Queer Youth in Family Therapy
REBECCA G. HARVEY*
LINDA STONE FISH†
Trends in popular belief about same-sex relationships have undergone noteworthy
change in the United States over the last decade. Yet this change has been marked by stark
polarizations and has occurred at varying rates depending upon regional, community,
racial, religious, and individual family context. For queer youth and their families, this
cultural transformation has broadened opportunities and created a new set of risks and
vulnerabilities. At the same time, youth’s increasingly open and playful gender fluidity
and sexual identity is complicated by unique intersections of class, race, religion, and
immigration. Effective family therapy with queer youth requires practitioner’s and treatment models that are sensitive to those who bear the burden of multiple oppressions and
the hidden resilience embedded in their layered identities. We present case examples of our
model of family therapy which addresses refuge, supports difficult dialogs, and nurtures
queerness by looking for hidden resilience in the unique intersections of queer youths’ lives.
These intersections provide transformational potential for youth, their families and even
for family therapists as we are all nurtured and challenged to think more complexly about
intersectionality, sexuality, and gender.
Keywords: Family therapy; Resilience; Gay; Lesbian; Transgendered youth
Fam Proc 54:396–417, 2015
People always did like to talk, didn’t they? That’s why I call myself a witch now: the Wicked Witch
of the West, if you want the full glory of it. As long as people are going to call you a lunatic anyway, why not get the benefit of it? It liberates you from convention. ― Gregory Maguire, Wicked:
The Life and Times of the Wicked Witch of the West
A
great deal has changed since we published Nurturing Queer Youth: Family Therapy
Transformed (2005), and a great deal has stayed the same. The tide seems to have
turned in the larger discourse around sexual minority acceptance. Queer1 people have
increasing access to equal opportunity in parity laws, the military, gay-straight alliances
in middle and high schools, boy scouts, and recently marriage equality and its benefits in
all 50 states.
*Department of Marriage & Family Therapy, Southern Connecticut State University, New Haven, CT.
†
Department of Marriage & Family Therapy, Syracuse University, Syracuse, NY.
Correspondence concerning this article should be addressed to Rebecca G. Harvey, Department of Marriage & Family Therapy, Southern Connecticut State University, Fairfield, CT. E-mail: harveyr7@southernct.edu
1
We use the term “queer” because it is more inclusive than other terms we have at the moment, and
because we mean to emphasize the liberatory benefits of defining and embracing oneself in the face of
oppression. That being said we encourage people to define themselves and use their own language as much
as possible in therapy.
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CHANGING TRENDS IN POPULAR BELIEF
Greater openness about same-gender sexuality is also reflected in popular attitudes
which have undergone remarkable and noteworthy change in a little more than a decade
(Bowman, Rugg, & Marsico, 2013; Pew Research, 2013). The American Enterprise Institute found that in the year 2000, 59% of the population of the United States indicated that
consensual sex between two adults of the same sex was “always wrong.” In 2010, this
figure decreased to 46% (Bowman et al., 2013), evidence that a small but increasing
majority of the population has shifted toward acceptance and equality for sexual minorities. Though these trends are promising, polls show attitudes of acceptance and tolerance
vary starkly and widely depending on a range of demographic variables. Younger people
are more accepting than older as are people who live in the northeast and the west of the
United States. Those with more education are more accepting, while those who identify as
more religious are less so. Finally, polls suggest that White respondents are more accepting than Black respondents (Bowman et al., 2013). The Pew Research data (2013) support
these findings among the global population: Countries that are more secular and more
affluent tend to be more accepting. Attitudes about homosexuality have remained
relatively stable since 2007 except in the United States, Canada, and South Korea where
acceptance has grown by at least 10 percentage points. Data like these are critical for clinicians to know as they attempt to understand the needs of diverse clients who come from a
wide range of family and community backgrounds and face various levels of oppression
and isolation.
RISKS AND VULNERABILITIES
While changing trends in popular belief have progressed, much has stayed the same.
Clinicians must be aware that while overall trends are positive, homophobia and its
effects have gotten worse for some individuals, families, and communities. Queer youth
are still more likely than their heterosexual counterparts to be at risk for homelessness
(e.g., Cochran, Stewart, Ginzler, & Cauce, 2002; Yu, 2010), suicidality (Centers for Disease Control, 2013), school dropout (e.g., Birkett, Espelage, & Koenig, 2009), addiction
(e.g., Austin & Craig, 2013), risky sexual behavior (e.g., Herrick, Matthews, and Garofalo
(2010), bullying, and school violence (e.g., GLSEN, 2011a,b). Queer youth are also more
likely to be kicked out of their homes because of their sexual orientation or gender nonconformity, a risk with particularly serious consequences, given that family acceptance is
invaluable to youth’s self worth (e.g., Ryan, Huebner, Diaz, & Sanchez, 2009), and that
homeless youth are more likely to be victimized (Cochran et al., 2002; Corliss, Goodenow,
Nichols, & Austin, 2011; Yu, 2010). Cochran et al. (2002) also discovered that queer
youth were at a heightened risk for unprotected sex and for drug abuse while living on
the streets.
