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Therapists’ Helpful and Unhelpful Situations With LGBT Clients:
An Exploratory Study
Tania Israel, Raia Gorcheva, William A. Walther, Joselyne M. Sulzner, and Jessye Cohen
University of California, Santa Barbara
The purpose of this exploratory study was to identify a broad range of variables that characterize
psychotherapists’ perceptions of helpful and unhelpful therapy experiences of lesbian, gay, bisexual, and
transgender individuals. In-depth, semistructured interviews were conducted with a diverse sample of 14
psychotherapists to identify such variables and patterns among them. Results suggest that a wide range
of variables, including the therapeutic relationship, therapist response to the client’s sexual orientation/
gender identity, type of presenting concern, and the therapy environment, may affect the therapy
experiences of this population. The data also suggest that factors such as ethnicity, gender identity,
therapy needs, and socioeconomic status should be considered when providing mental health services to
this population. Clients dealing with multiple types of marginalization may be particularly challenging
for practitioners. Implications for future research and clinical practice are discussed.
Keywords: LGBT, lesbian clients, gay clients, transgender clients, psychotherapy
Research on the therapeutic experiences of lesbian, gay, bisex-
ual, and transgender (LGBT) individuals is essential because of the
relatively high rates of therapy use for gay men and lesbians
(Bieschke, McClanahan, Tozer, Grzegorek, & Park, 2000) and the
risk factors associated with sexual minority status, such as in-
creased suicide rates, depression, and experiences of stigmatiza-
tion or victimization (Cochran & Mays, 2000; Remafedi, French,
Story, Resnick, & Blum, 1998; Safren & Heimberg, 1999). In
addition, the American Psychological Association advocates for
services that are responsive to the needs of LGB clients (Division
44/Committee on Lesbian, Gay, and Bisexual Concerns Joint Task
Force on Guidelines for Psychotherapy With Lesbian, Gay, and
Bisexual Clients, 2000), and current literature calls for the inclu-
sion of transgender individuals in discussions of LGB psychology
(Carroll, Gilroy, & Ryan, 2002; Gainor, 2000; Israel, 2005).
Several studies have identified variables that affect the experi-
ences of gay male and lesbian therapy clients in particular. Spe-
cifically, in their seminal study, Garnets, Hancock, Cochran,
Goodchilds, and Peplau (1991) found that the central factors that
made therapy with gay and lesbian clients helpful were therapists
exhibiting gay-affirming attitudes, understanding the effects of
homophobia, helping clients to overcome internalized homopho-
bia, not focusing therapy on the client’s sexual orientation unless
the clients wanted to, and being aware of LGB community re-
sources, among others. Other researchers identified additional fac-
tors that were associated with more positive therapy outcomes for
gay and lesbian clients: prescreening the therapist for gay-
affirming attitudes (Liddle, 1999), type of therapist professional
training (Liddle, 1999), and therapist disclosure of sexual orienta-
tion (Atkinson, Brady, & Casas, 1981). Factors that have been
TANIA ISRAEL received her PhD in counseling psychology from Arizona
State University. She is an associate professor in the Department of
Counseling, Clinical, and School Psychology at the University of Cal-
ifornia, Santa Barbara. Her research and professional interests include
mental health services for LGBT clients, social justice for historically
marginalized populations, and community-based participatory research
methods.
RAIA GORCHEVA is a doctoral candidate in the counseling emphasis in the
Department of Counseling, Clinical, and School Psychology at the Uni-
versity of California, Santa Barbara, where she received her MA in coun-
seling psychology. She is a predoctoral intern in Counseling and Psycho-
logical Services at the University of Pennsylvania. Her areas of
professional interest include the role of emotion in psychotherapy process
and outcome, psychotherapy with LGBT clients, and working with college
students.
WILLIAM A. WALTHER received his MA in counseling psychology from the
Department of Counseling, Clinical, and School Psychology at the Uni-
versity of California, Santa Barbara, where he is working toward his PhD
in the counseling emphasis. He currently works at the University of
California, Santa Barbara, Counseling Services and is a student supervisor
at the Hosford Counseling and Psychological Services Clinic. His areas of
research include LGBT counseling, therapeutic outcomes, service delivery,
and mental health issues facing college age populations.
JOSELYNE M. SULZNER received her MA in counseling psychology from the
Department of Counseling, Clinical, and School Psychology at the Uni-
versity of California, Santa Barbara, where she is working toward her PhD
in the counseling emphasis. Her areas of interest include human sexuality,
individual and societal factors relating to sexual assault, and sexual assault
education and prevention strategies.
JESSYE COHEN received her MS in rehabilitation counseling from Virginia
Commonwealth University, where she is currently a doctoral student in
counseling psychology. Her research interests include health behavior
change, LGBT issues in counseling, the psychotherapy process, and ad-
justment to chronic illness.
