Addressing multiple relationships between clients and therapists in lesbian, gay, bisexual, transgender communities

Therapists working in lesbian, gay, bisexual, and transgender (LGBT) communities are likely to experience the potential to engage in multiple relationships with their clients. Currently, the American Psychological Association's (2002) ethics code and the related literature base offer minimal direct guidance to therapists practicing in LGBT communities. In this article, the authors review current literature regarding multiple relationships in psychotherapy, considering how this literature addresses issues specific to practitioners working within LGBT communities, present a case study highlighting the negotiation of a multiple relationship between a client and therapist who both identify as lesbian, and offer recommendations for practitioners working within LGBT communities.     

Marriage and Family Therapy with Low-Income Clients: Professional,Ethical, and Clinical Issues

Economic stress greatly increases the likelihood of mental health issues occurring within a family. Although this is widely known within the mental health profession, there is a lack of literature that assists therapists in working effectively with low-income clients. As a result, marriage and family therapists may be ill equipped to meet the needs of those in poverty, and may even be conducting therapy that is ethically unsound. The authors of this article discuss several ethical and professional issues regarding therapy with families in poverty. A number of suggestions are presented for improving the effectiveness of therapy with low-income clients. Michele E. Grimes and Alyssa D. McElwain are masters students in Marriage and Family Therapy at Purdue University Calumet, Hammond, IN. Michele E. Grimes and Alyssa D. McElwain contributed equally to this article.     

Addressing disparities: The impact of a lesbian,gay, bisexual,and transgender graduate counselling course

Background: Lesbian, gay, bisexual and transgender (LGBT) individuals experience serious mental health disparities and treatment inequities. Counsellor education has been identified as both a contributing factor to these problems as well as an ameliorating mechanism to address these inequalities. Aim: The purpose of the current study was to evaluate the impact of an LGBT‐affirmative counselling course. Method: A total of 23 students enrolled in a graduate LGBT counselling course were administered the Sexual Orientation Counselor Competency Scale (SOCCS, Bidell, 2005) and the Lesbian, Gay, and Bisexual Affirmative Counseling Self‐Efficacy Inventory (LGB‐CSI, Dillon & Worthington, 2003) pre‐ and post‐course. In addition, a comparison group of 23 matched counselling students was obtained from an existing data source in order to make further assessments of the course's effectiveness. Those in the comparison group were not enrolled in the LGBT course, but were administered the SOCCS at analogous time intervals. Results: After completing the LGBT course, enrolled students demonstrated significant improvements regarding their sexual orientation counsellor competency and self‐efficacy. In addition, these students showed significant gains in SOCCS scores versus those in the comparison group. Implications: Results from this study show the positive effect a full‐credit LGBT psychotherapy course can have on graduate counselling students' sexual orientation counsellor competency and self‐efficacy. The findings also indicate that such a course can significantly impact counselling skills, a facet of LGBT cultural competency found to be the most attenuated. Findings are discussed in conjunction with LGBT‐affirmative counsellor training and clinical practice.     

A Multilevel Approach for Reducing Mental Health and Substance Use Disparities Affecting Bisexual Individuals

Despite bisexual individuals being at increased risk for mental health and substance use problems, clinicians’ ability to provide affirmative and competent care to bisexual clients is limited by their lack of bisexual-specific training. To address this common gap in training, this article provides a brief review of bisexual health disparities and the factors that influence them. Then, we describe a multi-level approach for improving the health and well-being of bisexual individuals. This approach addresses factors that influence health at the micro-level (e.g., strategies that clinicians can use to help bisexual clients cope with stigma-related stressors), mezzo-level (e.g., adaptations to clinical environments and training programs that promote bisexual-affirmative care), and macro-level (e.g., advocating for political change and implementing strategies to reduce prejudice against bisexual individuals at the population-level). Specifically, we describe how clinicians can adapt evidence-based interventions to tailor them to the needs of their bisexual clients. Additionally, we discuss the need for bisexual-affirmative clinical training and provide recommendations for how clinical training can be adapted to prepare clinicians to work effectively with bisexual clients. Finally, we describe how population-level interventions can be used to reduce prejudice against bisexual individuals in order to reduce bisexual health disparities. Given the striking health disparities affecting bisexual individuals, there is a critical need to develop, test, and disseminate interventions to improve the health of this population and to prepare clinicians to provide bisexual-affirmative care.     

