Available online at www.sciencedirect.

com

Cognitive and Behavioral Practice 17 (2010) 3744 www.elsevier.com/locate/cabp

Brief Cognitive Behavioral Family Therapy Following a Child's Coming Out: A Case Report
Brian L.B. Willoughby, Massachusetts General Hospital and Harvard Medical School Nathan D. Doty, Massachusetts General Hospital and Harvard Medical School
Few interventions have been proposed for the treatment of families following a child's disclosure of nonheterosexuality. To address this gap in the literature, the current paper outlines a brief cognitive behavioral family treatment (CBFT) for families negotiating the comingout process and illustrates this approach with a case example. Parents' attributions, beliefs, and expectations are explored and challenged. The family is exposed to increasingly salient topics and directed to increase the frequency of positive family experiences. Lastly, the family is taught specific listening and problem-solving skills to bolster adaptive family communication. This paper is among the first to apply an empirically supported therapeutic framework to support family adjustment following a child's disclosure of sexual orientation. The potential usefulness and limitations of this CBFT application are discussed.
ISCLOSURE of one's nonheterosexual identity (e.g., lesbian, gay, bisexual) to parents represents one of the most difficult developmental milestones faced by sexual minority young people (Mallon, 1998; SavinWilliams, 2001; Willoughby, Doty, & Malik, 2008; Willoughby, Malik, & Lindahl, 2006). Coming out to parents typically involves a high degree of anticipation and marked anxiety, as young people fear rejecting and unsupportive reactions to their sexual orientation. The parents of sexual minority children may also face significant distress and discomfort during the comingout process, as they struggle to understand and negotiate their child's nonheterosexual identity. Parents may experience a range of emotional and behavioral reactions, including denial, depression, shame, anger, and guilt (Savin-Williams, 2001; Willoughby et al., 2008), and research suggests that approximately half of parents will respond in rejecting or unsupportive ways following their child's coming out (Robinson, Walters, & Skeen, 1989; Savin-Williams & Ream, 2003). Willoughby and Malik (2006) found that some parents may even respond with extreme negativity, such as calling their child derogatory names (9%), asking their child to leave the home (5%), or withdrawing financial support (8%). A

small but growing body of research suggests that these negative parental reactions relate to poorer psychological and behavioral health among sexual minority young people (e.g., Floyd, Stein, Harter, Allison, & Nye, 1999; Savin-Williams, 1998). In particular, unsupportive reactions from parents have been linked to lower self-esteem (e.g., Savin-Williams, 1989), internalizing problems (e.g., Elze, 2002), substance use behaviors (e.g., Willoughby, 2008), and high-risk sexual activity (e.g., Vincke, Bolton, Mak, & Blank, 1993). Despite growing evidence of the adverse psychological and behavioral consequences of parental rejection, clinical researchers have yet to develop empirically based interventions targeting parental adjustment to coming out. To address this need, this paper outlines a cognitive-behavioral family treatment (CBFT) focused on promoting parental adjustment following a child's disclosure of nonheterosexual identity.

Parental Reactions to Their Child's Coming Out

There is a growing body of literature examining the coming-out process from family-based perspectives (e.g., Heathrington & Lavner, 2008; Willoughby et al., 2008). This research is largely guided by an overarching question: Why do some families deteriorate upon learning of a child's nonheterosexual orientation, while other families adapt and strengthen? Considering the heterocentric social climate of the United States, it is not surprising that parents, like most Americans, may develop core value and belief systems that are incompatible with the notion of homosexuality. It is theorized that these parental belief systems may, in part, account for parental reactions to their child's sexual orientation disclosure

DOIs of the original articles: 10.1016/j.cbpra.2009.08.002, 10.1016/j. cbpra.2009.04.008, 10.1016/j.cbpra.2009.04.007, 10.1016/j. cbpra.2009.04.009

1077-7229/09/3744$1.00/0 2009 Association for Behavioral and Cognitive Therapies. Published by Elsevier Ltd. All rights reserved.