THIS RESEARCH WAS SUPPORTED by National Institute of Mental Health
Grant K01MH063305. A poster based on this article was presented at the
American Psychological Association’s annual convention, New Orleans,
Louisiana, August 2006.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Tania
Israel, Department of Counseling, Clinical, and School Psychology, Ge-
virtz Graduate School of Education, University of California, Santa Bar-
bara, CA 93106-9490. E-mail: tisrael@education.ucsb.edu
Professional Psychology: Research and Practice Copyright 2008 by the American Psychological Association
2008, Vol. 39, No. 3, 361–368 0735-7028/08/$12.00 DOI: 10.1037/0735-7028.39.3.361
361
associated with unhelpful therapy experiences for gay and lesbian
clients include viewing homosexuality as a disorder, attributing all
presenting concerns to sexual orientation, lacking knowledge and
awareness about the possible consequences of coming out, using a
heterosexual frame of reference for a same-sex relationship, and
expressing demeaning beliefs about homosexuality (Bartlett, King,
& Phillips, 2001; Garnets et al., 1991; Hayes & Gelso, 1993).
Most of these extant studies have focused primarily on therapist
characteristics, behaviors, or responses to client sexual orientation.
Previous research has not included bisexual and transgender cli-
ents, nor have researchers inquired about variables beyond thera-
pist behaviors, such as characteristics of clients and service agen-
cies, that may have an impact on LGBT clients’ experiences and
outcomes in therapy. There is a need for a more complete under-
standing of the experiences of bisexual and transgender clients and
a need for research that extends previous findings.
The aim of this study is to fill this gap by identifying patterns
that characterize therapists’ descriptions of helpful and unhelpful
situations with LGBT clients. In addition, we explored a wide
range of variables associated with the helpful and unhelpful situ-
ations, including but not limited to the following: client and
therapist demographic characteristics, the type and climate of the
agency where the client was seen, the initial reasons for seeking
therapy, and the therapist’s knowledge of the client’s life outside
of therapy.
The variables characterizing helpful and unhelpful therapy sit-
uations for this study were identified through a content analysis of
phone interviews conducted with therapists who had worked with
LGBT clients. This study represents the second part of a larger
project on sexual minority individuals’ experiences in therapy. The
first phase of the project used a content analysis of interviews
conducted with LGBT individuals who had been in therapy (Israel,
Gorcheva, Burnes, & Walther, in press).
Method
Participants
Participants were 14 therapists: 7 women, 6 men, and 1female-
to-male transgender individual. They described their sexual orien-
tation as heterosexual (n⫽7), gay (n⫽3), bisexual (n⫽2), and
queer (n⫽1); 1 participant did not report sexual orientation.
Participants described their ethnicity as European American/White
(n⫽10), Hispanic/Latino/a (n⫽2), and multiracial (n⫽2). The
mean age for therapists was 44.5 years. Participants held master’s
or doctoral degrees in the following fields: social work, marriage
and family therapy, psychology, health promotion, human sexual-
ity, and counseling. The mean number of years in the field of
counseling/psychology was 12.5. The number of LGBT clients
seen by these professionals ranged from 5 per year to 25 per week.
Although we did not ask specifically about training in LGBT
issues, 4 participants described training placements in which they
worked with LGBT clients, 2 had training in sexuality education or
therapy, 1 conducted research on LGBT issues, and 1 sought out
continuing education on working with LGBT clients. At the time
of the interview, participants worked in the following settings:
university counseling centers, private practice, community mental
health centers, LGBT-specific counseling centers, a prison, and a
continuing care retirement community.
Procedures
Participants were recruited primarily through Listservs of pro-
fessional counseling and psychological organizations. Additional
targeted Internet recruiting included a variety of LGBT agencies
and counseling centers. As a result of these recruitment methods,
65 therapists indicated their willingness to participate in the study
by completing a brief demographic form. Because the goal of the
study was to identify a broad range of variables rather than to
generalize from a representative sample of therapists, we selected
interviewees who varied in terms of gender, ethnicity, sexual
orientation, geographic location, level of education, and field of
practice. Fourteen clinicians were selected for interviews to reflect
the aforementioned diversity.
The research team was composed of one faculty member and
four doctoral students in counseling psychology with expertise on
LGBT issues. The team included members who were gay, lesbian,
bisexual, and heterosexual; female and male; and European Amer-
ican, European, and biracial Asian American. Team members
ranged in age from 24 to 39 years. Several research team members
had prior experience conducting qualitative studies, and all re-
search team members received training in qualitative research
either prior to or during the course of the study.
Semistructured interviews were conducted by the research team
members. Interview times ranged from 19 to 64 min, with a mean
length of 49 min. Each participant was asked to recall one situation
in which he or she was particularly helpful with an LGBT client
and one situation in which she or he was particularly unhelpful.
