is preferable to asking what age the client started dating, because the individual might not have been in an environment in which they could date who they wanted, especially if sexual desire started when, say, the person was in school at the time," Read said.
In addition to the use of open language, Read advised that an affirmative psychotherapist refrain from imposing labels and instead ask questions to explore positionality.
Read offered an analogy, noting an affirmative psychotherapy session with an Indigenous client might include questions about how the person relates to their heritage, whether ceremonies are important and what it means for them to have this affiliation.
"The queer-affirming therapist would do the same thing," Read said. "They would ask how that relates, as opposed to telling the client this is who you are, this is what this means."
James highlighted a possible challenge to treating LGBTQIA+ clients with affirmative psychotherapy. Since people typically associate trauma with a life-altering event—such as a tragic accident, involvement in war, sexual assault—LGBTQIA+ people do not always cite trauma as an issue and instead might say they've sought therapy to address depression, anxiety, relationship issues or feelings of estrangement.
"As a result, affirmative psychotherapy necessarily includes an exploration of the client's upbringing and early relationships with parents/caregivers, siblings and friends in order to uncover the degree of homophobia, biphobia or transphobia the client faced within their family and community," James said. "[Then we would] assess the impact on the client through such reactions as so-called acting-out behaviors or emotionally shutting down, among others.
"That impact can then be easily connected to the client's life experiences of anxiety, depression or relationship difficulties," he added. "This process can be experienced as an unraveling of a tangled web of confusing feelings and experiences resulting from the hostility the client experienced toward their budding sexual and/or gender identity during their upbringing. What was previously disparaged as 'acting out' can be reinterpreted as rational self-defense in response to the struggle of living in an unwelcoming world—a reframing, conducive to affirming agency, rendering emotional life more coherent and enabling clients to validate their LGBT experiences and identities."
Chernin recalled a former patient from his previous practice in another state who tried to convince the courts and his ex-wife he had successfully completed conversion therapy in order to maintain co-custody of their child.
"He was deeply ashamed of the duplicity, and the affirmative therapy I provided offered him some relief," Chernin remembered.
James mentioned using affirmative psychotherapy to help a gay client understand the roots of the anxiety he had dealt with his whole life. Grasping its origin in familial homophobia that had long gone unacknowledged, the client came to augustly claim a gay identity.
"In another example, a female client was struggling with the feelings she was experiencing toward women and the internal conflict that was causing her," James recalled. "She was able to uncover lifelong feelings toward women going back to her childhood and how the mindset of heteronormativity was causing her inner conflict."
Affirmative psychotherapy supported the client's self-agency and she subsequently came out to her family and started dating women.
Drawing on the work of 20th-century psychiatrist Carl Jung, James uses an affirmative "depth-oriented gay-centered psychotherapy" to assist individuals in gay and lesbian self-realization. He helps clients cook their issues and trauma, so to speak, with protracted "feeling into" pertinent effect, affording transformation of those feelings as part of what some would consider a spirit-revivifying or soul-enriching process.
"One gay male client was assisted in opening up in session around the horrible physical abuse he experienced from his father as a gay kid," James recounted. "This client's breakthrough came in the form of intense sobbing that he had finally allowed himself to feel. After a time of cathartic sobbing, the client looked up and began smiling and wondering why he suddenly felt so good and free. This was his beginning experience of the alchemy of traumatic feelings that transformed into an experience of what I would call 'gay spirit.'"