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Cognitive–Behavioral Therapy with Gay,

Lesbian, and Bisexual Clients


Ä

Steven A. Safren
Massachusetts General Hospital/Harvard Medical School
and Fenway Community Health, Boston
Ä

Tracey Rogers
Fenway Community Health, Boston

Cognitive–behavioral therapy (CBT) can be adapted to a wide range of


clinical difficulties and presenting problems that face lesbians, gay men,
and bisexual persons. The following article presents general guidelines for
and two case examples of the use of CBT. The first case is a gay male
struggling with social phobia. This case is an example of how to adapt a
structured, empirically supported cognitive–behavioral treatment focusing
on social phobia to situations that are associated with his sexual orienta-
tion. The second is a woman struggling with multiple issues including
coming out. This case provides an example of how to add specific cognitive–
behavioral techniques to coming-out issues within the context of a more
eclectic, longer-term therapy. © 2001 John Wiley & Sons, Inc. J Clin
Psychol/In Session 57: 629–643, 2001.

Keywords: cognitive–behavioral therapy; lesbian, gay, bisexual clients;


coming-out; social phobia

Changes in mental health care delivery emphasize incorporating short-term, problem-


solving techniques into therapy. Cognitive–behavioral therapy (CBT) is one type of treat-
ment that actively focuses on present-day concerns by helping clients develop effective
coping strategies. There are a variety of specific, empirically supported, cognitive–
behavioral treatment protocols (Barlow, 1994), and many of these treatments show proven
efficacy in well-controlled research. However, most of these empirically supported

Correspondence and requests for reprints should be sent to: Dr. Steven A. Safren, Department of Psychiatry,
WACC-815, Massachusetts General Hospital, 15 Parkman St., Boston, MA 02114; e-mail: ssafren@partners.org.

JCLP/In Session: Psychotherapy in Practice, Vol. 57(5), 629–643 (2001)


© 2001 John Wiley & Sons, Inc.
630 JCLP/In Session, May 2001

cognitive–behavioral treatments focus on specific Diagnostic and Statistical Manual of


Mental Disorders (DSM-IV, American Psychiatric Association, 1994) psychological dis-
orders, and some have argued that the very nature of these studies requires participation
from a relatively homogeneous pool of clients (Seligman, 1995). Challenges for clini-
cians therefore include adapting CBT to a set of problems that do not neatly fit into a
DSM-IV category, formulating a longer term treatment plan when multiple or chronic
concerns exist, utilizing cognitive–behavioral techniques within the context of an eclec-
tic treatment, and conducting CBT with ethnic and/or culturally diverse populations.
This article discusses cognitive–behavioral therapy with lesbian, gay, and bisexual cli-
ents and includes general clinical guidelines as well as two case illustrations.

Clinical Guidelines
When conducting clinical work with gay, lesbian, and bisexual (GLB) clients, aspects of
sexual orientation may play a significant role in the therapist’s conceptualization of the
case as well as his or her treatment plan (see Bernstein & Miller, 1995; Purcell, Campos,
& Perilla, 1996, for reviews). However, there is some suggestion in the literature that
many therapists, when providing treatment to GLB populations, may downplay the role
of sexual orientation when it is actually of high importance to a client, and is at the root
of multiple clinical issues. Also noted are instances in which therapists overemphasize
the role of sexual orientation when it is actually not related to the development or main-
tenance of the clients’ problems. In other cases, therapists may provide clinical services
that can be viewed as biased (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991;
Spencer & Hammer, 1993).
One important guideline for therapists is to identify one’s own assumptions and
beliefs about lesbians, gay men, and bisexual persons. As discussed by Bernstein and
Miller (1995), therapists themselves are not immune to developing a conditioned nega-
tive emotional response to gay men, lesbians, and bisexual persons. This response can
lead to changes in the therapy such as avoidance of issues related to one’s sexuality,
making the initial assumption that a client is heterosexual, or other more subtle behaviors
that would lead to negative consequences for the client openly discussing his or her
sexual orientation. To avoid these types of clinical pitfalls, asking direct, nonjudgmental
questions that convey an acceptance of whatever sexual orientation choices the client
has made can reinforce the idea that therapy is a place where the client can talk about
these matters.
When conducting an initial assessment, it also is important for a therapist to assess
how the client’s sexual orientation fits into a conceptualization of the presenting problem.
In some cases, either the client or therapist clearly sees a connection between the pre-
senting problems and sexual orientation, as when a person presents with anxiety about
coming out to his/her parents. In other cases, the relation between the two may be more
oblique, such as when someone presents with depression and no immediate overt stressor.
When this occurs, a helpful first step can be to ask clients about their thoughts on the
connection between the two. When relevant, this assessment can consider not only the
client’s current feelings about sexual orientation, but also questions that address where
and how any negative thoughts or beliefs about a same-sex sexual orientation may have
emerged or been reinforced (e.g., family, role models, peers). As treatment progresses, it
is important to periodically revisit the question of how sexual orientation may be related
to the focus of therapy for sexual minority clients.
Another general guideline for conducting CBT with gay, lesbian, or bisexual persons
is to acknowledge the impact of societal norms in the development and maintenance of
Cognitive–Behavioral Therapy 631