The participants were instructed that a situation could be a moment
in counseling, a series of sessions with a client, or a particular
point in the participant’s professional history. For each situation,
participants were asked a standard series of questions related to
specific aspects of the situation, including client characteristics
(e.g., sexual orientation, gender identity, ethnicity), aspects of the
therapeutic relationship (e.g., working alliance, the client’s re-
sponse to the therapist’s interventions), the counseling experience
(e.g., interventions used, number of sessions), consequences of the
situation (e.g., impact on the client’s life outside of therapy, impact
on the therapist), and the setting in which the services took place
(e.g., student health center, community clinic, hospital). The com-
plete interview protocol is available at the following url: http://
www.education.ucsb.edu/tisrael/interview_questions/therapist_
administrator.htm.
Each interview was transcribed by a research team member who
had not conducted the interview, and each transcript was audited
by the interviewer. The data analysis was based on ethnographic
content analysis (Altheide, 1987), which enabled the researchers to
adapt categories based on emerging data, as well as to identify
patterns across a consistent coding system. Some categories (e.g.,
consequences of the situation, types of settings) were similar to
those developed for a previous study with LGBT clients (Israel et
al., in press); therefore, responses from the previous study were
used as a start list of response options, and additional response
options were added to reflect the content of the interviews from the
current study. For these categories, the coders identified interview
transcript material, which was reviewed to identify response op-
tions for these categories. A code sheet was developed on which
coders marked participant responses for each category. All re-
search team members who coded a transcript listened to the
362 ISRAEL, GORCHEVA, WALTHER, SULZNER, AND COHEN
interview beforehand. Each interview transcript was coded indi-
vidually by at least three members of the research team, and the
team argued to consensus in cases in which discrepancies in
coding arose.
Some topics (e.g., relationship with the client, consequences for
the therapist) did not lend themselves to simple response options
and required additional qualitative analysis. For each of these
categories, the research team reviewed the interview material
across all participants and developed a code sheet with response
options for that category. The team then coded, reviewed, and
developed consensus in the same way that they did for earlier
categories.
Results
Unless otherwise noted, results are based on the percentage of
the total number of participants. Because participants’ responses
fell into more than one category for certain topics, percentages
may add up to more than 100%. Because of the small sample and
cell sizes, the results reflect descriptive statistics and visual explo-
ration of graphical representations of the data as suggested by
Wilkinson (1999), rather than hypothesis testing; no statistical
comparisons were used. Percentile values presented in parenthesis
are listed in the order of helpful first and unhelpful second, unless
otherwise noted.
Description of Clients
All of the following information refers to therapist descriptions
of clients, because we did not collect data directly from clients in
this study. Most situations involved an individual client; however,
some situations involved multiple clients (14.3% for both helpful
and unhelpful situations). Table 1 summarizes the demographic
characteristics of the clients in the helpful and unhelpful situations.
For the situation in which the client identified to the therapist as
heterosexual, the therapist had information from other sources to
indicate that the client was gay. Therapists tended to provide less
information about clients in the unhelpful situations, which re-
sulted in several clients who could not be categorized in terms of
ethnicity or developmental stage of sexual orientation identity or
gender identity.
We did not consistently ask about socioeconomic status in the
interviews; thus, this information was missing for clients in the
majority of the situations. However, therapists volunteered the
information that clients in 21.4% of the unhelpful situations were
lower income or poor, whereas none of the clients in the helpful
situations were described this way. Although the interviewers
inquired about client employment, relationships, and family of
origin, there were more gaps in the information therapists provided
about the unhelpful compared with the helpful situations in these
areas, which prevented us from identifying any patterns in these
data.
Entry in Therapy
Presenting concerns. The reasons clients initially sought ther-
apy are summarized in Figure 1. The content of the sessions in the
helpful situations (in comparison to the unhelpful situations) was
more likely to address sexual orientation, both when it was the
presenting issue (helpful ⫽57.1%, unhelpful ⫽28.6%) and when
it was not (helpful ⫽50%, unhelpful ⫽21.4%).
Selection of therapists. Clients in the helpful situations were
more likely than those in the unhelpful situations to find their
therapist through a referral from another therapist (helpful ⫽
28.6%, unhelpful ⫽14.3%) or by choosing the therapist from
those available at a particular agency (helpful ⫽14.3%, unhelp-
ful ⫽0%). They were also less likely than clients in the unhelpful
situations to be assigned to their therapist by the agency (helpful ⫽
21.4%, unhelpful ⫽42.9%) or to have had the therapist chosen by
a third party (e.g., parents; helpful ⫽0%, unhelpful ⫽7.1%).
Agency and Environmental Factors Affecting Therapy
Type of setting. The situations occurred in a variety of settings
in which therapy services are offered, including college counseling
centers (helpful ⫽42.9%, unhelpful ⫽28.6%); private practices
(28.6% for both helpful and unhelpful); community mental health
agencies (helpful ⫽7.1%, unhelpful ⫽21.4%); LGBT community
agencies (helpful ⫽14.3%, unhelpful ⫽7.1%); and hospital
outpatient settings (helpful ⫽0%, unhelpful ⫽7.1%). Addition-
ally, there was 1 participant in each of the following settings: a
hospital emergency room, a retirement community resource center,
and a maximum-security prison.