INTERSECTIONALITY AND CULTURAL COMPLEXITY
Though cultural attitudes toward homosexuality have become more accepting in the
past decade, the relational and cultural worlds of queer youth remain complex. As mentioned earlier, attitudes toward homosexuality vary widely depending on a host of demographic variables. As a result, queer youth find themselves at intersections of differing or
conflicting cultures based on their race, class, religion, ethnicity, immigration status, and
regional affiliations. As Collins (1998) notes, these intersections are not “passive backdrop
(s) for active family process” (p. 28) in the lives of queer youth. Rather, they actively affect
and change individual and family processes. As a result, the experience of being queer
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cannot be examined separately or understood effectively without also understanding how
queerness intersects with cultural, familial, and individual variables.
The concept of intersectionality and its impact on queer identity is beginning to receive
the attention it deserves. Walker and Longmire-Avital (2013) have shown how nonheterosexual, Black, religious, adults must work to define a positive sense of self in the context of
their religious traditions, their own internalized homophobia, and racism in the larger culture. Han (2009) also addresses the difficulties of people whose racial identities intersect
with the LGBT community: “[G]iven the prevalence of negative racial attitudes in the larger gay community and the homophobia in communities of color, it’s not surprising that so
many GLBTQ people of color come to hold negative perceptions of themselves and of
others like them” (p. 111). Daley, Solomon, Newman, and Mishna (2008) found that race
and ethnicity complicated queer youths’ understanding of the motives of individuals and
groups who bullied them. Queer youth of racial and ethnic minority groups were also
found to frequently use alcohol and drugs even while living at home (Austin & Craig,
2013). Their substance use was due in part to a lack of family support and in part due to
chronic stress brought on by living in the margins without a safety net (Austin & Craig,
2013). Other variables besides race also intersect with sexual identity and complicate the
developmental process of queer youth including geographic location (e.g., GLSEN, 2011a,
b), religiosity, and poverty (e.g., Kosciw & Diaz, 2006).
The concept of intersectionality is reflected in Savin-Williams’ (2001) work on differential developmental trajectories in clients’ lives. According to Savin-Williams, treatment
must be crafted to explore the ways queer youth are:
• similar to all youth facing the same developmental tasks
• different from heterosexual youth and similar to all queer youth because of the shared
stigma they experience
• different from other queer youth because of their various social and cultural contexts,
including oppression
• and finally, different and unique from every other human being because of their singular individual, family, and cultural traits.
Gender and sexuality are uniquely expressed in every person’s specific developmental trajectory. These trajectories intersect and influence queer and cisgendered2 youth alike and
the ways in which their communities respond to them. For example, youth who do not gender conform are often “outed” by their peers and families earlier than those who appear
traditionally gendered and are therefore more prone to bullying, violence, and the other
effects of being different. Clearly queer youth are facing increased vulnerability and in
some cases risk extreme violations in their families and communities. But at the same
time adults who attempt to intervene must be aware of the formidable and sometimes
ambiguous strategies of resilience that queer youth use to thrive. Otherwise we run the
risk of over-focusing on maladaptive behavior, underestimating queer youth and thwarting their agency and the development of their own mastery. Evidence of resilience and
mastery abound. Singh (2013) interviewed transgender youth of color and found many
able to develop resilient responses to devastating experiences. They matured quickly,
learned to advocate for themselves in their school systems, developed complex identities,
and found social support in online communities.
Understanding intersectionality in the lives of queer youth we encounter can help clinicians intervene more effectively in youths’ lives. This is evident in the issue of coming out.
Coming out is often seen as a hallmark of health and therefore a goal for all queer people
2
A person whose gender identity is consistent with their biological sex, i.e., traditionally gendered.
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(Rosario, Hunter, Maguen, Gwads, & Smith, 2001). However, the developmental process
for queer people who have other marginalized identities is complicated in ways that have
not been widely understood or explored (das Nair & Thomas, 2012). This is particularly
true when dealing with vulnerable populations such as youth who are financially, physically, and emotionally dependent. The process of coming out to one’s family must not be
the only measure of successful therapy. Indeed sometimes it is not safe or in one’s best
interest to do so.
The unique map that results from intersectionality must be considered when formulating effective treatment for all youth, especially those who bear the burden of multiple
oppressions. Without consideration of the multiple identities and complex contexts in
which youth are embedded, a one-size-fits-all mentality for treating queer youth fails to
account for the specific liabilities, vulnerabilities, resources, and supports that are unique
to individual youth. das Nair and Butler (2012) call specifically on clinicians to use intersectionality to “. . .recognize how norms function within nonheterosexual communities and
the problematic assumption that there is homogeneity within such communities” (2012, p.