negative thoughts or beliefs about same-sex sexual attractions. From a behavioral per-
spective, many stressors associated with having a same-sex sexual orientation “punish”
exploration of a nonheterosexual sexual identity. These can include overt acts of harass-
ment, pressure to avoid the process of discovering one’s sexual orientation, isolation
from others, lack of role models, and fears of rejection. Additionally, some national insti-
tutional organizations overtly discriminate against gay, lesbian, and bisexual persons
(e.g., the military), which contributes to negative societal norms about this population.
These chronic stressors can reinforce negative thoughts and beliefs about one’s same-sex
sexual orientation, having a profound influence on one’s mood. As is exemplified in the
case illustrations described next, an important part of case formulation is to help patients
identify automatic thoughts about their sexual identity, utilize techniques such as behav-
ioral experiments and cognitive restructuring to test this type of thinking, and develop
realistic and effective coping responses.
Because issues of isolation are typically of concern for sexual minorities, another
general guideline is to attend to the relative presence or absence of social supports. Due
to the fears of humiliation, harassment, rejection from others, or similar concerns, gay,
lesbian, and bisexual role models are not always readily available to persons in this
situation. In contrast to ethnic minority persons, sexual minority persons do not typically
share their minority status with their family. In fact, the family can be a stressor when
gay, lesbian, or bisexual individuals are struggling with coming-out issues. An important
aspect of planning CBT with lesbians, gay men, and bisexual persons may be to identify
positive environments where the client can meet others who have gone through similar
experiences and can provide support outside of the therapy environment.
Some patients may inquire about utilizing behavior therapy for the purpose of chang-
ing one’s sexual orientation. This approach is generally believed to be ineffective and
may actually be harmful rather than therapeutic (for a thorough review, see Haldeman,
1994). On the basis of science and ethics, it is generally believed that any attempt to do
this would not only be unsuccessful but also may reinforce negative beliefs about oneself
as a result of failed attempts. The American Psychological Association (1997) issued
policy statements on lesbian, gay, and bisexual concerns that acknowledge the risks of
“conversion” treatment. The conclusion of these statements explicitly “opposes portray-
als of lesbian, gay, and bisexual youth and adults as mentally ill” and supports accurate
and appropriate interventions for sexual minority individuals.

Case Illustrations

In the two cases we discuss, the importance of sexual orientation, per se, as a factor in the
clients’ presenting problems and treatment plans varies. This was done for several rea-
sons. First, we sought to provide an example of utilizing an empirically supported, short-
term, cognitive–behavioral approach in working with a gay, lesbian, or bisexual client.
Second, we also sought to provide an example of how to incorporate cognitive–
behavioral strategies into a longer term therapy that addresses a variety of clinical con-
cerns. Third, we sought to show that the general principles of CBT are not different for
gay men, lesbians, or bisexual persons. However, as stated by Purcell et al. (1996), sim-
ilar to incorporating concepts of cultural diversity when working with ethnic groups,
“lesbians and gay men present unique political, social, interpersonal, and personal qual-
ities that define culture” (p. 391). Accordingly, when using cognitive–behavioral tech-
niques with gay and lesbian populations, therapists must exercise some creativity in adapting
specific treatment strategies.
632 JCLP/In Session, May 2001

Although neither case presented was identified as bisexual, we included bisexual


persons when discussing several of the therapy issues as well in the title of the article
because many of these issues, including coming out, being a member of a marginalized
group, and coping with associated stressors, do in fact apply to persons’ issues. However,
we also acknowledge that bisexual persons have unique struggles that are beyond the
scope of this article.

Case 1: A Gay Man with Social Phobia


Presenting Problem/Client Description. At the time of treatment, Michael was a
25-year-old gay, White male who was referred for CBT for social phobia by his primary
care doctor. Michael graduated from college three years earlier and, at the time of treat-
ment, had a job working with computers. Although he had wanted to be in a significant
relationship with another man, he never had been. He had only a few sexual experiences,
none of which was in the context of an ongoing relationship. He had few friends; his
primary social contact was a woman whom he had known since high school, and would
speak to or see her every other week. He also had a few gay-male acquaintances who, he
believed, only called him when they needed a favor. He lived by himself in an apartment
outside of a moderately sized metropolitan city, but had difficulty finding enjoyable activ-
ities to engage in during free time. Weekends especially were difficult because they were
less structured, and, unlike the weekdays when he worked, he was not forced to socialize
with people. During these times, he would experience increased depression, hopeless-
ness, and sometimes suicidal thoughts.
Michael reported that he had been suffering from social anxiety for quite some time.
He believed it began when he was in junior high school, when he began to feel different
from other boys his age. Although he did well in his classes throughout high school, he
had a difficult time with his peers and only had a few friends. During college, his social
anxiety grew in intensity. Michael chose to attend college near his parents’ house, and
although he lived at the school, he went home for most weekends and avoided involve-
ment in most school-related social activities. During this time, Michael began to realize
that his sexual, affective, and emotional attractions were predominately toward other
men. The few friends he had in college were people who lived with him on the same floor
his first year. He recalled that he did not really like them, and they would ridicule people
who were known to attend the school’s lesbian, gay, and bisexual student union. Due to
his social anxiety, Michael felt unable to make other friends and therefore just kept these
acquaintances.
It was not until his senior year that he started to be open about his sexuality to
himself, and discovered places where he could meet other men, but mostly in anonymous
situations. However, after such experiences, Michael would experience strong guilt feel-
ings and would become somewhat depressed. He knew of several gay bars in his area;
however, when he would go to them, he would feel extremely anxious, not talk to anyone,
and, due to his discomfort, leave after only a few minutes.
After graduating from college, Michael found a job developing software applica-
tions. He initially lived with his parents, but after several months found his own apart-
ment. Despite his goal of independence, he developed few friendships during this time.
Michael did meet several acquaintances from occasionally going to a gay church orga-
nization in the area. However, he reported being unsatisfied with these acquaintances
because he felt the relationships were one-sided.
Michael felt that the main reason for not meeting people or maintaining friendships
was his social anxiety. On occasions when new people would approach him or start
Cognitive–Behavioral Therapy 633