Involvement of other professionals. In both the helpful and
unhelpful situations, other professionals were involved, including
psychiatrists, cotherapists, supervisors, case managers, consult-
ants, and administrators. In the helpful situations, 28.6% of ther-
apists had a supportive supervisor, and none described a problem-
atic supervisor. In the unhelpful situations, 35.7% had a supportive
supervisor, and 28.6% had a problematic supervisor. A supportive
Table 1
Characteristics of Clients in Helpful and Unhelpful Situations
Characteristic
Helpful Unhelpful
%n%n
Gender
Male 35.7 5 57.1 8
Female 42.9 6 14.3 2
Transgender
a
14.3 2 14.3 2
Gender match with therapist
Gender match 57.1 8 28.6 4
Gender mismatch 28.6 4 35.7 5
Sexual orientation
Gay male 35.7 5 50.0 7
Lesbian 35.7 5 0.0 0
Heterosexual (self-identified) 0.0 0 7.1 1
Unspecified (transgender) 14.3 2 14.3 2
Bisexual 0.0 0 0.0 0
Ethnicity
White 64.3 9 57.1 8
Latino/a 7.1 1 7.1 1
African American 0.0 0 14.3 2
Multiracial 7.1 1 0.0 0
Age (median) 25 25
Note. Percentages may not add up to 100% because of missing data and
because some participants fit into more than one category.
a
One transgender client in the helpful situation category was female-to-
male transgender, and one was unspecified; both transgender clients in the
unhelpful situation category were male-to-female transgender.
363
THERAPY EXPERIENCES WITH LGBT CLIENTS
supervisor was characterized as being available and encouraging
or as offering particularly helpful feedback. A problematic super-
visor was characterized as being unavailable, having poor mentor-
ing skills, or being generally unsupportive.
Agency environment. Participants’ descriptions of the agency
environments ranged from those that supported staff (e.g., pro-
vided opportunities for professional development, had liberal ad-
ministrations, or had low turnover rates) to those that lacked
support for staff (including those with hierarchical staff relation-
ships, homophobia, or lack of LGBT staff). In the helpful situa-
tions, 50% of therapists described a supportive environment for
staff, and 7.1% described a lack of support. In the unhelpful
situations, 21.5% described a supportive environment, whereas
14.3% described a lack of support. Confidentiality was specifically
maintained or supported in 21.5% of both the helpful and unhelp-
ful situations, and problems with confidentiality (e.g., crowded
waiting rooms or lack of soundproofing) arose in 7.1% of both the
helpful and unhelpful situations. Some agencies provided other
services in addition to therapy, and in 7.1% of both the helpful and
the unhelpful situations, the client’s use of multiple services was
advantageous. However, problems with multiple services, such as
a lack of shared goals and inconsistency in messages or commu-
nication, were more likely to arise in the unhelpful (28.6%) com-
pared with the helpful (7.1%) situations. Finally, 7.1% of both
helpful and unhelpful situations involved a welcoming office staff.
Regional factors. The situations occurred in almost every re-
gion of the United States, as defined by the U.S. Census Bureau,
and most of the situations took place in urban areas or small towns.
Cultural factors related to the region, community, and office en-
vironment also played a role in both the helpful and the unhelpful
situations. No therapists mentioned an affirming region as part of
helpful situations, but 14.3% said that a nonaffirming region (such
as a state with a pervasive conservative religion) was a factor in
both the helpful and unhelpful situations. On a more local level,
35.7% of the helpful situations were characterized by a nonaffirm-
ing local climate (e.g., campus or town), and 14.3% took place in
an affirming local climate. In the unhelpful situations only, 7.3%
of therapists mentioned a nonaffirming or affirming local climate
toward LGBT individuals.
Content of Therapy
Theoretical approach. More common theoretical orientations
used by therapists in the helpful compared with the unhelpful
situations were cognitive– behavioral (helpful ⫽42.9%, unhelp-
ful ⫽14.3%), humanistic (helpful ⫽28.6%, unhelpful ⫽7.1%),
feminist (helpful ⫽14.3%, unhelpful ⫽7.1%), and narrative
(helpful ⫽14.3%, unhelpful ⫽0%), whereas case management
was used only in the unhelpful situations. Theoretical approaches
distributed equally across helpful and unhelpful situations were
psychoanalytic/psychodynamic (21.4%) and family systems
(7.1%).
Therapeutic alliance. In the helpful situations, the therapeutic
relationship was most frequently characterized by safety and trust
(helpful ⫽42.9%, unhelpful ⫽7.1%) and by being enjoyable or
including the use of humor (helpful ⫽35.7%, unhelpful ⫽7.1%).
