Queering Therapy: Moving beyond LGBTQ+ ‘Affirmative’ Counseling

1. Queering Therapy: Moving beyond LGBTQ+ ‘Affirmative’ Counseling STEPHANIE DRCAR, PHD ASSISTANT PROFESSOR, CLEVELAND STATE UNIVERSITY MARISSA PATSEY, LPC PSYCHOTHERAPIST, PRIVATE PRACTICE

3. National Gay and Lesbian Task Force’s Institute for Welcoming Resources • Welcoming Toolkit

6. LGBTQ+ MENTAL HEALTH • As compared to people that identify as straight, LGBT individuals are 3 times more likely to experience a mental health condition. [4] • LGBT youth are 4 times more likely to attempt suicide, experience suicidal thoughts, and engage in self-harm, as compared to youths that are straight. [4] • 38-65% of transgender individuals experience suicidal ideation. [4] • An estimated 20-30% of LGBT individuals abuse substances, compared to about 9% of the general population. 25% of LGBT individuals abuse alcohol, compared to 5-10% of the general population. [4] • 2.5 times more likely to experience depression, anxiety, and substance misuse. [5]

7. LGBTQ+ MENTAL HEALTH Access/Insurance • In a survey of LGB people, more than half of all respondents reported that they have faced cases of providers denying care, using harsh language, or blaming the patient’s sexual orientation or gender identity as the cause for an illness. Fear of discrimination may lead some people to conceal their sexual orientation or gender identity from providers or avoid seeking care altogether. [5]

8. LGBTQ+ MENTAL HEALTH Treatment Issues • In mental health care, stigma, lack of cultural sensitivity, and unconscious and conscious reluctance to address sexuality may hamper effectiveness of care. [6] • Evidence suggests that implicit preferences for heterosexual people versus lesbian and gay people are pervasive among heterosexual health care providers. [6] • LGBT individuals that keep their sexuality hidden are at an increased risk of psychological distress. This also prevents them from accessing group-based coping resources that buffer against the negative effects of stigma. [7] http://www.mentalhealthamerica.net/lgbt-mental-health

9. “AFFIRMATIVE” COUNSELING “...embraces a positive view of LGBTQ identities and relationships and addresses the negative influences that homophobia, transphobia, and heterosexism have on the lives of LGBTQ clients.” (Rock et al., 2010) …”developing a counselor-client relationship in which the counselor engages in empowerment interventions with clients to explore the influence of internalized heterosexism on their mental health, coping, and overall well-being.” (ACA, 2010; Harper et al., 2013; Singh, 2010 in Singh & Moss, 2016)

10. “AFFIRMATIVE” COUNSELING Although admirable in its intent (compared to blatantly disaffirming practices in the past), affirmative counseling can recreate a problematic power dynamic in which the mental health professional is given the power to define reality (i.e., what is good, what is bad, what someone should work toward)

11. “One is not born, but rather becomes, a woman” (Simone de Beauvoir, The Second Sex, 1949)

12. “People invent categories to feel safe. White people invented black people to give white people identity.” -James Baldwin, A Dialogue, 1973

13. HISTORICAL CONTEXT OF COUNSELING • Five Forces of Counseling • Psychoanalysis, Behaviorism, Humanism/Existentialism, Multiculturalism… • Essentialism • Inner psychological or biological structure – this structure (fixed) then organizes a person’s sexual feelings and desires which directs their sexual practices • Social constructionism • Identity categories (actively constructed) products of context (historical, cultural, political) • Rejection of sex=biology, gender=culture (Clarke et al., 2014)

14. WHY IS QUEER THEORY IMPORTANT TO CLINICAL PRACTICE? Clinician awareness, knowledge, and bias (implicit/explicit) Likelihood of LGBTQ clients Intersectionality LGBT “affirmative” counseling Historical treatment of ‘others’ in our field

15. WHAT IS QUEER THEORY? • Critical lens • Deconstruction of language and systems of power • Consideration of context and normalcy • Challenge to identity and categories of identity