conversations with him, he would end the conversation quickly due to his fear that
the other person would not like him, would not find him interesting, or would notice
his anxiety. Despite Michael’s social anxiety, his social skills were quite good. He was
articulate, intelligent, well dressed, and was able to speak openly in therapy about
his difficulties.

Case Formulation. Michael’s treatment was based on Heimberg’s approach to CBT


for social anxiety (Heimberg, 1991; Hope & Heimberg, 1994). However, it was delivered
individually instead of in a group setting. I (SS) began to formulate a case conceptuali-
zation that included the cognitive and behavioral aspects of the problem that led to its
maintenance. Because assessment is an ongoing part of treatment in CBT (Barlow, 1984;
Hersen & Bellack, 1985), I began by establishing a baseline level of anxiety and avoid-
ance. This took the form of collaboratively making a “fear hierarchy,” a list of social
situations that Michael feared or avoided. For each item, Michael rated how much he
feared the situation on a scale of 1 to 100 and how much he avoided the item on a similar
scale. These items were used later as a focus for treatment. To further establish a baseline
anxiety level, Michael also completed the Social Interaction Anxiety Scale (Mattick &
Clark, 1998; Safren, Heimberg, & Turk, 1998), with modification of the item that asks
about “attractive members of the opposite sex” to “people I am attracted to.” He scored in
a range indicative of marked social interaction anxiety.
Feared situations included general social situations as well as gay-related situations.
Typically, items lower down on a fear hierarchy were significantly feared and avoided but
to a moderate degree whereas items higher up included the most-feared situations. From
Michael, lower items (anxiety and avoidance rated from 25–50) included attending the
gay church group, maintaining conversations with people at work, and making certain
types of telephone appointments. Items in the middle (anxiety and avoidance rated 50–75)
included initiating conversations at work, maintaining a conversation with someone at
the gay religious organization (which someone else would start), and assertive situations
such as saying no to unreasonable requests from others. Items that were most intensely
feared (items rated 75–100) were initiating conversations with other gay males, espe-
cially if he was attracted to them, going to a gay bar, and asking someone on a date.
Through this assessment process, we discovered that Michael’s depressed mood and occa-
sional suicidal thoughts were due to his social anxiety and avoidance of social situations
that he wanted to attend. Therefore, treatment was focused primarily on social phobia.
The first several sessions of CBT for social phobia typically include providing psy-
choeducational information about social anxiety and its treatment (Heimberg, 1991; Hope
& Heimberg, 1994). This is done to establish the credibility of treatment and the client’s
confidence in it (Safren, Heimberg, & Juster, 1997). We discussed a simplified cognitive–
behavioral model of social phobia, whereby Michael feared and avoided social situations
due to his negative expectations about social situations (e.g., “I won’t think of anything to
say,” or “I will be humiliated,” “If this person does not like me, then this is evidence that
I am a social outcast”). Also considered was his negative interpretation of the situation
after the fact (e.g., “He thought I was weird,” “He could tell that I was uncomfortable”),
emphasizing that one major area for improvement is to change his type of thinking by
testing negative expectations and accurately interpreting his successful social experi-
ences (Otto & Safren, 2001; Rappee & Heimberg, 1997). We also discussed the impor-
tance of decreasing avoidance of the situations that cause anxiety by slowly, with the use
of these cognitive skills, practicing doing the things that made him anxious.
Because Michael had adequate social skills, social skills training was not a major
component of treatment. Therefore, the main aspects of treatment included cognitive
634 JCLP/In Session, May 2001

restructuring, in-session role plays of anxiety-provoking situations, and in vivo (real life)
exposures to anxiety-provoking situations.