38

Willoughby & Doty (e.g., Armesto & Weisman, 2001; Willoughby et al., 2008). For instance, in an investigation of 27 gay adolescents' perceived parental reactions to coming out, Newman and Muzzonigro (1993) found that the more parents were reported to have traditional family values (e.g., placing importance on marriage and having children), the less supportive they were of their child's sexuality. In another study, Armesto and Weisman (2001) found evidence supporting the importance of causal attributions in prediction parental reactions to coming out. That is, parents attributing a child's sexual orientation to uncontrollable causes (e.g., biology, genetics) may respond more favorably to the disclosure compared with parents attributing sexuality to more controllable causes (e.g., lifestyle choice). While there is clear evidence that values, beliefs, and attributions predict parental reactions to their child coming out, these findings have yet to translate into clinical practice and intervention efforts, which is the focus of the current paper. nett, Foster, Murray, & Bowen, 1996; Willoughby et al., 2008). In fact, the disruptions arising from a child's coming out appear to closely resemble those of other family-based crises, such as a parental divorce, sudden geographical relocation, or disclosure of a teenage pregnancy. Existing evidence supports CBFT as an effective intervention for these types of family crises (e.g., Dattilio & Freeman, 2000). CBFT focuses on the reciprocal interaction of family members' cognitions, emotions, actions, and relationships (Friedberg, 2006, p. 2). According to CBFT, family members' cognitions (e.g., attributions, expectancies, standards) intrude upon and influence virtually every aspect of family life. Thus, a CBFT approach presumes that addressing the cognitive aspects of a problem represents the most effective means of modifying dysfunctional family patterns (Friedberg, 2006). CBFT seeks to help family members identify distress-causing cognitions and replace unhealthy patterns of thinking with healthy ones (Dattilio, 2000; Schwebel & Fine, 1994). Dattilio (2007) outlined a series of key CBFT principles to employ when treating a family in crisis. These strategies have been successfully employed in treating a variety of family-based crises, including unexpected medical emergencies (Dattilio, 2000), parental divorce (e.g., SpillaneGrieco, 2000), and family violence (e.g., Hamberger & Holtzworth-Munroe, 2000). The suggested steps for treating a family in crisis include the following: (a) ascertaining automatic thoughts and schemas of family members and identifying attributions, expectations, and standards from parents' families of origin that have filtered down into immediate family members; (b) testing automatic thoughts and challenging family members' underlying belief structures; (c) providing direct suggestions for alternative behaviors and ways of increasing the frequency of positive family interactions; and (d) bolstering family communication and problem-solving skills. Using this framework, the current paper outlines the application of CBFT in the treatment of families negotiating the coming-out process. It was expected that the empirically supported, goal-focused, and time-limited nature of CBFT would make it an ideal approach for intervening with families adjusting to a child's sexual orientation disclosure. The present report describes a case example of a family that responded favorably to the application of a CBFT approach.

Existing Treatments
Very few interventions have been proposed for the treatment of families following a child's coming out. Within existing case reports, therapists have typically relied on supportive approaches, which facilitate family adjustment through active listening, reflection, and validation. While, anecdotally, supportive approaches appear to have some utility, these interventions lack a clearly articulated theoretical framework. Additionally, the lack of standardized treatment protocols for these supportive approaches makes it difficult to ascertain their effectiveness. We could identify only one theoretically grounded article addressing the treatment of families following a child's coming out. Based on family systems theory and case examples, Lasala (2000) articulated several possible interventions to aid therapists in supporting families thorough the coming-out process, including parent education and strategies aimed at helping the family avoid the topic of sexuality while some time passes. A large part of Lasala's intervention focuses on the child, with individual sessions aimed at helping young people understand their parent's need to grieve. Although Lasala's work has been criticized for its overly narrow focus and lack of empirical support (Green, 2000), it remains the only theoretically grounded approach for assisting parents with their child's coming out. The dearth of existing literature in this area highlights the need for empirically based intervention strategies that target parental adjustment to a child's nonheterosexual identity.

Method
Family Characteristics and Referral Issue Wendy and Angelo Marano1, a married couple of Italian decent in their early 50s, presented at the child and adolescent psychiatry outpatient clinic seeking support in coping with their 18-year-old son's (Peter)
1

A Cognitive-Behavioral Family Therapy Approach

Researchers have conceptualized coming out as a family-based crisis that has the potential to disrupt family boundaries, beliefs, and expectations (e.g., Crosbie-Bur-

Pseudonyms are used to protect patient anonymity.