16. A QUEER LENS STRIVES TO… Become curious about the realities to which we attend to during the process of therapy Question and challenge our conceptualization of certain ideas/labels/categories

17. QUEER CHALLENGES TO DOMINANT WAYS TO VIEW SEX AND GENDER • Sexual identity is an aspect of who we are that is fixed from birth and endures throughout life --YOU HAVE A BODY • Sexuality is binary (straight/gay) and based on binary gender of attraction (to men/women) --YOU MAY PERFORM AN IDENTITY • People can be divided into normal and abnormal on the basis of their sexual attractions or preferences --YOU MAY HAVE DESIRES (Barker, M.J. & Scheele, J, 2016)

18. Examine power dynamics relating to sex, sexuality, and gender

20. Destabilize heterosexuality as the norm or natural standard of sexuality and categorization

22. Expose how sexual and gender identities are constructed by context and performed by everyone

23. Illustrations by Julia Scheele

24. HOW DO I PRACTICE QUEERLY? • Resist categorization of people • Challenge idea of essential identities • Question binaries • Demonstrate how experience and language are contextual • Destabilize heterosexuality as the norm or natural standard of sexuality and categorization • Examine power relations underlying certain understandings, categories, identities, etc. • Expose how sexual and gender identities are constructed by context and performed by everyone

25. HOW? • Co-create a therapeutic space in which we become critics of language, cultural beliefs and practices, and systems power (relational, language, organizations, institutions) • Avoid ways of working that limit possibilities for clients (context, categories, normalcy) • Attend to ways our own therapeutic theories and ways of being with a client (lens, perspective, introspection, how we see, orient to)

27. Questions? marissa@marissapatsey.com s.drcar@csuohio.edu

28. REFERENCES Foucault, M. (1978). The history of sexuality volume I: An introduction. New York: Random House. Hodges, I. (2008). Queer Dilemmas: The Problem of Power in Psychotherapeutic and Counselling Practice. In L. Moon (Ed.), Feeling queer or queer feelings? Radical approaches to counselling sex, sexualities and genders (7-22). New York: Routledge. Moon, L. (Ed.). (2008). Feeling queer or queer feelings? Radical approaches to counseling sex, sexualities and genders. New York: Routledge. Sanders, C. J. (2012). Queer shifts in therapy: Appropriating queer theory in pastoral counseling. Sacred Spaces, 4. Retrieved from http://www.aapc.org/Default.aspx?ssid=74&NavPTypeId=1216 Sedgwick, E. K. (1990/2008). Epistemology of the closet. Berkeley: University of California Press. ALGBTIC Transgender Committee. (2010). American Counseling Association Competencies for Counseling with Transgender Clients. Journal of LGBT Issues in Counseling, 4: 135-139. Barker, M.J. & Scheele, J. (2016). Queer: A graphic history. UK: Icon Books Ltd. Bieschke, K., Perez, R., DeBord, K. (2007). Handbook of counseling and psychotherapy with Lesbian, Gay, Bisexual, and Transgender Clients (2nd ed.). Washington, D.C.: American Psychological Association. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey. Washington, D.C.: National Center for Transgender Equality. Nadal, K., Skolnik, A. & Wong, Y. (2012). Interpersonal and systemic microaggressions toward transgender people: Implications for counseling. Journal of LGBT Issues in Counseling, 6: 55-82. Patton, J. & Reicherzer, S. (2010). Inviting “Kate’s” authenticity: Relational cultural theory applied in work with a transsexual sex worker of color using the Competencies for Counseling with Transgender Clients. Journal of LGBT Issues in Counseling, 4: 214-227. Singh, A. A. & Moss, L. (2016). Using relational-cultural theory in LGBTQQ counseling: Addressing heterosexism and enhancing relational competencies. Journal of Counseling & Development, 94: 398-404.