First impressions online: The inclusion of transgender and gender nonconforming identities and services in mental healthcare providers' online materials in the USA

Background: When accessing mental healthcare services, transgender and gender nonconforming (TGNC) individuals face systemic barriers to gender-affirmative care. Initial points of contact, like intake forms, may show limited consideration for the heterogeneity of TGNC identities and can lead to negative consequences prior to face-to-face interaction with providers. Aims: The first aim was to mimic a likely pathway a TGNC individual may follow to seek mental healthcare services in the USA and to describe the extent to which they may encounter enacted stigma or affirmative messages that may impede or facilitate access to care. The second aim was to determine if a positive State legal climate for TGNC people was associated with more affirmative provider materials. Methods: Content analysis was used to examine a national sample of websites and intake forms of mental healthcare providers who advertise online as working with TGNC clients. Intake forms were coded for usage of affirmative language in gender/sex questions and including questions for a client's pronouns and preferred name. Websites were coded for mentioning a variety of services or resources for TGNC clients. Results: While provider websites were found through Google searches for a “gender therapist,” only 56.6% of websites stated a provider specialty to work with TGNC clients and 32.1% of websites had no mention of services or resources for TGNC people. Additionally, a significantly larger proportion of intake forms from States with legal protections for TGNC people used affirmative language in gender/sex questions and asked for a client's pronouns than intake forms from States without legal protections. Discussion: Barriers to affirmative healthcare for TGNC people within patient and provider interactions have been identified in previous research and these data show TGNC individuals may face enacted stigma even in their search for a provider, particularly those TGNC people living in States without legal protections.     

Cross-fertilization versus transmission: Recommendations for developing a bidirectional approach to psychotherapy dissemination research

Psychotherapy researchers are increasingly engaged in collaborations with clinical practitioners and mental health administrators. Each party brings its own perspectives, values, and agendas to bear in these encounters. Viable research—practice collaborations depend on understanding and negotiating some of the tensions in these relationships. In this article, we discuss the contexts that prevail for various participants in a psychotherapy dissemination study as well as the values, goals, costs, and benefits related to research participation. This article is a collaboration among the researchers, mental health administrators, therapists, and clients involved in an ongoing treatment dissemination study. Our recommendations for research—practice collaborations are based on our experiences and dialogues over the course of this study.     

Effective Psychotherapy With Low-income Clients: The Importance of Attending to Social Class

The purpose of this article is to explore some of the issues associated with conducting psychotherapy with low-income clients. Throughout the article, we draw from our specific clinical experiences working with low-income Latina mothers in a depression prevention program. The themes that we address regarding class and psychotherapy are in the areas of assessment of social class, integration of class issues into the therapy process, and managing differences in social class between therapists and clients. As we discuss these themes, we provide concrete recommendations in order to advance awareness and effectiveness in working with economically disadvantaged populations.     

Cross-fertilization versus transmission: Recommendations for developing a bidirectional approach to psychotherapy dissemination research

Psychotherapy researchers are increasingly engaged in collaborations with clinical practitioners and mental health administrators. Each party brings its own perspectives, values, and agendas to bear in these encounters. Viable research—practice collaborations depend on understanding and negotiating some of the tensions in these relationships. In this article, we discuss the contexts that prevail for various participants in a psychotherapy dissemination study as well as the values, goals, costs, and benefits related to research participation. This article is a collaboration among the researchers, mental health administrators, therapists, and clients involved in an ongoing treatment dissemination study. Our recommendations for research—practice collaborations are based on our experiences and dialogues over the course of this study.     

Comparing Binary Transgender and Nonbinary People: Factors Associated with Psychological Well-Being Among a Predominately People of Color Sample

Binary transgender and nonbinary people face interpersonal and societal discrimination which can contribute to minority stress and negative mental health. Thus, it is important that family therapists understand what factors contribute to psychological well-being to be able to offer helpful and inclusive therapy services to these communities. This study addresses a gap in the literature regarding differences in factors contributing to psychological well-being between binary transgender and nonbinary people as well as understanding these factors in a predominantly People of Color (POC) sample. Utilizing secondary data from the Social Justice Sexuality Project (Battle and DeFreece in Women Gend Fam Color 2(1):1–31. https://doi.org/10.5406/womgenfamcol.2.1.0001, 2014; Battle et al. in Social justice sexuality survey: cumulative codebook, City University of New York-Graduate Center, New York, 2012), this study examined the relationships between perceived family support, religiosity, community connectedness and psychological well-being in a sample of binary transgender and nonbinary people. Results from a multiple group path analysis show that perceived family support, religiosity and being connected to an LGBT community were significantly associated with psychological well-being for binary transgender people, while only LGBT community connectedness was significantly associated with psychological well-being for nonbinary people. Implications for family therapists include helping families support binary transgender and nonbinary family members, deconstructing non-affirming religious messages about gender identity and connecting clients to affirmative religions and religious leaders, and being knowledgeable about community resources for binary transgender and nonbinary POC.