Course of Treatment. After a few sessions establishing the fear hierarchy and dis-
cussing the cognitive–behavioral model of social phobia, we actively began working on
the process of cognitive restructuring. This process involved maximizing adaptive think-
ing strategies about feared and avoided situations that perpetuate the disorder. The pro-
cess of cognitive restructuring involved identifying the negative thoughts that he had
about an anxiety-provoking situation, identifying “distortions” in these thoughts, and
developing a true, objective, “rational response” to them. The rational response was to be
used as a coping statement to help Michael approach anxiety-provoking situations.
To prevent the client from being overwhelmed, I typically start with a situation that
is low on the fear hierarchy. Therefore, we began by talking about attending a meeting of
the lesbian, gay, and bisexual church organization that Michael had gone to in the past.
The following is an example of the type of conversation that we had in which we iden-
tified Michael’s cognitive expectations about confronting a social situation that typically
made him anxious.

therapist: Okay, so what I want you to do is picture yourself thinking about whether or
not you are going to go to an event where there are going to be other single, gay men.
What thoughts immediately come to mind, what do you picture happening?
michael: I’ll be too anxious to talk to anyone.
therapist: Okay, let me write that down. What else is going through your head?
michael: If some guy does start to talk to me, I either won’t have anything to say, or I’ll
be so nervous that he will be able to tell that I am anxious.
therapist: Okay, I see. . . . Now let’s say you do go there, and you do start to talk to
someone, what would be the worst thing about appearing nervous, or someone else
noticing that you are anxious?
michael: Well if I look nervous, he won’t like me, he will think I am attracted to him,
and he will think I am a loser. Basically, he will see my anxiety and reject me.
therapist: So in your mind, looking nervous means being a loser.
michael: Yes. The other thing that goes through my head in these situations is how
pathetic I am. I mean, it’s just ridiculous that I can’t even talk to people because of
anxiousness. It makes me think that if even talking to someone is hard for me, I will
never meet anyone, and never have a relationship.
therapist: I see. Let me ask you one more question. Let’s say you begin to talk with
someone, and the two of you don’t hit it off. What does that end up meaning?
michael: It just makes me think that no one would ever like me, and that I will never
have a relationship ever. I might as well give up.

This conversation is very typical of the style of thinking seen in many people with
social phobia. In the treatment of depression, cognitive therapists refer to this pattern of
questioning as a “downward spiral” (e.g., Beck, 1995) because certain thoughts lead
progressively to perceived consequences that are much worse than the specific situation
would typically warrant. It is easy to see how this type of thinking would lead to avoid-
ance of most social situations or to anxiety in them.
To “restructure” Michael’s thinking, we would systematically go through the list of
his thoughts and identify whether the thought was distorted or realistically not true. To do
this, we looked at a list of typical cognitive distortions (e.g., “all-or-nothing thinking,”
“mind reading”) and used a list of questions to ask about each thought that would help to
Cognitive–Behavioral Therapy 635

dispute them (e.g., “What is the evidence that this is actually true?” “Is there an alternate
explanation?” “What would you say to a friend who is in a similar situation?”). Next is an
abridged version of a cognitive-restructuring dialogue I would have with Michael about
the first thought on the list of thoughts we came up with.

therapist: Okay, so the gist of your thought process is that if you tried to talk to another
guy at this event, you would be anxious and would therefore not be able to have a
conversation; he would see that you are anxious, will think you are a loser, and
therefore you would never be able to meet anyone ever.
michael: Yes.
therapist: That is certainly putting a lot at stake in one conversation.
michael: Well it’s just that if I can’t even have a conversation with someone, how am I
ever going to meet someone?
therapist: I see what you are saying. And, I can also see that if anyone had beliefs like
this about conversations, they too would also avoid them, and feel really terrible
about a conversation if they thought it didn’t go well.
michael: Exactly.
therapist: So, let’s think about this a little more. The first thought is that if you are
anxious then you will not be able to have a conversation. Let’s evaluate this thought
first.
michael: Okay.
therapist: How much do you believe this thought?
michael: I don’t know. Ninety percent, I guess.
therapist: Okay. And what makes you think this thought is true?
michael: I just know it is. Every time I get anxious in conversations, I can’t think of
anything to say.
therapist: Okay. Well let’s look at what we have for evidence of this. Think back to
your first appointment with me. Were you nervous coming into this appointment?
michael: Definitely.
therapist: Right. I think you told me that before. So, before coming into my office, if
you were to rate your anxiety about coming in to therapy and talking about your
problems with me, what would you rate it on a scale from 0 to 100?
michael: It was pretty high. I mean I did not know what to expect. I was not sure
whether or not you would like me. And, I thought that these problems were so weird
that you would think I was a loser.
therapist: So, your anxiety was pretty high.
michael: I guess so. Maybe about 90 or so.
therapist: So, your anxiety was very high, in fact almost as high as it could be.
michael: Right.
therapist: And when the therapy session started, I asked you about your difficulties,
and you were able to have the conversation and tell me about them.
michael: Yes, I guess that is true.
therapist: And you were anxious the whole time?
michael: Well, I was more anxious at the beginning, but less so as it went on.
therapist: Okay, great. This is a major thing to remember. Even though you were very
anxious, you were still able to have the conversation, answer all of my questions, and
even ask some questions on your own.
michael: That’s true I guess.
therapist: And, you also noticed that your anxiety started out high, but decreased as the
conversation went on.
636 JCLP/In Session, May 2001