29. REFERENCES ALGBTIC Transgender Committee. (2010). American Counseling Association Competencies for Counseling with Transgender Clients. Journal of LGBT Issues in Counseling, 4: 135-139. Bieschke, K., Perez, R., DeBord, K. (2007). Handbook of counseling and psychotherapy with Lesbian, Gay, Bisexual, and Transgender Clients (2nd ed.). Washington, D.C.: American Psychological Association. James, S. E., Herman, J. L., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). Executive Summary of the Report of the 2015 U.S. Transgender Survey. Washington, D.C.: National Center for Transgender Equality. Nadal, K., Skolnik, A. & Wong, Y. (2012). Interpersonal and systemic microaggressions toward transgender people: Implications for counseling. Journal of LGBT Issues in Counseling, 6: 55-82. Patton, J. & Reicherzer, S. (2010). Inviting “Kate’s” authenticity: Relational cultural theory applied in work with a transsexual sex worker of color using the Competencies for Counseling with Transgender Clients. Journal of LGBT Issues in Counseling, 4: 214-227. Singh, A. A. & Moss, L. (2016). Using relational-cultural theory in LGBTQQ counseling: Addressing heterosexism and enhancing relational competencies. Journal of Counseling & Development, 94: 398-404.

30. NEO RESOURCES Healthcare • Pride Clinic of MetroHealth (https://www.metrohealth.org/pride-clinic) • Cleveland Clinic LGBT healthcare (https://my.clevelandclinic.org/about/community/lgbt-health) • AIDS Taskforce of Greater Cleveland (http://aidstaskforce.org) Social / Advocacy / Support • LGBT Center of Greater Cleveland (lgbtcleveland.org) • OutSupport (outsupport.org) • Margie’s Hope (https://www.facebook.com/Margies-Hope-337276689630206/) • Equality Ohio (equalityohio.org) Housing • A Place for Us (http://www.apfuhousing.com) • Rainbow Steps (https://rainbowsteps.org)

31. NATIONAL RESOURCES Ethical Guidelines • World Professional Association for Transgender Health (WPATH) www.wpath.org • Association for LGBT Issues in Counseling (ALGBTIC) www.algbtic.org/competencies.html Resources (Academic, Advocacy) • Theories on LGBTQ Development www.safezone.uncc.edu/allies/theories#mccarn-fassinger • Gender Spectrum www.genderspectrum.org • GLAAD www.glaad.org • National Center for Transgender Equality www.transequality.org • SAGE www.sageusa.org • Lambda Legal www.lambdalegal.org Youth and Young Adults • GLSEN www.glsen.org • The Trevor Project www.thetrevorproject.org

32. SEX AND SEXUALITY “Sex has no history,”  because it’s “grounded in the functioning of the body. Sexuality, on the other hand, precisely because it’s a “cultural production,” does have a history. • In other words, while sex is something that appears hardwired into most species, the naming and categorising of those acts, and those who practise those acts, is a historical phenomenon, and can and should be studied as such. • Or put another way: there have always been sexual instincts throughout the animal world (sex). But at a specific point in time, humans attached meaning to these instincts (sexuality). When humans talk about heterosexuality, we’re talking about the second thing (David Halpern, University of Michigan)

33. GENDER • Trans*gender is “an umbrella term that can be used to refer to anyone for whom the sex she or he was assigned at birth is an incomplete or incorrect description of herself or himself” (Nadal, Skolnik & Wong, 2012) • Identifies outside the cisgender experience of the gender binary of male or female • Gender: socially constructed roles, behaviors, activities, and attributes that a given society considers appropriate for its members (World Health Organization) • Classification – SYSTEM - assignment from culture of category • Expression – how you perform your gender • Identity – WHO - how you see yourself • Assignment – WHAT – gender assigned/chosen • Role – function and belonging

34. TRANSGENDER EMERGENCE BY ARLENE ISTAR LEV (2004) Four Components of Identity • Biological Sex or Natal Sex: physiological makeup of a human being; complex relationship of genetic, hormonal, morphological, chromosomal, gonadal, biochemical, and anatomical determinants that impact the physiology of the body and sexual differentiation in the brain • Gender Identity: social construct dividing people into “natural” categories of men and women that are assumed to derive from their physiological male and female bodies. A person’s self concept of his or her gender (regardless of sex) is gender identity • Gender-Role Expression: expression of masculinity and femininity; reflections of one’s gender identity and are socially dictated and reinforced. Through gender roles, gender is enacted or performed (consciously or unconsciously) and may or may not be related to gender identity or sex • Sexual orientation: self-perception of one’s sexual preference and emotional attraction; experienced through a person’s gender identity