Cognitive Behavioral Family Therapy Following Coming Out coming out. Peter was attending his freshman year of college (out of state) and was not initially available to participate in the therapy. Mr. and Mrs. Marano reported struggling with Peter's nonheterosexual orientation, which he had disclosed to them 1 month prior during a weeklong visit home. That is, at dinner one evening, after Wendy's questioning about a possible girlfriend, Peter stated, I think I might be gay. Wendy and Angelo reported feeling shocked by their son's coming out, and several hours of questioning had ensued (e.g., Are you sure? How do you know? When did you know?). Wendy and Angelo both reported marked sadness and tearfulness the night of Peter's disclosure. Wendy described feeling depressed and unmotivated since Peter's initial disclosure. Angelo, on the other hand, noted feeling fine, didn't really care, and was trying not to think about it. The couple expressed interest in a brief course of therapy with the goal of better understanding and supporting Peter's sexual orientation. They hoped Peter would join the therapy once he returned home for his summer break from college. Therapist Characteristics The therapist was a Caucasian male completing his internship in child clinical psychology. His primary theoretical orientation was CBT, although he also had training in interpersonal, family systems, and psychodynamic interventions. The therapist's research training to date had focused on parental adjustment to their child's sexual orientation, with a specific focus on the predictors and psychological outcomes associated with parental rejection following coming out. For this particular case, the therapist received supervision from a licensed clinical psychologist guided by CBT and family systems perspectives. Assessment and Case Conceptualization The couple initially participated in a semistructured, 75-minute intake session covering chief complaints and history of the current problem, as well as medical, social, and psychiatric histories. Consistent with a CBFT framework (Dattilio, 2007), the goals at intake were to (a) define the crisis at hand and establish agreement among family members about the central problem, (b) maintain a directive stance in entering into the family to actively introduce change, and (c) begin to ascertain schemas and automatic thoughts of family members. At intake, Wendy and Angelo noted they had sought therapy for similar reasons: to better understand their son's sexual orientation and obtain an expert opinion about how to negotiate their son's recent coming out. Despite their quest for ultimate acceptance, Wendy and Angelo continued to struggle with their son's sexual identity. Wendy, in particular, espoused several stereotypic notions of homosexuality in session. She was worried her son would be dressing in leather and riding a float at one of those parades. Despite wanting her son to be happy and himself, she hoped his newfound sexuality was a phase that would quickly pass. Wendy recalled Peter's exact words during his disclosure, I think I might be gay, and she believed this was an indication of his uncertainty about his sexuality and a sign of hope that he may return to a heterosexual orientation. Wendy oscillated between hope for a change in Peter's sexuality and marked sadness. Peter's disclosure had dashed her expectations for grandchildren and a daughter-in-law, and she wondered if Peter would end-up like [her] cousin, whom she described as a flamboyant, HIV-positive elderly gay man without a significant other. Additionally, it became apparent that Wendy was employing suboptimal coping strategies to manage her distress. She had stopped attending yoga classes at her gym and spent hours laying on the couch watching television. Wendy also reported being preoccupied by thoughts of her son's sexuality, from replaying his coming out in [her] mind to worrying about his future (e.g., whether he would be discriminated against at work). She described her mood as depressed, and noted symptoms of lethargy, mild anhedonia, and sleep problems (i.e., frequent waking in the night). In comparison to Wendy, Angelo engaged in much more cognitive and affective avoidance. At intake, he noted feeling fine and didn't think [his son's coming out] was a big deal. He reported working longer hours since his son's disclosure, as it helped to stay busy. Angelo also presented with marked irritability. He became easily frustrated by others at work and noted more conflicts with coworkers than usual. Further, he avoided political and social discussions with fellow employees. Underlying Angelo's avoidance were feelings of guilt and inadequacy as a father. He attributed the cause of Peter's nonheterosexuality to absent father syndrome, noting he had worked long hours during Peter's development and wished he had engaged in more stereotypically masculine activities with his son. On several occasions, he said to the therapist, You're the expertwas I a bad father? Angelo also spoke about his own family of origin at intake, noting that his father had only expressed love for him during the final weeks of his life.

39

Intervention Process
Following the initial intake, Wendy and Angelo engaged in four, 50-minute couple sessions. Peter planned to join the final two sessions of treatment when he returned home for summer vacation. See Table 1 for a

40

Willoughby & Doty

Table 1

Outline of a brief CBFT following a child's coming out

Session Participating Family Members Session Description

Intake

Parents

Session 1

Parents

Session 2 Session 3 Session 4 Sessions 5 and 6

Parents Parents Parents Parents, child

Define the crisis at hand and establish agreement among parents about the central problem Maintain a directive stance in entering into the family Briefly begin to ascertain schemas and automatic thoughts of family members Obtain relevant social, medical, and psychiatric histories Identify belief systems and automatic thoughts of parents Ascertain attributions, expectations, and standards from parents' families of origin that have filtered down into immediate family members Test and challenge parents' automatic thoughts In vivo exposure to increasingly provocative topics Behavioral activation and direct suggestions for alternative behaviors Increase frequency of positive dyadic and family experiences. Bolster family communication (speaker-listener technique)