9). Clinical work guided by intersectionality assumes that lived experiences exist in the
midst of various power imbalances and seeks to assist clients in identifying and limiting
the effects of domination in their lives (das Nair & Butler, 2012). How a clinician accomplishes this will depend case-to-case on the salient intersections of a client’s life. These
authors go on to write “. . ..we challenge these frontiers further by examining the possibility for power and agency that these individuals and groups of people experience because of
their intersectional positions” (2010, p. 2–3). In our work, we have connected these ideas
to the concept of resilience and have attempted to foster and nurture queer youth in part
by uncovering hidden resilience in their everyday lives. In other words, gifts that queer
youth have, not despite their queerness but because of it (Stone Fish & Harvey, 2005).
RESILIENCE
Though defining identity is a core developmental task for all youth, it can be a much
more complex task for queer youth, whose lived experience and sense of themselves is outside (or somewhere between) cultural definitions and therefore requires resiliency to
accomplish. Resilience can be defined as the capacity to tolerate and rebound from overwhelming stress in a way that strengthens individuals and makes them more resourceful
(Walsh, 2012). This ability, however, is not merely a characteristic that one either possesses or does not. It is instead a dynamic possibility that is co-created within relationships (Harvey, 2012). Ungar (2004) suggests that individual resilience is a concept that is
negotiated between a person and her/his environment when someone is defined as healthy
amidst experiences that everyone acknowledges as difficult. In short, resilience is nurtured or not in relationships by the presence or absence of key elements. Walsh (2012)
observes that resilience is “. . .encouraged by bonds with kin, intimate partners, and mentors, such as coaches and teachers, who supported their efforts, believed in their potential,
and encouraged them to make the most of their lives” (Walsh, 2012 p. 174).
But queer youth often face disruption of these potentially nurturing relationships
because their lives and lived experiences are so foreign and threatening to parents and
mentors. The stigma of being a sexual minority youth has historically been so devastating
that the vast majority of queer youth simply hid their sexuality, compartmentalizing it
away from the people in their lives who were unable to nurture them. The risks of being
oneself continue for many queer youth today, especially those who live in deeply religious
cultures, rural communities, or those who are members of racial and ethnic minority
groups. When queer youth are members of a minority group, they face a double jeopardy
because these groups tend to be less accepting overall, and because youth face the real
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possibility of being cut off from the very people and contexts which affirm their racial or
ethnic minority identity and buffer oppression. The risks of being outed for these youth
continue to be so certain and terrible that invisibility acts as refuge. As a result, many
queer youth are not afforded familial and cultural contexts which may help them negotiate
or co-construct their resilience as a sexual minority.
However, with the overall cultural landscape changing rapidly the consequences for
queer identity are (in some places and for some youth) not so swift and certain. Many
queer youth who live in less hostile environments come to realize that invisibility is no
longer a refuge but a prison which leaves them at risk for a whole new set of challenges,
namely not being seen, known, or understood for the complex, not neatly categorized
human beings they are. Queer youth have begun to push back at these constraints by living their lives in ways that challenge essentialist notions of sexuality and gender and
threaten the categorical thinking of the vast majority of people.
Queer youth are not immune to traditional gender roles. Rather they tend to incorporate and play with them while increasingly adopting unlabeled identities that better
explain their experience of shifting, nonstable attractions and desires that defy traditional
designation (Diamond, 2008a,b; Dube, 2000; Harvey, 2012; Savin-Williams, 2005). These
youth:
. . . are less interested in anatomy defining them or in society labeling their sexuality. Instead
many glbtq youth push on the boundaries of gender, exchanging the relative safety of labels like
man, woman, gay, straight, masculine, feminine, for something less resolved. They fight for the
freedom of spaces in between these labels. In their world many genders are possible. Words such
as male, female, heterosexual, gay, lesbian, or bisexual seem like anachronisms that increasingly
belong to a previous age. These queer youth may simultaneously have a 5 o’clock shadow and a
French manicure. Some sport buzz cuts and tank tops while going braless. Some boys may look
like girls, while being attracted to boys that look like women. Other girls may look like boys who
fall in love with women who are femme or butch, or both, or neither (Harvey, 2012 p. 326).
Perhaps emboldened by the culture’s apparent softening toward sexual minorities, queer
youth may openly flout the popular notion of fixed gender identity or sexual orientation.
They may do this by repeatedly floating back and forth between labels like gay, bisexual,
and queer. They may do it by flamboyantly combining traditional masculine and feminine
gender performances or by using these gendered performance to pass as cisgendered to
challenge inconsistencies and gaps in fixed categories of gender role, identity, and sexual
orientation.
In sum, an openly queer identity is still widely threatening to traditional heteronormative culture and in those spaces where it is not completely disallowed it is still a somewhat
foreign, not quite knowable path. The result is that the nurturing relationships within
which resilience might be fostered are marred and disrupted. Instead some queer youth
are forced to be other than who they are and actively prevented from developing into the
people they have the natural potential to become. We believe, on the other hand, that
queer youths’ differentiated stance against conforming to normative categories are
strengths and we categorize them as resilient responses to challenging circumstances.