35. LGBTQ+ MENTAL HEALTH Demographics/Societal Issues • Among all U.S. adults aged 18 and over, 96.6% identify as straight, 1.6% as gay or lesbian, 0.7% as bisexual, and the remaining 1.1% as “something else.” [1] • Research suggests that LGBT individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide. [2] • Personal, family, and social acceptance of sexual orientation and gender identity affects the mental health and personal safety of LGBT individuals. [2][1]

36. LGBTQ+ MENTAL HEALTH • More than 1 in 5 LGBT individuals reported withholding information about their sexual practices from their doctor or another health care professional.  [3] • Nearly 30 percent of transgender individuals reported postponing or avoiding medical care when they were sick or injured, due to discrimination and disrespect. Over 30 percent delayed or did not try to get preventive care. [3] • Approximately 8 percent of LGB individuals and nearly 27 percent of transgender individuals report being denied needed health care outright. [3]

37. ADDRESSING LGBTQ COMMUNITY NEEDS • 73% of transgender respondents and 29% of lesbian, gay and bisexual respondents reported that they believed they would be treated differently by medical personnel because of their LGBTQ status. • Equally disturbing, 52% of transgender respondents and 9% of lesbian, gay and bisexual respondents reported that they believed they would actually be refused medical services because of their LGBTQ status. (When Health Care Isn’t Caring: Lambda Legal’s Survey of Discrimination Against LGBT People and People with HIV. New York: Lambda Legal, 2010. Available at: http://www.lambdalegal.org/publications/when-health-care-isnt-caring)

38. ADDRESSING LGBTQ COMMUNITY NEEDS • LGBQ clients continue to report considerable discrimination and hostility during the therapeutic process (Bowers, Plummer, & Minichiello, 2005; Greene, 2007) and that negative therapist variables such as bias and ignorance is present within many aspects of psychotherapy (i.e., intervention and assessment) (Garnets et al., 1991). • “While significant numbers of LGBT individuals seek professional counseling services, approximately 50% report dissatisfaction with the services they receive, mainly due to the counselor’s lack of professional conduct (Liddle, 1996; Palma & Stanley, 2002). Specifically noted are counselors’ negative, prejudicial attitudes toward and lack of understanding of LGBT issues as well as perceived heterosexist bias (Phillips & Fischer, 1998). Frank, D. & Cannon, E., 2010

39. ADDRESSING LGBTQ COMMUNITY NEEDS • Although LGB people utilize mental health services more than heterosexual individuals (Cochran & Mays, 2000b; Cochran, Mays, & Sullivan, 2003; Grella, Greenwell, Mays, & Cochran, 2009), it is not clear how frequently they access evidence-based, time-limited treatments that have been established to be most effective in reducing depression and suicidal behavior (Guthrie et al., 2001; Brown, Ten Have, & Henriques, 2005). • Evidence shows that targeted or modified mental health interventions for LGB individuals may increase treatment acceptability, retention, and effectiveness. (Jaffe, Shoptaw, Stein, Reback, & Rotheram-Fuller, 2007; G. S. Diamond, Siqueland, & Diamond, 2003)

40. MOVING ACTIVE, ORGANIC, DYNAMIC PROCESS TOWARD LEANING IN, PUSHING UP AGAINST MULTIPLICITY AMBIGUITY, UNCERTAINTY, POSSIBILITY

41. PRACTICING QUEERLY Do my practices of therapy allow dominant discursive ways of shaping my client’s life to remain unchallenged?

42. PRACTICING QUEERLY Does the therapeutic relationship, as currently constructed support dominant discursive practices that are limiting or harmful to my client?

43. PRACTICING QUEERLY How do my therapeutic practices open space for resistance to dominant discursive ways of defining, normalizing and totalizing my client’s life and way of being in the world?