brief outline of the session structure and intervention process. Session 1: Identifying Automatic Thoughts and Schemas of Family Members Consistent with Dattilio's (2007) suggested steps in CBFT for family crises, the first session aimed to ascertain automatic thoughts and schemas of family members. Further, the therapist sought to identify attributions, expectancies, and standards from Wendy and Angelo's families of origin that filtered down into their own family. Data collected during the intake session served as the foundation for this initial session. The therapist began the session by presenting several of the automatic thoughts recorded during the intake. Examples of Wendy's automatic thoughts included, This is just a phase, and He will end up like my flamboyant HIV-positive gay cousin. She added other automatic thoughts to the list: I will never be a grandmother, Maybe he will find a girlfriend when he comes home for the summer, and Maybe his gay friend from high school turned him gay. Angelo's automatic thoughts were also recorded. Examples included, My son is gay because I was an absent father, and This isn't a big deal. The therapist then employed the downward arrow technique (Beck, 1995), attempting to uncover Wendy and Angelo's underlying fears and beliefs. Collectively, this line of questioning revealed several core beliefs held by Wendy and Angelo, such as Peter will not lead a normal life, We failed as parents, and Sexual orientation can change. In the latter part of the session, the therapist explored beliefs from Wendy and Angelo's families of origin. Wendy remembered her mother referring to her openly gay cousin as a queer, who was headed nowhere in life. Angelo could not recall his family's notions about sexual orientation, noting that it was a topic that was never discussed. He did reiterate, however, that his own father

had difficulty expressing his emotions and that talking about feelings was off limits. At the end of Session 1, the therapist assigned homework to Angelo and Wendy, providing them with carefully selected readings discussing the biological underpinnings of sexuality, such as subsections from the American Psychological Association's Answers to Questions for a Better Understanding of Sexual Orientation and Homosexuality (http://www.apa.org/ topics/sorientation.pdf). Additionally, as a means of validating their experience, Wendy and Angelo were provided with vignettes describing other parents' thoughts and feelings about their child's coming out. Lastly, the therapist and the couple brainstormed possible ways to have direct contact with someone in their lives that identified as gay (e.g., coworker, neighbor). This strategy was based on the contact hypothesis (Brewer & Miller, 1984), a social psychological principle purporting that contact with other members of an outgroup will reduce preexisting prejudice and result in more positive intergroup attitudes. Wendy and Angelo were also encouraged to join their local Parents and Friends of Gays and Lesbians (PFLAG) chapter. Session 2: Testing and Challenging Automatic Thoughts of Family Members At the beginning of the second session, the therapist introduced the notion of testing automatic thoughts in an effort to challenge the couple's underlying belief structures (Dattilio, 2007). When reviewing homework assigned in the previous session, the couple expressed surprise at the abundance of evidence supporting the biological causes of homosexuality. The readings discussed genetic and hormonal evidence, as well as evolutionary aspects of homosexuality. During this discussion, the therapist revisited automatic thoughts regarding the causal nature of homosexuality that had arisen in the previous session, such as Peter is gay