NURTURING QUEER YOUTH: TREATMENT VISION
Effective treatment must be crafted to honor the sociocultural intersections of queer
youth’s lives and the singular way these individual traits, family dynamics, and cultural
junctions produce unique constraints of oppression. Informed by queer theory we understand that the overarching cultural discourse still assumes and privileges heterosexuality
and dichotomous gender expression. Because of this the parts of human experience that
live outside traditional sexual and gender categories are often challenged and go
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unexplored, disallowed, or silenced. Queer theory recognizes the powerful potential in the
disallowed and unexplored. Therefore in our clinical work, we mine for hidden resilience,
identifying resources that have been previously untapped, and help clients utilize these
strengths to lessen domination and oppression in their lives.
Hidden resiliencies are unconventional, ambiguous, and often problematic ways queer
youth protect their burgeoning identities and promote their own growth (Harvey, 2012).
“These strategies, typically viewed as maladaptive by families, schools, religious groups,
and others, may in fact be valid self driven attempts to succeed and grow in unsupportive
cultures and contexts” (Harvey, 2012, p. 25). Understanding hidden resilience is critical to
supporting queer youth precisely because of the complexity which frequently marks their
lives. They often live bi-culturally. An identity and self-expression which make them targets at school or make no sense to their families or communities may make complete sense
in their virtual online world or in the big city they plan to move to and may prove to be life
lines to the adult people they will become.
Informed by queer theory, our treatment challenges rigid beliefs about our identities
and posits that the exploration of the complexity of gender and sexual identities has the
potential to transform all of us, however we identify.
Queer people often are expected to make an accounting of their sexuality. We are expected to
explore, explain, and defend our desires. This process is rich and powerful, especially when it is
not done under threat or coercion. This is a gift that queer people have to offer their straight counterparts (Stone Fish & Harvey, 2005, p. 39).
We have been evolving a model of therapy that incorporates intersectionality along with
key relational processes identified by Walsh (2012) which nurture resilience including
meaning making, positive outlook, which we think of as agency or mastery, transcendence (a connection to something bigger), flexibility, and connectedness to others. Our
family therapy model is also informed by the strength-based three-stage collaborative
change model used to help families who have experienced complex trauma (Barrett and
Stone Fish, 2014). The collaborative change model identifies resources and resiliencies
and helps harness the natural cycle of change so important in healing disrupted relationships.
We use our model of therapy illustrated below to help nurture queer youth to grow up
queer while acknowledging the difficulty inherent in integrating multiple identities. Our
model of therapy helps to foster youth’s resilience to mitigate the multiple layers of oppression they will face, and to identify and limit the effects of domination in their lives so they
can emerge as adults who have been strengthened by the experience, more able, more creative, and more flexible.
Our therapy model fosters youth and family resilience. As youth come out younger than
ever before, families are facing parenting challenges that were unheard of even 10 or
15 years ago and families are face to face with loved ones who are different from them in
profound ways. Patricia Hill Collins writes:
It’s hard to regulate affairs of the heart. This is one reason that segregation remains so deeply
entrenched within American society. If people fail to come into contact with one another as equals
across differences of class, race, ethnicity, gender, immigrant status, sexual orientation and religion, they are unlikely to grant one another full humanity. You can’t love someone you have no
opportunity to meet (Willis et al., 2004).
With this in mind we help family systems recognize their strengths and vulnerabilities
and then mobilize resources to provide effective, on-track parenting (Stone Fish & Harvey,
2005) that allows for increasing humanity and increasing ability to meet, recognize, and
fully love their nonheterosexual children who yearn to be seen and known (to varying
degrees) by their loved ones.
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Creating Refuge
Our three-stage family therapy stage model starts with creating refuge (stage one) so
that we can help clients tolerate difficult dialogs (the second stage). Working through
difficult dialogs helps clients resolve conflict and engage in more intimate conversation,
leading the way to nurture queerness (the third stage). Queering families, what we hope
happens when we nurture the whole individual and family system, leads the way to transformation, which is the ultimate goal of our therapeutic encounter.
We use our therapeutic compassion to create refuge so that family members can share
the worries and fears that are often created by societal messages they have internalized
about how people and families are supposed to behave. We believe that without critical
consciousness (Hooks, 1994) most of us, regardless of our sexual identity, will internalize
societal messages we receive about the truth in cultural “isms.” When clients share homophobic and heterosexist beliefs, we understand these beliefs to be endemic to the complex
normative systems which fostered them. For many people, these beliefs have been learned
without thought or reflection. Critical analysis and subtle challenge in the first stage of
therapy helps some unlearn the most damaging cultural messages they have internalized.
