APA’s Guidelines for Psychotherapy with Lesbian, Gay and Bisexual Clients: The Fundamentals for Practice

by Kristin A. Hancock, PhD

January 20, 2006 — Most psychologists are likely to encounter a lesbian, gay or bisexual (LGB) client at some point in their practices (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991). LGB individuals tend to seek psychotherapeutic services more frequently than their heterosexual counterparts (Bell & Weinberg, 1978; Jones & Gabriel, 1999).

It is important for practicing psychologists to acquire knowledge and skills in providing services to these clients. A therapist’s understanding of issues specific to LGB clients has been found to relate to client satisfaction (Liddle, 1996).

This article focuses on the APA’s “Guidelines for psychotherapy with lesbian, gay and bisexual clients,” beginning with a brief discussion of significant effects of stigma and “minority stress" on LGB individuals.

Stigma and “Minority Stress”

Although some progress has been made regarding the human rights of LGB people in the past 30 years, LGB individuals are still subject to prejudice, discrimination and violence. “Minority stress” is the term used by researchers such as DiPlacido (1998) and Meyer (2003) to describe the cumulative negative effects associated with the prejudice, discrimination, violence and other adverse social conditions experienced by individuals in stigmatized groups.

Indeed, there is evidence to suggest that LGB individuals may have higher rates of stress-related disorders than do their heterosexual counterparts (e.g., Cochran & Mays, 2000; Cochran, Sullivan, & Mays, 2003; Gilman, Cochran, Mays, Hughes, Ostrow, & Kessler, 2001; Mays, Cochran, & Roeder, 2003). Meyer (2003) found that people who felt more frequently stigmatized or discriminated against, who felt they needed to conceal their sexual orientation, or who were prevented from affiliating with other LGB people did tend to report more mental health concerns.

So it is important for providers to understand and appreciate the particular ways in which stigma and prejudice affect the mental health and well-being of LGB clients. Practitioners sometimes have a tendency to associate the increased mental health concerns of LGB clients with their nonheterosexual orientation, rather than considering the effects of stigma.

The “Guidelines for psychotherapy with lesbian, gay and bisexual clients” (APA, 2000) were created to help psychologists identify the fundamental issues unique to the assessment and treatment of LGB individuals, couples, and families. Each guideline statement is accompanied by a rationale for the guideline and some specific recommendations for psychologists. The document also contains references that practicing psychologists can use to pursue subjects covered in greater depth.

Attitudes and Awareness: The Essentials

The first four guidelines serve as the foundation upon which all assessment and treatment rest. The main points include:

• Homosexuality and bisexuality are not indicative of mental illness although (as described above) stigma and prejudice may contribute to an increased need for psychological services in this community.

• Self-awareness and sensitivity to negative attitudes and/or heterosexist bias are important for those who treat LGB clients.

• Stigma poses risks to the mental health and well-being of LGB clients.

• A health professional’s prejudice and inaccurate or outdated information about homosexuality and bisexuality on the provider’s part may affect a client’s presentation and the process of psychotherapy.

Understanding Families and Relationships

In the absence of socially sanctioned forms and supports for their relationships and family systems, LGB people may create their own relationship models and support systems (APA, 2000). The guidelines furnish providers with explanations of this phenomenon and its importance. They also challenge with research findings some of the major misconceptions that have been associated with the impact of LGB parents upon their children.

• It is important to understand and respect LGB relationships. 

• It is important to understand the special circumstances and challenges faced by LGB parents. 

• LGB families may include people who are not legally or biologically related. 

• A person’s homosexual or bisexual orientation may have an impact upon his or her family of origin and the relationship with that family of origin.

Diversity Within the LGB Communities

The guidelines also provide information regarding the diversity within the LGB communities. The effects of race and ethnicity, generational differences and disability are addressed as are the issues of LGB youth and bisexual men and women. Research literature pertaining to these areas is discussed and specific recommendations for practice are provided.

• It is important to understand particular life issues or challenges related to multiple and sometimes conflicting cultural norms, values, and beliefs faced by LGB racial and ethnic minorities.

• Bisexual individuals experience unique challenges associated with a dichotomous understanding of sexual orientation.

• It is important to understand the particular problems and risks faced by LGB youth.