Cognitive Behavioral Family Therapy Following Coming Out because I was an absent father. When probed by the therapist, Angelo and Wendy did not report reading anything about parental factors involved in the causation of homosexuality. In fact, Angelo noted it was a relief that [he] didn't have anything to do with it. Beliefs regarding the possibility that Peter's sexuality would change were also examined. The readings assigned for homework had been selected to specifically address this cognition and strongly supported the stability of homosexuality. The therapist reiterated this in session. Additionally, the therapist focused on affective changes resulting from this change in perspective. Wendy noted that she dreaded hearing that Peter's sexuality was unlikely to change, but noted acknowledging this fact paradoxically gave her a sense of peace because now [she] could move on. Other beliefs were tested directly in session. For example, Angelo was encouraged to collect evidence from Wendy about his role as a parent, and vice versa. When questioned, both parents described each other as outstanding parents. Angelo described Wendy as loving and the perfect mom. Wendy spoke highly of Angelo's parenting, reminding him that he had coached Peter's soccer team for 5 years and spent more time with [his children] than most fathers. Thus, in the latter part of the session, the therapist revisited Wendy and Angelo's core beliefs (e.g., We failed as parents, Peter will not lead a normal life) and reiterated the evidence gleaned from readings and during the session that challenged these cognitions. Session 3: In Vivo Exposure to Increasingly Salient Topics In the third session, the therapist introduced the concept of exposure. Although not part of Dattilio's (2007) original CBFT approach, exposure has been shown to be an effective strategy in cognitive-behavioral interventions with individuals and families (e.g., Foa & Goldstein, 1978; Friedberg, 2006). By sustaining the heightened emotional state brought on by the stressor, exposure exercises help the individual to eventually habituate to the emotional experience and experience a noticeable decline in distress. Exposure proved particularly useful when working with Angelo, as he tended to avoid his emotional reactions to Peter's sexuality. At times, he also directly instructed Wendy to engage in avoidance behaviors along with him. For instance, when Wendy exhibited signs of depressed mood at home, he would suggest she snap out of it and stop thinking about it. In session, the therapist suggested it might be helpful to focus the couple's attention on sadness and worry surrounding Peter's coming out. The therapist explained that acknowledging and immersing themselves in the emotional reactions could help them habituate to the distress. Consistent with the principles of exposure, it was thought that discussion of increasingly provocative and salient topics in session would eventually help the couple's anxiety subside. In the third session, therefore, the therapist pressed the couple on topics that had been avoided or were yet to be considered. He posed several provocative questions, including, What would it be like if Peter introduced you to his boyfriend? How do you think extended family members will react? and Do you think Peter has thought about having children one day? At various points in the discussion, the therapist collected verbal distress ratings from the couple using the Subjective Units of Distress (SUDs) scales, and highlighted that distress ratings showed self-reported declines throughout the course of the session. The couple's homework assignment at the end of the third session was to monitor instances of emotional avoidance throughout the week and to converse about their anxieties with one another rather than actively avoiding. Session 4: Providing Suggestions for Alternative Behaviors and Increasing Positive Family Interactions Consistent with Dattilio (2007), the goals of the fourth session were twofold: (1) to provide direct suggestions for alternative behaviors and (2) to increase the frequency of positive interactions among family members. Throughout the therapy, it became apparent that Wendy exhibited depressive symptoms consistent with a typical grief or adjustment reaction. In particular, she no longer attended exercise classes and experienced lethargy, mild anhedonia, and disrupted sleep patterns. Thus, the therapist described the principles of behavioral activation (Martell, Addis, & Jacobson, 2001) to the couple and helped them to plan a series of enjoyable activities for the coming week. Wendy committed to attending a yoga class twice during the week, and the couple planned two enjoyable activities (i.e., seeing a movie, eating out at a restaurant). They noted that Peter would return home from college at the end of the week and expressed anxiety about his arrival. Thus, the therapist encouraged Wendy and Angelo to organize several enjoyable family activities that would be rewarding to all family members, explaining that increasing time spent engaging in positive activities would likely decrease the frequency of engaging in negative interactions. Thus, homework included following through on plans made during the session to increase the frequency of positive individual, dyadic, and family experiences. Sessions 5 and 6: Bolstering Family Communication The fifth and sixth sessions focused on introducing Peter into the therapy, providing direct instruction on adaptive family communication skills, and further reinforcing the skills learned during the brief course of therapy. Peter presented as polite and well-spoken young man,