Additionally, the therapeutic relationships in the helpful situations
were characterized by validation, acceptance, empowerment, or
affirmation (21.5%), by the establishment of an adequate working
relationships (28.6%), and by the client’s initiation of amicable
contact with the therapist after termination (helpful ⫽21.5%,
unhelpful ⫽14.3%). In an additional 14.3% of the helpful situa-
tions, therapists noted that a strong working alliance was instru-
mental to therapeutic change.
14.3
7.1
7.1
7.1
28.6
21.4
7.1
27.4
0
14.3
14.3
14.3
28.6
14.3
28.6
35.7
57.1
7.1
0 102030405060
Medical
Family of Origin
Adjustment
Recurring Mental Health Issue
Depression
Mandated
Romantic Relationships
Employment
Sexual Orientation/Gender Identity
Helpful
Unhelpful
Reason for seeking therapy
Percentage
Figure 1. Comparison of reasons clients sought treatment in helpful and unhelpful situations.
364 ISRAEL, GORCHEVA, WALTHER, SULZNER, AND COHEN
The most frequent descriptions of the working alliance in the
unhelpful situations included the following: disengaged, aloof, or
combative behavior from the client in session (57.1%); the estab-
lishment of an adequate (rather than strong) working alliance
(35.7%); or a rupture occurring in the working alliance (21.5%). In
21.5% of the situations, circumstances, such as clients being man-
dated to attend therapy, negatively impacted the therapeutic rela-
tionship. In 14.3% of the unhelpful situations, the therapeutic
relationship was negatively affected by the therapist’s experience
of countertransference. In addition, when asked what occurred in
therapy, 21.4% of therapists noted that they failed to create a
connection with the client in the unhelpful situations.
Interventions and client responses. The therapists reported
using a greater overall number of interventions for the helpful
situations in comparison to the unhelpful situations. The most
common interventions therapists used in the helpful situations
were specific techniques (e.g., cognitive– behavioral therapy;
78.6%); psychoeducation or help accessing resources (42.9%);
directive or structured approaches (e.g., setting goals; 35.7%);
validation, normalization, and empathy (35.7%); and self-
disclosure (35.7%). The most common interventions therapists
used in the unhelpful situations were interpretation or feedback
(28.6%), questions or exploration (28.6%), psychoeducation or
help accessing resources (28.6%), self-disclosure (28.6%), and
history taking or testing (28.6%).
Therapists reported that clients responded positively to, utilized,
or were receptive to interventions in 71.4% of helpful situations
compared with 35.7% of the unhelpful situations. Therapists re-
ported that clients were resistant to the therapist or interventions,
including being defensive, avoidant, or challenging, in 50% of the
unhelpful situations, whereas such a reaction was never described
in the helpful situations. In 14.3% of the helpful situations and in
7.1% of the unhelpful situations, the therapist described the client
as actively engaged in therapy, beyond simply responding posi-
tively to interventions. Clients in the helpful situations were also
characterized as receptive to the therapist’s feedback (7.1%) and as
expressing appreciation or positive feedback to the therapist
(7.1%). Finally, in 14.3% of unhelpful situations, the client re-
sponded to the therapist or to the interventions by terminating or
missing sessions, a response that was not described in any of the
helpful situations.
Descriptions of the Situations
At least half of both the helpful and unhelpful situations, 64.3%
and 50% respectively, occurred within the overall experience of
therapy. Approximately one third of both the helpful and unhelpful
situations referred to a specific incident in therapy. An additional
14.3% of the unhelpful situations were related to the client’s
experience with mental health services or a mental health agency.
Helpful situations occurred from 1995 to 2005, and unhelpful
situations occurred from 1986 to 2005.
Helpful situations. Therapists defined the majority (64.3%) of
the helpful situations as ones in which they were knowledgeable,
helpful, appropriate, or affirming in dealing with the client’s
sexual orientation or gender identity. Situations that were coded in
this category included therapists helping clients explore choices
related to identity and coming out, helping a client understand
sexual orientation as a continuum, exploring clients’ internalized
homophobia, and providing validation and resources. Furthermore,
helpful situations were commonly defined by the therapist’s pos-
itive relationship with the client (42.9%), the effectiveness of the
treatment in resolving the client’s presenting concerns or alleviat-
ing symptoms (35.7%), the therapist helping the client gain insight
(28.6%), the therapist focusing appropriately on the client’s con-
cerns (21.4%), and the therapist being nonjudgmental (21.4%).
Less frequently, helpful situations were defined by the therapist
teaching the client new skills (14.3%), disclosing an LGBT-related
experience or his or her own sexual orientation (14.3%), providing
the client with a positive LGBT role model (14.3%), providing
LGBT-related resources (7.1%), using a structured approach to
therapy (7.1%), being available outside of session (7.1%), and
pushing the client to explore difficult topics (7.1%).