For others we go more slowly. When rigid adherence to homophobic and heterosexist belief
systems consistently block relational processes we respond by assuming good intentions
and a desire for better relationships. With that as the focus, we stay curious and open to
how a better balance might be struck for these individuals between holding on to their
beliefs about sexuality/gender and their desire for improved relationship.
Creating refuge means holding all parts of the family’s motivational forces that prevent
them from supporting one another. We hold the homophobia of the parent and the child (if
either or both exists). We hold the anxiety of parents, who we believe want to be the best
parents they can be but are organized by their worry and fear for their child. We hold the
child’s developmental phase, the tendency for youth to be self-focused, to make impulsive
decisions, to be idealistic and feel invulnerable, and to unrealistically expect their parents
to be on board as quickly as they are in accepting their identity. We also hold the youth’s
mostly unspoken need to be loved, understood, and seen by their parents and their longing
for their parents’ pride and adoration.
For some of the families we see in therapy, this is the first time they have come out to
themselves and to others. Part of creating refuge involves guiding families through the
treacherous waters of self- and other-disclosure. Coming out is both an event and a process, though most people think of it as purely an event. Part of creating refuge, then, is
psychoeducational. We share what we know about the process and inform parents and
caregivers of how vital their role and responses are to their child’s coming out. Even when
adults have religious and moral conflicts with queer sexuality, communicating their love
and affection for their children is incredibly powerful and important for reducing the
youth’s vulnerabilities (Ryan et al., 2009). We also recommend that individuals and families gather resources within their community (if available), and online (e.g., The Family
Acceptance Project). We also warn clients that the raw specificity of their own pain may
make it difficult for them to resonate with someone else’s story or makes social support
difficult to digest. Creating refuge then holds out hope that lives can be eventually more
fulfilling, while also accepting current limitations.
Difficult Dialogs
Difficult dialogs occur when therapists create a space where people can be more honest
with each other and tolerate their differences with compassion and kindness. We must
first make room for a variety of meanings and truths. This often starts with therapists
paying attention to the multiple cultural locations that may situate the therapist and
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family in different and competing communities, paying particular attention to the dynamics of hierarchy, oppression, and marginalization. We begin to explore by asking questions
about how these differences and dynamics currently affect the relationships in the room.
We then leave space for family members to come to know parts of themselves and each
other they may not previously have been familiar with or comfortable sharing. Difficult
dialogs are inherently stressful, which is why they are so often avoided both in and out of
the therapy office. When clients risk these dialogs and experience a deepening intimacy
the stress of engaging in them often feels worthwhile.
Many families who present with adolescent difficulties suffer from what we call
“off-track parenting,” in which the parenting process has been derailed because parents
have stopped knowing their children. This is especially apparent when youth are queer
and aware that who they are is not acceptable to their families so they may hide themselves away. We believe that youth need love and limits and actually will respond to limit
setting when it is done in a context of being known. For example, if a heterosexual teenaged girl is feeling confused by inappropriate attention she is receiving from an older,
teenaged boy, she might be able to talk with her mother about appropriate responses.
Then her mother might decide to set a limit and not let the daughter go to the party this
weekend in which parents will not be home. The youth may resist this limit while simultaneously experiencing it as a relief. On the other hand, if a lesbian teenaged girl is feeling
the same way but has not come out to her parents, she misses the lesson and the valuable
limit setting that does not occur. Instead, the youth may doubt herself or misread her own
safety gauge and put herself in a situation that she is unable to handle alone. When parents are on track and know their children, they can provide guidance that youth crave
even though most would never admit to it. Difficult dialogs help create openings so that
parents move back on track and the relational process of helping youth grow and develop
can continue and be meaningfully expanded upon.
Nurturing Queerness
We help families accept and nurture their children’s burgeoning queerness, integrating
it into a more expanded and complex version of family life. Part of this process is honoring
the hidden resiliencies and the gifts that queerness brings and part of this process is
expanding the family’s worldview in unexpected ways. Many queer youth have an inherent sense of solid self (Kerr & Bowen, 1988) that is not taught but simply known. They
know they are different and despite harsh consequences find ways to persist. When families can tolerate the dissonance of queer differences their queer children begin to trust
that it is safe to share honest information about their experiences in the world. This is a
gift as it offers all members of a family an expanded vision of the world that many families
have not had the privilege of exploring. Queer youth teach their families and their
extended communities about the pain and the joy of life lived, from an early age, with the
wisdom that things are more complex than they seem.
COMPOSITE CASE EXAMPLE JAMAL AND DENISE
Jamal was a 15-year-old African American male when he and his mother were first
referred for therapy. He was born and raised in a mid-size city in the Southern United
States within a close knit African American community that was centered around a Southern Baptist church. Jamal was an only child and had always been very close to his mother.