41

42

Willoughby & Doty who appeared willing to engage in therapy with his parents. Upon meeting the therapist, Peter reported that his parents had been providing him with weekly updates over the phone about the progress of therapy. The therapist enlisted the help of Peter's parents in providing him with a brief overview of the therapy thus far, focusing on the positives and highlighting family strengths. Homework from the previous session was reviewed, and the family reported a weekend trip to the bowling alley. The family then committed to another positive family activity during the upcoming week. In the latter part of the fifth session, the therapist introduced the speakerlistener technique, a structured communication paradigm that has been found to be an effective treatment for families in distress (e.g., Dattilio, 2000; Spillan-Grieco, 2000). The speaker-listening technique focuses on increasing the speaker's use of brief I and feelings statements, while encouraging the listener to paraphrase without rebutting or defending. The therapist explained that practice and frequent use of the speaker-listener technique should help to replace maladaptive family communication patterns, such as invalidation, negative interpretation, and escalation. The family practiced the technique in session using a recent disagreement between Peter and his parents about borrowing the car. The therapist intentionally directed the family in choosing a relatively mundane topic in order to optimize their chances of success in implementing these new communication skills. At the end of the fifth session, the family was encouraged set aside time during the week to practice the speaker-listener technique at home, but only for topics not related to Peter's sexuality. In the sixth session, the family reviewed the speakerlistener technique and recounted situations where they had employed the technique successfully and unsuccessfully during the week. The focus then shifted toward a discussion about Peter's sexuality using the speakerlistener approach. The therapist began by asking Peter about when he first became aware of his sexual orientation. With guidance and scaffolding from the therapist, the family was able to successfully engage in a conversation about Peter's sexuality. The therapist also used elements from the discussion to reinforce other skills taught in previous sessions, such as challenging automatic thoughts and misconceptions about sexuality. For instance, in speaking about his sexuality, Peter noted that he had always been gay and was never more sure of anything in his life. This countered his parents' belief that Peter's sexuality might be a phase. following each session using the Global Assessment of Relational Functioning (GARF) Scale from the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994); (b) subjective report of all family members at the end of Session 6; and (c) subjective impressions from the treating clinician following treatment. The GARF Scale is commonly used by family clinicians to rate family functioning on a hypothetical continuum ranging from disrupted or dysfunctional (1 20) to balanced or optimal (81 100). The GARF bears similarity to the Global Assessment of Functioning (GAF) Scale of the DSM-IV, which is a broad subjective rating of psychological, social, and occupation functioning ranging from 1 (suboptimal) to 100 (optimal). On the GARF, particular attention is given to the family's problem-solving skills and organization, as well as the overall family affect (e.g., tone, volume, empathy). GARF ratings have been used as reliable indicators of outcomes in various family treatment studies (e.g., Dausch, Miklowitz, & Richards, 1996). At intake, the Maranos' GARF rating was a 50, indicating the family has occasional times of satisfying and competent interactions, though unsatisfying and unresolved patterns of communication tend to dominate. Following Sessions 1, 2, 3, and 4, GARF ratings increased moderately to 53, 55, 55, and 57, respectively. By the completion of Session 5, the Maranos received a subjective GARF rating of 63, which moved the family into the 60 to 80 range. A GARF score in this range indicates that some conflicts continue to be unresolved, but many are resolved satisfactorily and without complaint. Further, a GARF rating in the 60 to 80 range indicates that a variety of feelings are wellcommunicated, though instances of emotional blocking or tension are evident. Following the final session, the Maranos' GARF rating was 70. It is of note that family was not rated as falling in the 81-to-100 range, which would have indicated a optimal pattern of family interaction, with an atmosphere of caring and sharing of values among all family members. At the end of the final session, Wendy and Angelo subjectively reported feeling more comfortable with their son's sexual orientation. More specifically, they noted less concern about Peter's future and a greater understanding regarding the etiology of sexual orientation. Wendy noted less anhedonia and did not endorse feeling sad for more days than not over the previous 2 weeks. However, she continued to note some sleeplessness and guilty ruminations. Angelo reported less agitation and irritability at work, though had not confided in coworkers about his son's sexuality. Collectively, the family agreed the most enjoyable aspect of the treatment was learning and practicing the speaker-listener technique. By the end of the sixth session, the family was able to successfully engage in a 30-minute, respectful, and appropriate conversation

Results
Findings regarding treatment outcomes for the Marano family are detailed here. Treatment outcome was assessed in the following ways: (a) clinician ratings

Cognitive Behavioral Family Therapy Following Coming Out about Peter's sexual orientation, as judged by the clinician. Wendy and Angelo expressed hope that they would continue to grow more accepting of Peter's sexuality with time. mended by true CBFT practionners (e.g., Friedberg, 2006); however, starting treatment with the parents alone proved to be useful in this case. Meeting alone with the parents initially allowed them to be candid about their thoughts and feelings regarding their son's coming out. Further, without the temptation to shift their attention to their son as the symptom bearer, the parents were better able to focus on their own reactions to the coming out process. This approach is quite different from the intervention outlined by Lasala (2000), which focuses more on helping the youth to cope with their parents' adjustment to the coming-out process. The intervention outlined here is not without limitations. First, to date, it has not been empirically validated as an effective treatment for families adjusting to a child's coming out. Second, CBFT intervention strategies may be less effective when parents hold moral or religious objections to nonheterosexuality. Third, the therapist did not employ standardized assessment tools to track the family's progress. Treatment outcome was defined by subjective report of the family, as well as the therapist's observations and ratings on the GARF. In future case studies employing this approach, it would be important for clinicians to integrate a variety of objective measurements to ascertain the success of treatment. Standardized measures could be employed at the individual level (e.g., Beck Depression Inventory) as well as the dyadic and whole family levels (e.g., Family Environment Scale; Moos & Moos, 1994). Fourth, this study follows a sequence of sessions similar to the sequence outlined by Datillio (2007); however, without empirical data from treatment studies, it is unclear if this sequence needs to be followed explicitly or whether or not all sessions need to be included. That is, at some point, a deconstruction study would be helpful in delineating the most effective aspects of the treatment. Lastly, it is unclear how this treatment approach may differ based on a family's cultural identity. While there is some evidence to suggest that the comingout process differs by ethnicity (e.g., Morales, 1989), there is a need for further commentary and research elucidating the unique interplay between culture and sexual orientation. Despite these limitations, this paper outlines an evidence-based approach, which may serve as a foundation for the treatment of families who are grappling with coming out. Future research in this area should seek to refine and test this unique application of CBFT.