Unhelpful situations. Most commonly, the unhelpful situa-
tions were characterized by the therapist exhibiting unhelpful,
harmful, or dissatisfying reactions to the client’s sexual orientation
(21.4%), the therapist evaluating the outcomes of therapy as not
helpful or as harmful (21.4%), the therapist having difficulties
connecting with or engaging the client (21.4%), and the therapist
viewing the client as LGBT without the client disclosing such an
identity (21.4%). An example of the latter involved a therapist who
continued to view her client as gay after he insisted that he was
heterosexual, although the client came out to the therapist after
termination. Other aspects of therapy that defined the unhelpful
situations were the client not trusting the therapist (14.3%); the
therapist not being prepared to deal with LGBT clients with
complex identities (e.g., sexual orientation, gender, and ethnic
identities) or complex presenting situations (14.3%); the therapist
imposing values, judgments, or decisions on the client (e.g., the
therapist disapproving of the client’s lifestyle or way of expressing
his or her gender and communicating this disapproval in the
session; 14.3%); the client experiencing the therapist as not caring,
disinterested, cold, distant, disrespectful, or disengaged (14.3%);
the therapist not focusing on what the client wanted to focus on
(7.1%); the therapist pushing the client to explore topics (7.1%);
and the agency or setting not being LGBT affirming (7.1%).
Consequences of the Situations for the Clients
Helpful situations. The therapists viewed the consequences of
the helpful situations primarily in terms of the client’s improved
quality of life related to an alleviation of the presenting concerns,
the acquisition of new skills, improvement of relationships, or
behavior change (64.3%); positive impact on the counselor– client
relationship (50%); and positive impact on the client’s sexual
orientation, gender identity, or coming out process (50%). Addi-
tional perceived consequences of the helpful situations included
the client’s increased self-acceptance (35.7%), the client’s in-
creased insight or self-awareness (28.6%), the client moving to-
ward goals more quickly (7.1%), the provision of a safe environ-
ment for the client to discuss LGBT issues (7.1%), and a reduction
of the client’s feelings of isolation (7.1%).
Unhelpful situations. The therapists viewed the consequences
of the unhelpful situations primarily in terms of negative impact on
the counselor– client relationship (57.1%) and the client terminat-
ing therapy or interventions (42.9%). This is consistent with the
lower number of total sessions reported for the unhelpful situations
(M⫽19) compared with the helpful situations (M⫽52). Addi-
365
THERAPY EXPERIENCES WITH LGBT CLIENTS
tional perceived consequences of the unhelpful situations included
negative impact on the client’s quality of life in terms of lack of
progress, increased symptoms, damaged relationships, or de-
creased self-acceptance (35.7%); negative impact on the client’s
sexual orientation, gender identity, or coming out process (21.4%);
client’s negative impression of therapy in general (7.1%); client’s
lack of disclosure or exploration of concerns (7.1%); client’s lack
of hope of the possibility of therapeutic change (7.1%); and cli-
ent’s lack of progress in therapy, which led him or her to engage
in potentially harmful behavior (e.g., womanizing to disavow
homosexuality; 7.1%).
Consequences of the Situations for the Therapists
Positive consequences. Only the helpful situations resulted in
participants feeling good about helping the client, such as being
pleased to witness client progress (57.1%) or being more open to
understanding and discussing LGBT issues (7.1%). Other positive
consequences were reported for both helpful and unhelpful situa-
tions: Therapists felt that their clinical effectiveness increased
either with the specific client or overall (helpful ⫽21.4%, unhelp-
ful ⫽14.3%), felt grateful or fortunate to work with the client
(helpful ⫽21.4%, unhelpful ⫽7.1%), increased their knowledge
or insight related to LGBT experiences (14.3% for both), sought
additional training or knowledge on LGBT issues (helpful ⫽7.1%,
unhelpful ⫽14.3%), and expanded or improved services for
LGBT clients in their agency (7.1% for both).
Negative consequences. Unlike the positive outcomes for ther-
apists that arose in both helpful and unhelpful situations, the
majority of the negative consequences emerged from unhelpful
situations uniquely, the most prominent of which was feeling like
a failure (i.e., ineffective, inept, disappointed in clinical skills;
64.3%). Other negative consequences that resulted from only
unhelpful situations were guilt or regret (42.9%), considering a
new job or career (21.5%), and decreased effectiveness with the
client (e.g., closing down or becoming passive; 21.5%). The only
negative consequence for therapists that was present in both help-
ful and unhelpful situations was the experience of negative feel-
ings toward the client, such as dislike, frustration, irritation, or
repulsion (helpful ⫽7.1%, unhelpful ⫽21.5%).
The only consequence for the therapists that was not clearly
positive or negative was working through countertransference,
because this response typically reflected both struggling with
difficult feelings toward a client and learning and growing from
these feelings. This dynamic was present in 14.3% of helpful and
7.1% of unhelpful situations.
Discussion
Implications for Practice
The primary goal of this study was to identify a broad range of
variables that characterize helpful and unhelpful psychotherapy
experiences of LGBT clients. This study represents the second
phase of a larger study on the experiences of LGBT clients in
therapy and complements data collected from interviews with
LGBT individuals who had been in therapy. Because of the ex-
ploratory nature of the study, the findings require confirmation and
should be considered tentative.