     

Facilitating Mental Health Support for LGBT Forced Migrants: A Qualitative Inquiry

Evidence suggests that lesbian, gay, bisexual, and transgender (LGBT) individuals who flee their countries of origin may arrive in host countries with persecution‐related mental health problems. This qualitative study explored facilitators and barriers to mental health care in Canada for forced migrants who are LGBT through the perspectives of 22 service providers and 7 migrants. Using thematic analysis, the authors identified 4 themes: recognizing stigma and shame, accessing competent mental health providers, managing distress/manifesting resilience, and healing through community connections. The authors discuss implications for counseling.     

Understanding the psychological processes of the racial match effect in Asian Americans

Some studies on mental health outcomes research have found that when clients and therapists are ethnically or racially matched, this tends to be related to greater satisfaction and better outcomes. However, the precise underlying mechanism for the match effect has not been extensively examined. In this experimental study, we tested the effect of racial match on critical counseling processes (i.e., therapist credibility and the working alliance) using a sample of 171 Asian American respondents. We also examined Asian ethnic identification as a potential moderator of the racial match effect. Structural equation modeling analyses indicated that racially matched individuals perceived greater experiential similarity with the therapist than nonmatched individuals, and experiential similarity was positively associated with therapist credibility. Although racial match did not predict attitudinal similarity, attitudinal similarity was strongly related to the working alliance and therapist credibility. Counseling implications are discussed.     

Context and Culture: The Initial Clinical Interview with the Latina/o Client

Changing social demographics require that psychotherapists and mental health delivery systems become accountable for developing attitudes and skills for working multiculturally. This article immerses the reader in contextual and cultural principles for establishing an initial therapeutic relationship with Latinas/os. These contextual and cultural principles also can be implemented across any theoretical orientation or clinical interview structure psychotherapists employ. This article also reports on data from a subset of participants (n = 27) that self-identified as bilingual, bicultural, and highly culturally competent from a larger mixed-methods study of 89 Latina/o therapists. The results support the utility of personalismo, respeto, charlar (small talk), language and education, and self-disclosure in building respectful relationships with, and in conducting the initial interview with Latina/o clients. These findings are highly consistent with the common factors literature and lend further support to the proposition that the therapeutic relationship serves as the base for therapeutic interventions across all cultures.     

Countertransference issues in psychotherapy with lesbian and gay clients

This article briefly reviews literature on responses towards same-sex (lesbian and gay) sexualities from psychoanalytic and ‘lesbian and gay affirmative’ psychotherapeutic perspectives. An analysis is presented of reports of countertransferential reactions to lesbian and gay clients, obtained from interviews with fourteen psychotherapists who work in a lesbian and gay affirmative manner and eighteen clients who had received affirmative psychotherapy. Data were subjected to grounded analysis. Participants consistently attended to the thoughts, feelings and values that therapists held in relation to lesbian and gay clients and how these affected the meanings and practices available to them. These were linked with the therapist's sexual identity among other factors. Negative countertransferential reactions were regarded as potentially occurring among heterosexual and lesbian and gay therapists and were seen as arising from therapists’ conscious and unconscious fears about same-sex sexualities. These findings indicate a need to continue debating these issues more widely in the professional arena.     

Nonbinary-Affirming Psychological Interventions

Nonbinary individuals experience unique stressors and stigma compared to binary transgender individuals. Given the many social systems that operate on a binary gender system, nonbinary individuals frequently experience microaggressions, discrimination, and harassment and suffer from high rates of negative mental health outcomes as a result. The unique stressors that nonbinary individuals face warrant specific clinical considerations for working with this population. Yet, limited published clinical guidance exists on working with nonbinary clients. This article uses minority stress theory to understand the unique stressors and mental health risks that nonbinary individuals face, a cultural competency framework to describe affirming practices, and ecological theory to contextualize how mental health providers can intervene and support nonbinary individuals. Concrete micro-, mezzo-, and macro-level interventions are provided for clinicians to enact to support the well-being of nonbinary clients including affirming the client’s experience of gender, taking a stance of openness and flexibility, and advocating for inclusive policies and practices.     