He was small for his age and had been consistently bullied for being shy, gentle, and not
masculine enough. Denise, Jamal’s mother, mentioned in the first session that beginning
when he was around 8 or 9 some of her family members began making comments about
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Jamal’s effeminate behavior, teasing him for being “too soft” and “too close to his momma”
and finally joking about whether he was “a girl in a boy’s body.” Denise, too, began worrying about how “soft” Jamal was and when he was 13 she moved with Jamal to a Northeastern city so that she could look for a better paying job and Jamal could connect with his
uncles who would help to “bring out his more masculine traits.” They currently attend a
Black Baptist church and are very involved in the church socially.
Creating Refuge
Two months prior to their referral for therapy (by a family friend), Denise read a text
message string between Jamal and another young man from his school that clearly indicated his sexual interest in men. Denise was repulsed and horrified by this information
and Jamal was clearly humiliated. He denied her accusations about his “abnormal lifestyle” and became withdrawn and mute. Denise had not told any of her family members
about the text message specifically but she had begun more indirectly talking to her
extended family about her concerns about Jamal’s softness. She described her brothers as
increasing their efforts at trying to toughen up Jamal; they encouraged him to play sports,
talked with him more about women and sex and were openly disparaging of effeminate
men, including “faggoty acting men.”
The therapist for the family, Stephanie, was a 38-year-old White, heterosexual mother
of two. When Stephanie met the family for the first time, the only information she had
was that the family had parent/child conflict. She agreed to meet with both Denise and
Jamal for the first time together. When Stephanie asked them what brought them to therapy Denise began silently crying. She gathered herself together and explained that she
had always been very close to Jamal and said, “This whole situation is my fault.” Jamal
sunk deeply into the couch while Denise went on to describe how far away she felt from
her son. She was tearful and loving and then in turn aggressive and spiteful saying that
Jamal was ungrateful and disgusting to her. Stephanie was taken aback in the moment by
the intensity of Denise’s anger toward Jamal and concerned that while it was important
that Denise express her anger it was equally important that therapy be a safe place for
Jamal. She decided then to break the session in half, meeting individually with Denise
first and then Jamal.
When alone with Denise, Stephanie intervened first by saying “there is a lot I still don’t
understand about the pain you are experiencing. But let me start by saying how clear it is
to me how much you love your son and how worried you are for him. What has gotten you
so worried?” Denise responded that she did not think therapy would work but that she
was at her wits end. She explained about finding the text messages and concluding that
“my baby is going gay and I do not know how to save him from that sinful lifestyle.” Stephanie mirrored back “so you are thinking that your son is gay? What has Jamal said
about this?” Jamal apparently completely shut down as soon as his mother confronted him
with this information. He put his head down and said nothing. He stayed silent about the
subject for the entire 2 months prior to therapy. Denise mentioned that during this time
she had brought him to church frequently but was afraid to tell anyone at the church for
fear they would be outright hostile to him and to her for being a single mother who could
not raise her son right.
Stephanie So your fear is that Jamal is gay. What would it be like for you if Jamal were
gay?
Denise
It has been like a two month long nightmare I can’t wake up from.
Stephanie What is the worst part?
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Knowing he lied to me, feeling like he is going down the path of sin into some
alternative lifestyle condemned by God and thinking it is my fault because I
could not keep his daddy in his life. I was too soft on him and raised him to
be too close to women.
Stephanie So part of what is so hard is that your faith is so vital and you are fearful
that you and he will be rejected. And another part is that you are feeling at
fault for having caused this and worried that he will be separated from God
because of it?
Denise
Yes, that’s it.
Stephanie That is a great burden to bear on your own. Do you know of other parents
who have had to deal with something like this?
Denise
Mostly people do not discuss this. I have heard of some people who this has
happened to but I don’t know them personally. My friend Loreana referred
me to you. She is more open-minded. She sees how Jamal is being treated.
She doesn’t know about the text message but I think she worries for him.
She is always telling me about homosexual people she knows who are good
people. But I do not know any church-going homosexuals. I don’t think they
would be allowed. I want him (Jamal) to know Jesus. . . to stay in community
with his people.
Stephanie spent a few more minutes asking Denise about her faith and what
it meant to her and came to understand that a very real and frightening
concern for Denise was that being gay would mean Jamal would be
ostracized and isolated from a tightknit community of African American
folks who shared similar life experiences and looked out for each other.
Stephanie It is important that you know there are other people who go through this.
You are not alone even though I know it feels like that right now. There are
other parents who have felt similarly to the way you are feeling. It sounds
like just as you are hurt and confused Jamal may be as well. What do you
think he is thinking and feeling?
Stephanie then asked Denise about what Jamal was like as a person outside
of the current worries that Denise had about him. Denise was readily able to
talk about how proud she had always been of Jamal’s grades. She reported
that he was a smart young man and his respectfulness and kindness made
him popular especially with the older generation in their church.