Therapists defined the majority of the helpful situations as those
in which the therapist was knowledgeable, helpful, appropriate, or
affirming in dealing with the client’s sexual orientation or gender
identity. This finding is consistent with earlier studies that dem-
onstrated the importance of using LGBT-affirming approaches
when counseling lesbian and gay male clients (Garnets et al., 1991;
Liddle, 1996). Our findings suggest that even if the client’s pri-
mary concern is not sexual orientation, it is likely important that
the therapist display positive and affirming attitudes toward LGBT
issues.
The therapeutic relationship emerged as a crucial variable that
characterized both the helpful and unhelpful situations, as well as
their consequences. We found that creating a positive therapeutic
relationship characterized almost half of the helpful situations,
whereas experiencing the therapist as judgmental, indifferent, cold,
or disaffirming defined almost half of the unhelpful situations.
These findings are consistent with research showing that a good
working relationship is characterized by therapists’ respect for
clients (Bachelor, 1995), clients perceiving their therapist as caring
and skillful (Hersoug, Hoglend, Monsen, & Havik, 2001), client
ratings of therapist understanding, clarity, and supportive attitude
(Price & Jones, 1998), and therapist warmth and friendliness
(Mohl, Martinez, Ticknor, & Huang, 1991). Even though some of
the therapists in the unhelpful situations established adequate
working relationships with their clients, the working alliance in
these situations was never as strong or as positive as in the helpful
situations, and poor working alliance occurred exclusively in the
unhelpful situations.
In terms of consequences of the situations, strengthening of the
therapeutic relationship was one of the most prominent outcomes
in the helpful situations. These findings echo the results of two
large meta-analytic reviews of the empirical literature on therapy
outcome and alliance, both of which yielded a moderate and
consistent relationship between working alliance and therapy out-
come across types of treatment, types of clients, or measures of
alliance (Horvath & Symonds, 1991; Martin, Garske, & Davis,
2000). The deterioration of the therapeutic alliance (including
premature termination) was the most common consequence in the
unhelpful situations. In fact, client resistance to interventions and
early termination were reported only for the unhelpful situations.
This finding is consistent with earlier research associating weaker
alliance and liking the clinician less with early dropout and pre-
mature termination (Mohl et al., 1991). The prominence of the
therapeutic relationship in characterizing the situations and their
consequences may reflect this well-established relationship be-
tween working alliance and helpfulness of therapy. An alternative
explanation is that the therapists used quality of working alliance
as a criterion for defining the situations as helpful or unhelpful;
such an explanation would be consistent with findings that thera-
pist expectancy of usefulness is related to therapist impression of
alliance (Joyce & Piper, 1998). In either case, the therapeutic
relationship seems to be an important aspect of therapy with LGBT
clients, as it is with non-LGBT clients. These results are particu-
larly important considering the relationship between therapeutic
alliance and therapy outcomes (Hayes & Gelso, 1993; Horvath &
Symonds, 1991).
Some types of presenting concerns or client circumstances may
lend themselves more easily to successful treatment than others.
For example, sexual orientation/gender identity was a prominent
366 ISRAEL, GORCHEVA, WALTHER, SULZNER, AND COHEN
presenting concern in the helpful situations. This may reflect that
therapists have a clear understanding of how to work with LGBT
clients when the clients are presenting for sexual orientation/
gender identity, whereas they may not know how to work effec-
tively with LGBT clients’ other concerns (Mair & Izzard, 2001). It
may be particularly challenging for therapists to be helpful to
LGBT clients who are mandated to receive counseling.
The extent to which clients were experiencing multiple disad-
vantages and marginalization differentiated the helpful from the
unhelpful situations, a pattern that is likely the case for non-LGBT
clients as well. Present only in the unhelpful situations were clients
whose gender identity was male-to-female transgender, whose
ethnic group membership was African American, and/or whose
socioeconomic status was low. Also present only in the unhelpful
situations were therapists who were drawing on a case manage-
ment approach. Clients requiring case management services may
have been dealing with a more complex array of issues and less
economic stability than those seeking therapy alone. Even thera-
pists who are knowledgeable about working with LGB clients may
not be familiar with the unique needs of transgender clients (Israel,
2005). Notably, the two African American clients were either
transgender or were required to attend counseling to access other
services offered by the agency. Thus, we cannot draw any conclu-
sions about the role of ethnicity per se, although therapists may be
unfamiliar with the unique cultural contexts of people of color with
same sex attractions (Fukuyama & Ferguson, 2000), and ethnicity
may intersect with other identities and social statuses in ways that
impact therapy. Thus, therapists may need assistance or training
regarding working with transgender clients, LGBT people of color,
and those who have limited access to resources.