Play Therapy in a Natural Setting: A Case Example

Play therapy is commonly used when working with children in counseling. Play therapists work at a developmentally appropriate level to assist children with a variety of mental health and behavioral concerns. Traditionally, play therapy and many counseling methods occur in office settings. We propose that play therapists and other mental health professionals working with children integrate nature and natural settings into their work. The use of nature has been shown to be effective in helping people cope with mental health and physical ailments. In this article, we explore the benefits of the use of nature in mental health and provide a case example of the use of nature and natural settings in counseling.     

Ayahuasca in Western society and the metacognitive counselling approach

Ayahuasca is a hallucinogenic plant used throughout South America for religious, cultural and healing ceremonies. Previous studies have analysed it as a therapy method from either the microperspective, such as physiological and psychological effects of substance use, or the macroperspective, such as legal issues or cultural appropriation of ayahuasca by Westerners. There is a need to combine those two aspects to fully understand the effects of ayahuasca for therapists and clients in Western communities. By utilising an autoethnographic instrumental case study, we discuss the possible risk of ayahuasca gaining popularity in Western societies without an understanding of how the social context plays a tremendous part in healing using this method. We also discuss the risk of intrapsychic experiences brought about by ayahuasca that may deter individuals from seeking appropriate treatment. It is not our intention to present ayahuasca as an illegitimate or invalid method of healing; rather, we emphasise the importance of integrating micro- and macroperspectives in psychotherapy practice. We suggest that the metacognitive counselling approach be taken by both clients and therapists when adopting indigenous methods of therapy which may add a significantly positive effect. Although we hope this study offers realistic and lived experiences to generate pragmatic solutions for therapists and clients, we recognise that it is necessary to collect data from a larger number of both clients and therapists to better support our suggestion of the metacognitive counselling approach.     

Diagnoses,Relational Processes and Resourceful Dialogs: Tensions for Families and Family Therapy

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐5), given its psychiatric focus on mental disorders in individuals, presents families and family therapists with challenges. Despite considerable controversies over its adoption, the DSM‐5 extends a process of standardizing a language for human and relational concerns. No longer a diagnostic language of professionals alone, its use is medicalizing how mental health funders and administrators, as well as clients, respond to human concerns. For family therapists who practice systemically, particularly from poststructuralist and strengths‐based orientations, many tensions can follow when use of the DSM‐5 is expected by mental health administrators and funders, or by clients who present concerns about themselves or a diagnosed family member. In this paper, I explore how such DSM‐5 related tensions might be recognized, navigated, and negotiated in the practice of family therapy with clients, and with administrators and funders.     

The Provision of Assistive Technology by Occupational Therapists Who Practice in Mental Health

The purpose of this study is to determine what assistive technology devices occupational therapists working in mental health settings use with their clients. Based on the literature, the authors expected that no tech and low tech assistive technology solutions are being used with clients in these settings even though high technology options are available for people with mental illness who have co-existing cognitive disabilities. The findings of the study reveal that indeed no tech and low tech interventions are most often used. Implications for professional development educational programs and further research are suggested.     

Working With Couples and Substance Abuse: Recommendations for Clinical Practice

Misuse of alcohol and drugs is widespread in modern society with the associated emotional and physical tolls on individuals, couples, and families. Yet, many therapists do not assess nor address substance misuse when clients do not identify it as a presenting problem. This article presents an overview of the literature on key aspects of couples and substance use and makes important clinical recommendations for mental health professionals who work with couples that struggle with substance use.     

Trainee psychotherapy effectiveness at a psychodynamic training clinic: a practice-based study

The degree to which clinical experience is a significant factor in predicting positive psychotherapeutic outcomes is an open question. Empirical studies comparing experienced and beginning practitioners on differences in client outcomes have yielded mixed results. While multiple sources have indicated that trainees are generally effective therapists, few of these studies have examined the effectiveness of graduate-level therapists in a psychodynamic training program. In this study, conducted in the United States, we use a practice-based research approach to examine the outcomes of clients working with trainees at a community mental health clinic in the northeast United States. The theoretical orientation identified by the clinic and training program is psychodynamic with an interpersonal and/or relational emphasis. Results indicated that clients working with trainees at this clinic demonstrated improvement across several indicators of symptoms and psychosocial functioning over the time they received treatment. Implications for training and service reimbursement are discussed.