This type of discussion was used to challenge the association between being anxious
and not being able to communicate. At the end, we eventually developed the rational
response, “I can still have a conversation even if I am anxious,” which Michael was to
test in further situations that cause anxiety. For the remainder of the cognitive-
restructuring dialogue, we then proceeded down the list of other thoughts Michael had
about approaching this situation. Through a similar process of Socratic questioning and
examining the objective evidence, we restructured the other thoughts and came up with
additional rational responses and coping statements such as “ This one person’s opinion
of me does not determine my entire self-esteem.”
We also addressed Michael’s catastrophic thinking regarding taking new risks by
beginning to talk to people. We discussed the natural progression of having a first con-
versation with someone, to having a second conversation with someone, to maybe plan-
ning to do something together, and then maybe becoming friends. Michael also used this
type of restructuring to find more objective evidence for his rational response, “ This one
person’s opinion of me does not determine my entire self-esteem.”

therapist: So, one of the major reasons you become anxious is because you are afraid
that the person will reject you. Is that correct?
michael: Yes.
therapist: Okay, let’s also talk a little more about this, so that we can come up with a
more helpful and realistic way of thinking about a conversation before it even begins.
michael: Okay.
therapist: Taking a couple of steps back, in general, do you think that every person
would be compatible with every other person?
michael: No.
therapist: So if you saw someone you were attracted to, and wanted to know if the two
of you were more compatible, either as friends, or as boyfriends, how could you try
to find that out?
michael: By talking to them, I guess.
therapist: Great. Okay, now let me have you imagine a situation. Let’s say that there are
two guys at a gay, singles social function. One is attracted to the other, and they make
eye contact. He first guy goes up to the other guy and starts talking to him. What are the
chances that the two of them will end up actually liking each other and going on a date?
michael: I don’t know. Maybe 25.
therapist: Great. So let’s say that when you go talk to someone who you are attracted
to, there is about a 25% chance that the two of you will hit it off.
michael: Well if it’s me, it’s probably a lot lower.
therapist: Okay, well if it’s you, what are the chances that if you were to actually go talk
to a guy who you are attracted to at one of these functions, after making eye contact,
that the two of you will hit it off?
michael: Pretty low, probably about 1 in 10.
therapist: Okay, and when you have this conversation, your worst fear is that he will
end up not liking you, and you will end up not having a relationship.
michael: Right.
therapist: So, what are the chances, if you do not talk to him that you will end up
having a relationship?
michael: Ha. Zero, I guess.
therapist: Right. So let’s just say that it’s a given that in order to meet and eventually go
out with a person, even if you are great at having conversations and don’t have social
anxiety, it is going take at least four conversations to have one date. Am I right?
Cognitive–Behavioral Therapy 637

michael: Right, but as I said, for me it’s a lot lower.


therapist: Well, that is something that is testable. But let me ask you this. . . . How
many conversations have you started at these events lately?
michael: None.

These excepts illustrate some examples of the cognitive aspects of Michael’s treat-
ment toward the beginning and middle of his therapy. Throughout the remainder of the
treatment, we continued to use a similar strategy to help him continue to progressively
approach more and more situations that cause him anxiety. His goal was centered mainly
with help around finding other gay male friends. Therefore, we continued to practice
ways to prepare in advance for having conversations and attending gay-related social
events.
Additionally, we worked on how to interpret a successful social situation after it was
over. For example, as with most persons with social anxiety, Michael’s way of evaluating
a success was whether he felt anxiety in that situation. By the end of treatment, we
worked on having Michael use more concrete goals as ways to determine if a social
situation was successful. This meant that he would set goals in advance, such as talking
to two men that he might be attracted to (as either friends or romantically), introducing
himself to both, and asking each two questions. If he met the goals, the situation was
considered a success regardless of whether he was anxious in the situation. Slowly, he
learned through actual experience and cognitive restructuring that he could have conver-
sations even if he was anxious. Consequently, he gradually became less concerned with
the fear of having anxiety in a social situation and therefore actually did experience less
fear in social situations.

Outcome and Prognosis. After about 15 sessions of therapy, Michael, as part of his
therapy, was going to a gay-related event about once a week and had practiced almost all
of the items on his initial fear hierarchy. With various goals of talking to one or two
people at each event, he ended up going on several dates and meeting friends whom he
would see both at these events and outside of them. With respect to his ongoing assess-
ment, Michael’s scores on the Social Interaction Anxiety fluctuated somewhat every few
weeks, but by the end he was scoring somewhat lower than he did when he began.
Although he did not have a relationship, he felt much better about his ability to meet and
speak to friends. Most of the situations still caused anxiety, but his rating of how anxious
each one made him had decreased significantly. Additionally, he developed the strategy
of actively putting himself in situations that would likely cause anxiety but would also
increase the likelihood of him meeting new friends and potential relationships. By actively
participating in social activities, reducing his anxiety in them, and more adaptively inter-
preting situations after they ended, Michael became less depressed. When negative events
invariably did occur (such as a weekend with no social plans), he was better able to cope
by participating in an organized event or by making more adaptive interpretations of his
lack of plans.
Although Michael is a gay client, one might notice that his cognitive–behavioral
treatment would not be radically different if he were heterosexual. The major change of
CBT for social phobia for him was that the situations confronted and the goals were more
oriented toward developing gay friendships and relationships. Of course, as in the treat-
ment of clients with issues at all related to sexuality, it is important to determine the
degree to which developmental aspects of sexual orientation, per se (e.g., coming out to
self, to others, and so on), are to be directly addressed in treatment versus helping clients
638 JCLP/In Session, May 2001

actively cope with areas of their life that cause distress and are somewhat associated with
sexual orientation.