Agency variables seemed to influence the helpfulness of the
situations as well. Although supportive agency environments were
present in both the helpful and the unhelpful situations, problems
with multiple services, administrators, or supervision were char-
acteristic only of the unhelpful situations. Thus, having an agency
where staff members feel comfortable and having good, supportive
supervision and affirming administrators may affect the experi-
ences of LGBT clients receiving services at these agencies.
Implications for Research
A larger scale study is necessary to test the patterns we noted, to
investigate intersections among the variables, and to generalize
these results to a broader sample. In particular, it would be bene-
ficial to develop a survey based on the variables we identified in
this series of studies and to collect data from a large sample of
LGBT therapy clients to test these preliminary findings in a
quantitative way.
Furthermore, future research may benefit from inquiring specif-
ically about therapists’ helpful and unhelpful experiences with
various subpopulations of LGBT clients. In this study, therapists
discussed lesbian clients only in the context of helpful situations
and none of the situations involved a bisexual client. Therapists did
not necessarily view all of their experiences with lesbian clients as
helpful; rather, it is possible that therapists more readily recalled
helpful situations with lesbians, because they may have held more
positive attitudes toward this group than toward gay men (Kite &
Whitley, 1996). The absence of situations with bisexual clients
may have been due to therapists not conceptualizing a client as
bisexual, viewing any same sex attractions as indicative of a
lesbian or gay orientation. It is also possible that therapists did not
describe their clients as bisexual because the clients themselves did
not identify as such, even if they had attractions toward or sexual
experiences with both women and men. In the context of a mono-
sexist society, it would not be surprising that clients and therapists
would see a nonheterosexual individual as lesbian or gay, rather
than considering the possibility of bisexuality. Therefore, future
studies should inquire specifically about therapist experiences with
bisexual clients and about unhelpful situations with lesbian clients.
Moreover, the topic of the unique experiences of transgender
individuals in therapy is relatively new and scarcely researched
and, thus, deserves further attention. There is potential for different
experiences, not only of transgender clients in comparison to LGB
clients, but also between female-to-male and male-to-female trans-
gender clients. Future research should attend to the unique expe-
riences of subgroups of LGBT individuals, including ethnic mi-
nority LGBT individuals and those with more complex social,
physical, medical, or psychological issues.
We have identified several additional directions for future re-
search on the basis of these study results. One important issue for
further investigation is how therapists should address sexual ori-
entation when it is not the client’s presenting concern. The findings
of this study indicate that sexual orientation was addressed more
often in the helpful situations than in the unhelpful ones, whether
or not it was a presenting concern. In contrast, other studies have
found that LGBT clients may find it unhelpful to focus on sexual
orientation when it is not the presenting concern (Garnets et al.,
1991; Israel et al., in press). There is a need for more clarity on this
topic. Other important topics for further exploration are the theo-
retical orientations and specific interventions used with LGBT
clients, as well as the different modes of therapy for this popula-
tion, including group, couples, and family therapy. Finally, envi-
ronmental variables, such as agency support and local community
values, should be looked into further to develop a fuller under-
standing of LGBT clients’ experiences in therapy.
Limitations
Although we interviewed a diverse sample of clinicians working
with LGBT clients, this sample may not be representative of all
mental health professionals. The self-selection bias of our recruit-
ment procedure may have resulted in a sample of therapists who
had generally positive attitudes toward LGBT individuals and
were concerned enough with this population to want to participate
in our research. Therefore, these findings have limited generaliz-
ability to the experiences of all therapists working with LGBT
clients. Furthermore, the therapists’ breadth of experience, diverse
settings, and varied professional backgrounds present a challenge
for making generalizations across the situations and to the circum-
stances of other practitioners.
Incomplete client information for the unhelpful situations hin-
dered our ability to identify patterns related to clients’ lives outside
of therapy. One of the reasons for this information gap may be that
clients typically had fewer sessions in the unhelpful situations than
in the helpful situations, so the therapists may have known or
remembered less about them than they did about the clients in the
helpful situations. The incomplete information is also a conse-
quence of gathering data only from the therapist perspective.
367
THERAPY EXPERIENCES WITH LGBT CLIENTS
Finally, a limitation to our retrospective approach was that it was
dependent on participant recall, and sometimes the period of time
since the situation occurred was quite lengthy.
Conclusion
This study, which consists of a content analysis of semistruc-
tured interviews with a diverse group of therapists who have
worked with LGBT clients, identified factors that may contribute
to helpful and unhelpful therapy experiences for LGBT individu-
als, including interpersonal, relational, and environmental factors,
theoretical orientation, specific interventions, demographic char-
acteristics, and conditions of therapy. Furthermore, client charac-
teristics, such as ethnicity, gender identity, socioeconomic status,
types of needs, and the nature of their marginalization, should be
considered when providing therapy for LGBT clients. LGBT cli-
ents who experience marginalization on multiple levels or have
complex needs may present a particular challenge for therapists.
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Received June 13, 2007
Revision received November 15, 2007
Accepted December 10, 2007 䡲
368 ISRAEL, GORCHEVA, WALTHER, SULZNER, AND COHEN
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