During the first session with Jamal, Stephanie began by asking him his view of what happened. Jamal was clear that he was no “faggot” and that his mother had this idea about
him that was not correct. Stephanie accepted this and told Jamal that clearly his mother
loves him very much and that she is worried about him. Jamal appeared angry saying that
he wished everything could “just go back to normal.” Stephanie wondered what going back
to normal would look like and Jamal told her that his mother would not be watching over
him every minute. “She won’t leave it alone. She is talking about this text message all the
time. Making it a big deal. I just thought this guy’s abs looked good that was what I was
talking about. I wished I could have abs like that.” Stephanie empathized and suggested
that it seemed like his mother and he were going through a lot. She de-emphasized the
issue of sexual orientation and framed the issue as being about a distance that had developed between Jamal and Denise sensing that even if Jamal was gay, he was not ready to
discuss his sexuality with his mother (nor with the therapist). Stephanie brought them
together to share that she had learned in the first session that they were a strong family
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with a lot of love between them. Stephanie shared how much they are missing each other
and how much hurt had been built up between them. She also told Denise and Jamal that
she would like to continue to meet with them separately for a little while to learn how she
could best help them to repair their connection to one another.
In this first session, Stephanie worked hard to create a refuge, a space where both
Denise and Jamal could feel safe and understood and a focus for treatment could
develop. Stephanie did this by using compassion and curiosity to learn about the unique
elements of this dilemma from both points of view. She did not challenge either Denise’s
conservative religious beliefs or Jamal’s assertion of heterosexuality but rather accepted
these and attempted to learn more. Stephanie also slowed down the process because she
sensed that Denise was moving too quickly to get to some resolution before being clear
about what the actual problem was, especially considering that Jamal was denying a
minority sexual identity. Stephanie separated Denise and Jamal so that Denise could
talk about her revulsion, fear, and hopes for Jamal as she needed to without saying
something that might further damage the parent/child relationship. She also separated
them so that Jamal could, when he was ready, openly talk about his sexuality, his relationship with his mother, and other parts of his life that might be causing difficulties for
him.
Stephanie assumed Denise’s love and dedication to her son and she also recognized that
Denise’s parenting was off track in moments influenced by vulnerabilities in the intersections of race, class, gender, and religion in Denise’s life. This was most clear in her self-recriminations and guilt about her shortcomings as a single African American mother. This
along with her homophobia was pushing Denise to do and say things that were damaging
their relationship and decreasing her influence with her son. Eventually Stephanie would
share this directly with Denise. For now she began to slowly move Denise’s parenting
back on track by allowing Denise space to openly talk about her fears, anger, and selfdoubt. She also connected Denise back to all of the positive things she knew to be true
about her son. This is important because so often when parents are confronted with their
child’s sexuality they lose sight of the complete, whole person the child is and instead
focus myopically on the threatening component part (Stone Fish & Harvey, 2005).
Through this lens all things are negative, threatening, and incomplete, making effective
parenting even more difficult. Stephanie attempted to shift the focus of Denise’s parenting
away from this and helped her see the pain her child may be in whether or not he was
gay.
This theme was continued in the next few sessions where Stephanie helped Denise consider how isolated Jamal felt. Denise recognized that Jamal had withdrawn from those
around him, especially her family, and she attributed this to how hard they were all working to toughen Jamal up. Stephanie shared with Denise her worry that these attempts
were isolating Jamal further. She asked Denise to instead invest time and energy into connecting with Jamal on the types of things that had been ‘easy’ for them to enjoy together.
Stephanie conducted a short family session to have Denise and Jamal come up with a list
of these. Movies, reality TV shows, cooking together, and visiting older relatives were at
the top of the list. It made sense to Denise that Jamal was isolated and needed to feel normal. She too, wanted this and recognized that when her “fears got the best of her” she felt
urgency to make Jamal change which disconnected them and as Stephanie pointed out
actually decreased her influence with Jamal because he withdrew from her. In moments,
Denise was really worried and energized by her fear to do something about Jamal’s sexuality. Stephanie empathized with Denise’s fears and offered therapy as a place for Denise to
explore and articulate these but recommended that what Denise could do was to actively
back off of the sexuality discussions with Jamal and instead focus on strengthening their
connection.
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Difficult Dialogs
Stephanie felt confident about her connection with Denise and Jamal. They had agreed
upon a direction for therapy and the first few sessions though tense in moments seemed to
go well. With an initial sense of trust established Stephanie began moving toward increasing the complexity of the dialog.
Making room for multiple truths
In a subsequent session, Denise asked Stephanie directly about her beliefs about homosexuality and God. Stephanie had nervously sensed this direct question was coming and
she had gone to her supervisor to discuss the dilemma. On one hand Stephanie knew she
had to be authentic about her affirmative stance regarding sexuality. On the other hand
she wanted to put off the question and avoid answering it because she thought that Denise
might not return to therapy if she was honest with her. Her supervisor helped Stephanie
map out a strategy. During the next session when Denise directly asked Stephanie what
she would do if her own child were gay Stephanie told Denise that she believed that this
question deserved an answer especially because Denise was trusting her to help her family. She told Denise that she had been raised to believe very similarly to what Denise
believed, homosexuality was a sin and people could be cured and become heterosexual.