Case 2: The Coming-Out Process of a 24-Year-Old Female

Presenting Problem/Client Description. Anne, a 24-year-old White female, entered


treatment upon the recommendation of her job counselor. Anne was seeing the job coun-
selor to address her long-standing problems with attention and concentration, which resulted
in being laid off from several jobs over the past three years. Knowing Anne’s history of
childhood sexual abuse, the job counselor thought that therapy might be able to address
how this history may be affecting Anne’s job performance. However, another major con-
cern that Anne believed was related to her current difficulties—one that she had been
unable to discuss with anyone else, including the job counselor or a therapist she saw for
during her last two years of college—was that Anne was beginning to realize that she is
a lesbian.
Anne was a long-term therapy patient whose treatment focused on many issues,
including her history of childhood sexual abuse, symptoms of posttraumatic stress disor-
der that affected her ability to concentrate at work, and social isolation as well as her
coming out to herself and others. Her work on coming out did not occur at a particular
phase of the treatment, but rather was an integral part of it throughout. To illustrate the
application of cognitive–behavioral techniques while providing a longer term eclectic
therapy, this discussion will spotlight the coming-out aspect of her treatment. As with the
previous case, the coming-out process often involves an individual having to navigate
major developmental milestones, often with little or no help from others (Savin-Williams
& Cohen, 1996). It also is a process that is unique to lesbians and gay men. Because this
involves overcoming, both internally and externally, many of society’s negative beliefs, it
is well suited to cognitive–behavioral interventions.
When Anne first entered treatment, she was living with her mother and two of her
four older brothers in the home in which Anne had grown up. Anne had moved back
home after graduating from college with a degree in art and art history. Within a few
months of returning home, Anne had wanted to move out, as she felt she was moving
backwards in her growth and was feeling stifled. However, her job performance issues
and frequent lay-offs made this impossible. When she began treatment, Anne was work-
ing as a cashier despite her education and abilities. Although she was performing well
thus far, she was not feeling challenged or excited by what she was doing. Anne had few
friends and often felt quite isolated both at home and at work. She had one close friend
from college whom she often visited on the weekends, but he was the only person in
whom she ever confided.

Case Formulation. As with many clients negotiating the coming-out process, one of
the initial challenges to working on Anne’s negative feelings about herself as a lesbian
was her discomfort in talking about these issues even in therapy. Although Anne had
quite deliberately sought therapy at a clinic known for its sensitivity to gay men and
lesbians (and can be seen as one of her first major steps in coming out), she struggled with
even raising coming out as an area she wanted to explore. She only very hesitantly began
to drop hints that she had always felt “different” from other women, that she was “always
a tomboy,” and that she resented her mother’s assumption that she would date and even-
tually marry a man. Anne also began sharing her wish to attend activities in the lesbian
community.
Cognitive–Behavioral Therapy 639

Once Anne was able to express her questions (albeit obliquely) about her sexual
orientation, I (TR) began to address what seemed to be her fear and tentativeness in so
doing. She began to articulate many of her concerns and negative judgments about les-
bians, a “group” she both feared and to which she wanted to belong. It is very common
for both men and women to exhibit such intense, often mixed feelings during the coming-
out process, and for Anne it was quite easy to accept one of the main tenets of CBT:
namely, that her feelings were a consequence of those cognitions and beliefs that were
learned from and reinforced by negative societal messages. Accepting the theory, how-
ever, in no way signaled the “end” of her negative feelings about herself.
In addressing this aspect of Anne’s treatment, the approach very closely followed
Beck’s outline of the four processes involved in cognitive restructuring: eliciting auto-
matic thoughts, testing automatic thoughts, identifying maladaptive underlying as-
sumptions, and testing the validity of maladaptive assumptions (Beck, Rush, Shaw, &
Emery, 1979).
I began by asking her to join me in an exercise of writing down all her automatic
thoughts about (a) lesbians in general and (b) about what it would mean for her to be a
lesbian. We began the list together during a session, and she then continued to work on it
during the two weeks before we our next meeting. She came back with a two-page list of
what she described as “some pretty nasty words.” As is often the case when people are
asked to make explicit their “automatic thoughts,” Anne was both surprised and disturbed
by how negatively she viewed lesbianism and how frightened she was of “admitting” she
was “one of them.” Her descriptions of lesbians in general included such terms as “fat,”
“angry,” “man-hating,” “serious,” “unhappy,” and several other noncomplimentary adjec-
tives. In terms of her beliefs about herself as a lesbian, her list included such statements
as “I couldn’t have children,” “I would be alienated from my family,” “I would be dis-
criminated against,” and, ultimately, “I would be lonely for the rest of my life.”