• It is important to consider the effects of age and generational differences in the treatment of older LGB people.

• LGB people with physical, sensory and cognitive-emotional disabilities experience special challenges.

Education

The guidelines encourage various approaches to enhanced understanding of LGB issues and related professional interactions with LGB clients, including:

• Keep current through continuing education, training, supervision and consultation.

• Become familiar with relevant mental health, education and community resources locally and at the state and national levels.

• Support the provision of education and training regarding LGB issues and the integration of LGB-related information at all levels of graduate training.

Using the “Guidelines for Psychotherapy with Lesbian, Gay and Bisexual Clients”

The guidelines can be approached in a number of ways and can be used for a number of purposes. The guidelines offer practicing psychologists:

• A list of the major treatment concerns in psychotherapy with LGB clients and their families.

• Concise review of the pertinent literature (much of it empirical research) for each guideline.

• Specific suggestions for applying each guideline in practice.

• A resource for clinical training sites and supervision.

• A source of information for consultants regarding institutionalized stigma and its effects upon LGB individuals, their relationships, and their families.

The “Guidelines for Psychotherapy with Lesbian, Gay and Bisexual Clients” provide practitioners with a concise overview of the most fundamental issues relevant to clinical practice with LGB clients. They remind psychologists of the fundamentals for affirmative practice with these clients and their families and supply psychologists with places to look for more in-depth information about a variety of practice-related concerns.

Dr. Hancock coauthored the “Guidelines for Psychotherapy with Lesbian, Gay and Bisexual Clients,” which were adopted by APA in February 2000. She is a professor of psychology in the PsyD Program at the Graduate School of Professional Psychology at John F. Kennedy University, and the 2006 chair of the APA Board of Professional Affairs.

American Psychological Association. (2000). Guidelines for psychotherapy with lesbian, gay, and bisexual clients.

Bell, A., & Weinberg, M. (1978). Homosexualities: A study of diversity among men and women. New York: Simon & Schuster.

Cochran, S.D., & Mays, V.M. (2000). Lifetime prevalence of suicide symptoms and affective disorders among men reporting same-sex sexual partners: Results from NHANES III. American Journal of Public Health, 90, 573-578.

Cochran, S.D., Sullivan, J.G., & Mays, V.M. (2003). Prevalence of mental disorders, psychological distress, and mental services use among lesbian, gay, and bisexual adults in the United States. Journal of Consulting and Clinical Psychology, 71, 53-61.

DiPlacido, J. (1998). Minority stress among lesbians, gay men, and bisexuals: A consequence of heterosexism, homophobia, and stigmatization. In G. Herek (Ed.), Stigma and sexual orientation: Understanding prejudice against lesbians, gay men, and bisexuals (pp. 138-159). Thousand Oaks, CA: Sage Publications.

Garnets, L., Hancock, K., Cochran, S., Goodchilds, J., & Peplau, L. (1991). Issues in psychotherapy with lesbians and gay men: A survey of psychologists. American Psychologist, 46, 964-972.

Gilman, S.E., Cochran, S.D., Mays, V.M., Hughes, M., Ostrow, D., & Kessler, R.C. (2001). Risk of psychiatric disorders among individuals reporting same-sex sexual partners in the National Comorbidity Survey. American Journal of Public Health, 91, 933-939.

Jones, M.A., & Gabriel, M.A. (1999). Utilization of psychotherapy by lesbians, gay men, and bisexuals: Findings from a nationwide survey. Journal of Orthopsychiatry, 69, 209-219.

Liddle, B.J. (1996). Therapist sexual orientation, gender, and counseling practices as they related to ratings of helpfulness by gay and lesbian clients. Journal of Counseling Psychology, 43, 394-401.

Mays, V.M., Cochran, S.D., & Roeder, M.R. (2003). Depressive distress and prevalence of common problems among homosexually active African American women in the United States. Journal of Psychology & Human Sexuality, 15, 27-46.

Meyer, I. (2003). Minority stress and mental health in gay men. In L. Garnets & D. Kimmel (Eds.), Psychological perspectives on lesbian, gay, and bisexual experiences (pp. 699-731). (2nd ed.) New York: Columbia Press.