Internal conflicts of specific clients (Reading)

A special ethical issue can rise up when working with LGB clients is what to do when a client comes with the request of changing their sexual orientation. This raises the question of how ethical principles meet the respect of the client’s values and articulated needs. How can a psychologist contract to “change” someone’s sexual orientation while respecting the client’s integrity? Module 6 outlines that conversion therapy is a harmful method and scientific evidence suggests that one’s sexual orientation can not be changed by efforts.

To deal with these dilemmas, therapists must familiarise themselves with the internal conflict LGB persons can experience. The conflicted feelings can manifest externally or internally. Manifestations may include:

• anxiety,
• depression,
• low self-esteem,
• emotional distress,
• feeling of loneliness.

The source of conflict can be:

• the heterosexism of society and the negative associations with homosexuality it proposes,
• the individual’s cultural context: it might explicitly condemn sexual orientations different from the heterosexual one, or in marginalised groups heterosexuality may be a source of privilege, or being part of one group means being excluded from another because of cultural differences,
• religion: most religions are heterosexist and vocalise negative or hostile attitudes toward homosexuality and LGB individuals and relationships (although there are religious groups and communities with progressive views, and the mental health professional should be familiar with such groups).

One’s cultural or religious background may be a central part to one’s identity, or the only source of social support, and if these can’t be aligned with one’s sexual orientation, this can lead to intra-personal conflicts, and “getting rid of” the unwanted part seem to be the easier option for some.

Based on existing evindence of the significant harmfulness of conversion therapy and ideologies, it is unprofessional and unethical to offer such therapeutic outcomes. So what happens when a client seeks to change their sexual orientation? Suggestion is for psychologists is to embody a relatively neutral stance where they don’t accept the request of changing one’s sexual orientation but stays open and normalise the clients feelings towards their sexual orientation. The reason for this is that if the psychologist expresses their view on conversion too harshly, the client may feel violated and would seek conversion elsewhere. Before settling on a desired outcome, therapists need to explore the following:

• client’s biases about sexuality,
• the underlying intra- and interpersonal conflict,
• the idea of an acceptable identity or lifestyle.

In such situations the therapist has a psychoeducational role and they can provide information on conversion therapy, sexual orientation etc. It might be useful to keep the goal setting of the therapy as a dynamic process, and first contract for a deeper understanding of the clients self (not just regarding their sexual orientation).  If the client is reluctant and certainly wants the therapist’s help in changing their sexual orientation or gender identity, the therapist can ask for a follow-up session or ask the client to return to therapy when their wish to change becomes more uncertain, and their feelings and thoughts become more conflicted around this topic.

Manifestations of internalised homophobia

As Module 5 has discussed the topic of internalised homophobia, we are focusing on the clinical aspects of it. Internalised homophobia and transphobia can be a central clinical theme in a practice working with LGBTQI+ people. It can have various effects like:

• lower self-esteem
• self-doubt
• disturbances in self-acceptance to a highly negative self-representation
• self-hatred
• depression
• destructive behaviour (e.g. substance abuse, self-harm, suicide).

To map internalised homo- or transphobia, the therapist should ask about and give place for expression of negative thoughts on someone’s sexual orientation or gender identity. Being affirmative is not only flowers and rainbows, it also means dealing with and accepting the client’s negative feelings regarding their own gender and sexuality. However, providing space for the expression of such feelings doesn’t mean you have to “push” them, as the client might interpret that as homophobia or heterosexism on the part of the therapist. The fact that it is hard to articulate negative feelings towards one’s group which is already marginalised should be taken into consideration when approaching such topics.

As follows for the above mentioned reasons, clients usually don’t arrive at therapy with the topic of internalised homo- or transphobia, but other issues such as problematic substance use. Therapists should also be aware of ego defence mechanisms that might be active because of the internalised homophobia the person experiences. The most common ones are:

• projection
• rationalisation
• identification with the aggressor
• reaction formation
• denial
• repression.

Your clinical psychologist participants are most probably familiar with these defence mechanisms, but it is a good idea to enumerate them together and discuss how these mechanisms can work regarding LGBTQI+ identities.

Also, one of the most common fears which LGBTQI+ persons share are related to the negative future narratives:

• they feel like they will never have a “normal” family,
• they will always be alone,
• the option of having children is perceived to be impossible.

The therapist’s role here is to explore all these options with the client, to accept them as a reality, to respect these fears and to navigate through them. The role of the social context is of huge importance – what are the good role models we can use as examples of a positive alternative, what are the safe spaces where a person can meet up with other LGBTQI+ individuals. Going back to the level of self-acceptance – at what stage is the person with their own awareness and acceptance. The more we normalise their future, the better they will feel. But this also holds the tricky situation of sometimes promising them that everything will be ok – the therapist should refrain from such promises.