Course of Treatment. Addressing Anne’s negative beliefs about lesbians and about
herself as a lesbian was done a bit differently than what is outlined by Beck et al. (1979)
for treating depression. In this framework, the negative beliefs to be addressed are more
commonly those attributes or judgments people make about themselves. Applying these
techniques to beliefs or prejudices against a group of people and the resulting “internal-
ized oppression” when one is a member of this group has not been widely discussed. Yet,
because individuals’ homophobia usually results from a combination of their own feel-
ings, having grown up as a member of this society, and those of the society-at-large, it is
essential that these be examined. Due to long-term development of Anne’s negative beliefs
about lesbians, and consequently about herself, attacking these core beliefs (i.e., Beck
et al., 1990) through cognitive restructuring and behavioral experiments became a focus
of this aspect of her treatment.
Our next step was to look at the list of Anne’s beliefs and develop evidence for
alternative statements. The following excerpt from one of these earlier sessions illustrates
how important it is to begin addressing these negative thoughts early in treatment.

therapist: So, at the top of your list is the word “angry.”


anne: Yeah, well that’s my picture of what most lesbians are like.
therapist: Where do you get those pictures of lesbians?
anne: I don’t know. It just seems that any pictures in the paper, like from the Gay Pride
parade, are of these women with short hair and T-shirts advertising some cause,
yelling as they march down the street.
therapist: Quite an image—where else do you get these pictures or images?
640 JCLP/In Session, May 2001

anne: I don’t know. That’s just out there as who lesbians are. That’s probably why they
are lesbians, right, because they are angry, angry at men.
therapist: So most of your support for the idea that lesbians are angry—that you would
be an angry lesbian—comes from both newspaper or media images, as well from
“society’s atmosphere” for lack of a better word.
anne: Yeah—I had thought it had a little more basis than that.
therapist: Well, maybe it does. But, it’s also possible that it doesn’t. As you remember,
part of this type of treatment is to test your assumptions. Can you think of a way in
which you might be able to check this out?
anne: Well, if I knew other lesbians maybe I could talk to them, but I don’t really know
anyone, or anyone I would feel comfortable enough to talk to about this.

In CBT, it is well known that clients tend to notice that which is consistent with their
thinking rather than evidence against it. It is therefore the job of the therapist to provide
cognitive and behavioral exercises to assist the client in noticing and discovering evi-
dence that is contrary to his or her belief system, and more adaptive. A similar approach
was implemented with Anne and her automatic thought that “lesbians are angry.” As a
result of the previous discussion, Anne and the therapist collaboratively designed a “ther-
apy homework” assignment to test Anne’s automatic thought that “lesbians are angry.”
Because she reported that she did not know any lesbians, she decided to go to a well-
known lesbian bookstore. This would provide direct exposure to lesbians (who would be
in the store) and would provide exposure to literature, magazines, and newspapers that
may not depict images of lesbians in the same way that Anne has always noticed.
One of the reasons that part of the assignment involved behaviorally “seeking out” other
images is that when dealing with prejudices, it is often difficult to generate alternative thoughts
from a solely cognitive approach. Although depressed patients, for example, also may ex-
perience difficulties in generating alternative thoughts, they may at least have some posi-
tive feelings about themselves upon which they can draw. With certain marginalized groups,
however, this is not usually the case, as the negative beliefs have such strong reinforcement
from the society-at-large and there is a lack of visible role models.
The next week, Anne came to our session carrying a backpack that was clearly
loaded down with several books. Upon seeing her collection, I wondered what kind of
“evidence” she brought to share with me. I asked how the week had been in terms of
seeking out other images of lesbians. Anne smiled as she handed me one of the books
opened to a picture of two women sitting on a park bench, deep in conversation (with
T-shirts advertising a cause).

therapist: So, in terms of “evidence” for thoughts, where does this fit in?
anne: These women are smiling and seem so happy and bright. This is actually a picture
I had seen three years ago when I was in college. When I found this picture it reminded
that there was a time when my images of who lesbians are was much more positive.
And then something changed.
therapist: So, do you want to add to our original list now that you are remembering
some other ideas you have?

Anne now had some tools to use in testing her automatic thoughts and identifying her
underlying assumptions. During this time,Anne began to keep a record of her thinking about
lesbians and her own sexual orientation. She became increasingly proficient in identifying
her prejudices against herself and others, examining the evidence for them, and generating
alternative thoughts or associations. At those times when she “drew a blank” and felt stuck
Cognitive–Behavioral Therapy 641