43

Discussion
This report is among the first to apply an empirically supported therapeutic framework in supporting family adjustment following a child's coming out. Although the effectiveness of the above-mentioned intervention has not been explicitly tested, it employs empirically based CBFT principles which have been shown to be effective in treating families in crisis (e.g., Dattilio & Freeman, 2000; Friedberg, 2006). Additionally, the treatment employed here addresses several factors known to predict parental reactions to a child's coming out, such as family resources available to manage the distress and the parental attributions and beliefs about homosexuality (Willoughby et al., 2008). A CBFT approach proved particularly useful in working with the Marano family, as it is directive, goalfocused, and brief in duration. This relatively simplistic and successful case was chosen to best illustrate this application of CBFT. However, it would not be uncommon for additional issues to arise for families in therapy. For instance, in our experience, it is not uncommon for adolescents to show signs of internalized homophobia during the coming-out process, which may pose complications in the latter sessions of the therapeutic process and could warrant direct attention or a referral to an individual therapist. Additionally, unlike the Maranos, parents may present to a therapist with the goal of changing their child's sexual orientation, rather than seeking help for themselves. It is unclear whether or not this treatment could be expanded or modified to treat such families. In this scenario, the first goal would be to validate the parents' desire to change their child's sexual orientation, while highlighting the lack of evidence for sexual reorientation therapy, as well as the negative outcomes associated with this approach (e.g., shame, guilt, further rift in parent-child relationship). Next, it would be important to highlight that clinicians have an ethical obligation not to engage in reorientation therapy, but do have other approaches that focus on bolstering healthy communication and problem solving in families. The therapist could suggest that an optimal starting point might be exploring their beliefs about sexualityand that therapy could serve as a place to test their ideas and beliefs about sexuality. At this point, a sequence of therapeutic steps, similar to those outlined in this paper, could commence, albeit at a slower rate. It is also of note that, in the case example presented, the majority of sessions focused on treating the parent dyad, in part because the child was not initially available for therapy. This approach is not commonly recom-

References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: Author. Armesto, J., & Weisman, A. G. (2001). Parents' reactions to the identity disclosure of a homosexual child. Family Process, 40, 145161. Beck, J. (1995). Cognitive therapy: Basics and beyond. New York: Guilford Press.