with her more negative thoughts about herself, Anne knew that at least she needed to seek
out possible alternatives through images, works, or talking to others.
Several months later, we began focusing on Anne’s social isolation. Despite the many
internal changes she had been able to make regarding automatic thoughts and core beliefs
about “life as a lesbian,” she still was having difficulty going to places where she might
meet other women for friendship or romance. This phase of the treatment used cognitive
restructuring, much as the previous case illustrated. Anne had many concerns about her
ability to meet people and to be accepted in this new community. Therefore, we looked at
Anne’s anxiety about upcoming events and examined her assumptions about how her
interactions would evolve.
Anne very slowly became more comfortable attending groups and events and soon
developed a small circle of friends and acquaintances. She began to clearly feel that she wanted
to come out to some important people in her life, and yet was becoming increasingly
anxious about coming out to members of her family. This anxiety was significantly dis-
tressing to her, was beginning to interfere with her functioning, and thus, became a clinical
issue to be addressed. There are a variety of times in the process of coming out that people
choose to tell others about their sexual identity. It is therefore important to explore with
each person the reasons for the particular timing as well as the realistic “pros” and “cons.”
When asked about this, Anne said that it was becoming increasingly difficult to live
at home and not be seen for who she is. She also was beginning to be able to imagine
having a relationship with another woman, which brought her to anticipate all the prob-
lems that secrecy about her sexual orientation would bring.
The next phase of the treatment addressed this anxiety primarily using the techniques
of cognitive rehearsal and role play, which involved having Anne imagine the various
steps in meeting and mastering a challenge and then rehearsing various aspects of the
challenge. We began by making a list of the people to whom Anne truly wanted to come
out, but felt she needed help with. I asked Anne to rate each person on a scale of 1 to 10,
with 1 being pretty easy and 10 being very scary. Not surprisingly, the person whom Anne
most wanted to come out to—her mother—also was the one that felt most frightening.
Anne rated several other people as 2 or 3, such as her sister and her friend from college.
I suggested that we first focus our efforts on “rehearsing” coming out to them. In essence,
we used a fear hierarchy, similar to that used in treating anxiety disorders, in the hopes
that Anne could gradually move up the hierarchy and ultimately confront the most anxiety-
provoking but most important task to her—to come out to her mother.

Outcome and Prognosis. By the time Anne’s therapy terminated, she was not only
experiencing less depression and anxiety about her sexual orientation, and therefore mul-
tiple other aspects of her life, but she was also increasingly able to feel pride and comfort
in thinking about herself and her lesbian identity. As stated earlier, our work together
focused only in part on the coming-out issues discussed previously. The negative thoughts
and beliefs about what this meant about her and her life gradually were replaced by a sense
of relief and freedom in being able to define who she is. Anne was able to come out to her
sister and friend, both of whom were quite happy for her that she was able to know what she
needed and happy that she felt comfortable in confiding in them. These reactions took Anne
by surprise, as she had not anticipated such support, and provided her courage for the more
difficult task of coming out to her mother. Although Anne was able to tell her mother about
her sexual identity, her mother’s reaction was less than supportive. Specifically, her mother
expressed many of her own biases about lesbians and the kind of life “they” lead, warning
Anne about what she will most likely lose out on in life. Anne, however, felt that the coping
skills she developed in treatment, including attaining and using social supports and being
642 JCLP/In Session, May 2001

able to talk with them about her feelings about her mother’s reactions, made this situation
manageable. She therefore felt much less vulnerable to her mother’s biases about lesbians
and was able to hold onto her own increased comfort with her identity.

Conclusion
The guidelines and the two cases presented highlight several issues that are common
when treating lesbian, gay, or bisexual persons from a cognitive–behavioral perspective.
Although validated cognitive–behavioral treatment protocols exist for specific disorders,
the roots of CBT lie in the therapist’s ability to conceptualize the case in terms of thoughts,
behaviors, and feelings that result in the maintenance of a client’s difficulties (Barlow,
1984; Persons, 1989).
For Michael, his main clinical difficulty was coping with social phobia. This was
related to his sexual orientation in several ways. The people with whom he wished to
interact were primarily gay. He wanted to be able to put himself in situations where he
would have the chances of meeting a partner, and previously could not do so because of
his social anxiety. Additionally, the original development of his social phobia may have
been partly influenced by his “feeling different” throughout several critical time points in
his social development. His treatment was primarily cognitive–behavioral, and focused
directly and primarily on his social phobia. By doing so, he became able to accomplish
many goals he would have avoided without being able to overcome this clinically signif-
icant and debilitating anxiety.
Anne had several issues in her life, and the illustration represented how to address
one aspect of her comprehensive treatment with cognitive–behavioral techniques. This
included the utilization of CBT strategies to help her cope with coming out, and conse-
quently, deal with her internalized negative beliefs about her sexual identity and herself.
Cognitive–behavioral techniques directly addressed negative thoughts and beliefs about
being a lesbian through the use of cognitive-restructuring and through the actual experi-
ences designed to further test these thoughts and beliefs. Additionally, cognitive–
behavioral techniques were used to help her accomplish the important and difficult goal
of coming out to various important people in her life. As a result, she was able to develop
a more adaptive sense of herself as a lesbian woman and was better able to begin meeting
the challenges in other areas of her life.
These two cases are examples and are not meant to extensively present a compre-
hensive review of cognitive–behavioral approaches to the treatment of lesbians, gay men,
or bisexual persons. When applying CBT to work with lesbian, gay, and bisexual popu-
lations, assessment and treatment interventions are guided by the same general principles
of CBT. However, the role of sexual orientation in influencing thoughts, behaviors, and
emotions should be part of a comprehensive case conceptualization. As with other types
of therapy with ethnic, cultural, or sexual minority persons, the therapist should be cog-
nizant of the necessity of providing care in a nonjudgmental, culturally sensitive manner.
This will include attention to unique stressors that may face a particular marginalized
group and the role of these stressors in the client’s presenting difficulties.

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