44

Willoughby & Doty

Brewer, M. B., & Miller, N. (1984). Beyond the contact hypothesis: Theoretical perspectives on desegregation. In N. Miller, & M. B. Brewer (Eds.), The psychology of desegregation (pp. 281302). New York: Academic Press. Crosbie-Burnett, M., Foster, T., Murray, C., & Bowen, G. (1996). Gays' and lesbians families of origin: A social-cognitive-behavioral model of adjustment. Family Relations, 45, 397403. Dattilio, F. M. (2000). Families in crisis. In F. M. Dattilio, & A. Freeman (Eds.), Cognitive-behavioral strategies in crisis intervention (pp. 316338), 2nd ed. New York: Guilford Press. Dattilio, F. M. (2007). Families in crisis. In F. M. Dattilio, & A. Freeman (Eds.), Cognitive-behavioral strategies in crisis intervention (pp. 327351), 3rd ed. New York: Guilford Press. Dattilio, F. M., & Freeman, A. (2000). Cognitive-behavioral strategies in crisis intervention, 2nd ed. New York: Guilford Press. Dausch, B. M., Miklowitz, D. J., & Richards, J. A. (1996). Global Assessment of Relational Functioning Scale (GARF): II. Reliability and validity in a sample of families of bipolar patients. Family Process, 35, 175189. Elze, D. (2002). Risk factors for internalizing and externalizing problems among gay, lesbian and bisexual adolescents. Social Work Research, 26, 89100. Floyd, F. J., Stein, T. S., Harter, K. S. M., Allison, A., & Nye, C. L. (1999). Gay, lesbian, and bisexual youths: Separation-individuation, parental attitudes, identity consolidation, and well-being. Journal of Youth and Adolescence, 28, 719739. Foa, E. B., & Goldstein, A. (1978). Continuous exposure and complete response prevention of obsessive-compulsive neurosis. Behavior Therapy, 9, 821829. Friedberg, R. D. (2006). A cognitive-behavioral approach to family therapy. Journal of Contemporary Psychotherapy, 36, 159165. Green, R. J. (2000). Lesbians, gay men, and their parents: A critique of Lasala and prevailing clinical wisdom. Family Process, 39, 256257. Hamberger, K. L., & Holtzworth-Munroe, A. (2000). Partner violence. In F. M. Dattilio, & A. Freeman (Eds.), Cognitive-behavioral strategies in crisis intervention (pp. 339361), 2nd ed. New York: Guilford Press. Heatherington, L., & Lavner, J. (2008). Coming to terms with coming out: Review and recommendations for family systems-focused research. Journal of Family Psychology, 22, 329343. Lasala, M. C. (2000). Lesbians, gay men, and their parents: Family therapy for the coming-out crisis. Family Process, 39, 6781. Mallon, G. P. (1998). We don't exactly get the welcome wagon: The experience of gay and lesbian adolescents in child welfare systems. New York: Columbia University Press. Martell, C. R., Addis, M. E., & Jacobson, N. S. (2001). Depression in context: Strategies for guided action. New York: Norton. Moos, R. H., & Moos, B. S. (1994). Family Environment Scale. Palo Alto, CA: Consulting Psychologists Press. Morales, E. S. (1989). Ethnic minority families and minority gays and lesbians. Marriage and Family Review, 14, 217239. Newman, B. S., & Muzzonigro, P. G. (1993). The effects of traditional family values on the coming out process of gay male adolescents. Adolescence, 28(109), 213216. Robinson, B. E, Walters, L. H., & Skeen, P. (1989). Response of parents to learning that their child is homosexual and concern over AIDS: A national study. Journal of Homosexuality, 18, 5980. Savin-Williams, R. C. (1989). Coming out to parents and self-esteem among gay and lesbian youths. Journal of Homosexuality, 18, 135. Savin-Williams, R. C. (1998). The disclosure to families of same-sex attractions by lesbian, gay, and bisexual youths. Journal of Research on Adolescence, 8, 149168. Savin-Williams, R. (2001). Mom. Dad. I'm Gay. Washington, DC: American Psychological Association. Savin-Williams, R. C., & Ream, G. L. (2003). Sex variations in the disclosure to parents of same-sex attractions. Journal of Family Psychology, 17(3), 429438. Schwebel, A. I., & Fine, M. A. (1994). Understanding and helping families: A cognitive-behavioral approach. Erlbaum: Hillside, NJ. Spillane-Grieco, E. (2000). Cognitive-behavioral family therapy with a family in high conflict divorce: A case study. Clinical Social Work Journal, 28, 105119. Vincke, J., Bolton, R., Mak, R., & Blank, S. (1993). Coming out and AIDS-related high-risk sexual behavior. Archives of Sexual Behavior, 22, 559586. Willoughby, B.L.B. (2008). Family rejection, victimization, and outcomes of lesbian, gay, and bisexual young people: The role of negative LGB identity. Unpublished doctoral dissertation, University of Miami, Coral Gables, FL. Willoughby, B. L. B, Doty, N. D., & Malik, N. M. (2008). Parental reactions to their child's sexual orientation disclosure: A family stress perspective. Parenting Science and Practice, 8, 7091. Willoughby, B.L.B., & Malik, N.M. (2006, November). Mothers, fathers, and their gay sons: A study of coming out. Paper presented at the annual meeting of the Society for the Scientific Study of Sexuality, Las Vegas, NV. Willoughby, B. L., Malik, N. M., & Lindahl, K. L. (2006). Parental reactions to their sons' sexual orientation disclosures: The roles of family cohesion, adaptability, and parenting style. Psychology of Men and Masculinity, 7, 1426. Address correspondence to Brian Willoughby, Ph.D., Massachusetts General Hospital and Harvard Medical School, Dept. of Psychiatry, 151 Merrimac St., 5th floor, Boston, MA 02114; e-mail: bwilloughby@partners. org. Received: December 27, 2008 Accepted: April 17, 2009 Available online 27 January 2010