Stephanie then said that she no longer believed that and instead believed that being gay
was no different from being right- or left-handed, no better or worse. Stephanie also told
Denise that she believed (and scientific research supported) that any attempts to ‘cure’
homosexuality were unethical and ineffective. Stephanie disclosed to Denise that her older
brother was gay and had had a very difficult time as a young person because of her family’s religious beliefs. Knowing her brother and learning about his struggles had powerfully affected Stephanie and helped her change her beliefs.
Stephanie said that while she believed differently from Denise she would do the best
she could to honor her belief system while also questioning what she felt was damaging to
Jamal and to her relationship with her son. Denise was very quiet during this part of the
session and Stephanie asked her what it was like for her to know they believed differently.
This was a tense time for Stephanie and she expected the worst. To her great surprise
Denise expressed relief. She mentioned that her friend Lorena believed the same way that
Stephanie did and Denise found this comforting though confusing. She mentioned that
she was getting closer to Lorena these days as she found it increasingly difficult to be
around community and family members she knew were judgmental about Jamal.
In individual sessions with Jamal, Stephanie reminded him that they had all agreed
that whatever he said in session alone with Stephanie would remain confidential (provided there was no direct threat of harm to self or other) until he was ready to discuss it
with his mother. Jamal was pretty withdrawn at first and Stephanie wondered what he
was feeling, suggesting that he looked sad. He eventually responded that he just felt
lonely and angry that everyone looked at him funny now. He said that his mother had gotten all of his family worried about him and that maybe even people at church were now
looking at him weird and thinking like his mom that he was a “faggot.”
Stephanie You know Jamal you have used that word a few times and I’m not actually
sure what you mean by it. What does that word mean to you?
Jamal
It means someone who is weak, someone who is doing wrong and deserves to
be punished for it.
Stephanie And I can clearly see you are not weak or wrong. And you do not deserve
punishment. That is very clear to me. You know some people use that word
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to describe men who love other men romantically? And I know a lot of good
people, smart people who think badly about those men.
Jamal
Yeah.
Stephanie I just want you to know I do not think that way. I think we are all made by
God and are beautiful just as we are.
Psychoeducation
Stephanie asked Denise to return to the topic of fears for Jamal.
Denise
I do not want that gay lifestyle for him. I just want him to tell me he likes
women! I want him to get married and have children and be a successful
black man. But he will not talk about this with me. He stays completely
silent. Simply silent and I’m begging him to just tell me he likes girls. Once
in awhile he gets angry and then he simply yells “I’m not a punk. I’m not a
faggot.” But mostly he simply won’t talk with me about it at all.
Stephanie If he were gay, what do you think he would face?
Denise
Homosexuality is a sin and if Jamal goes down that path he would be lost.
Stephanie Can you be more specific, Denise? What would it mean to be lost?
Denise
He would be cast out. I do not think they would allow him around the
church. I do not know if I could be around him. It would be too disgusting to
think about.
Stephanie Wow! That sounds horrible and isolating.
Denise
I know not everyone has this and you may not understand. But black folks
have a sense of church community that is TIGHT. I do fine in the world. I
have a good job. I have white friends. But they don’t know me like that. My
community, my church, we understand what it takes to get along in this
world. Jamal and I belong there. I have a place and we are protected when
things are hard.
Stephanie So it sounds like if Jamal did not identify as heterosexual he would face
being disconnected from his community and he might also rightly worry that
he would be disowned by you and his family as well?
Denise
(very quietly) Yes.
Stephanie I don’t think Jamal is ready to discuss his sexuality with anyone but I worry
that if he was gay he would not feel like he could talk openly without losing
everyone. And it seems to me that part of your point is that as a young black
man it is already harder for Jamal to feel understood and connected in the
larger world. He is affirmed and protected as a black man by the church
community that would also condemn him as a gay man? So where could he
go?
Denise looked stricken and Stephanie needed to give her information and direction. Using
clinical implications from the work of Ryan et al. (2009), Stephanie offered some facts for
Denise to consider about the higher risk of destructive behaviors in lesbian, gay, bisexual,
and transgendered youth including drug and alcohol use, suicidality, promiscuous sexual
behavior, etc. Stephanie told Denise that these youth are at risk but families in particular
can offer youth increased protection from these risks simply by not being rejecting and
emphasizing their love and connection with their children. Stephanie reiterated that
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youth whose families made even small changes in limiting alienating, negative, rejecting
behaviors helped lower some of the risks. Denise reacted strongly at first wondering if Stephanie was suggesting that she “condone” Jamal’s behavior and lifestyle choices. Stephanie assured Denise that she simply meant for Denise to emphasize the ways she loves and
cares for Jamal while limiting hurtful behavior that Jamal would experience as rejecting
and isolating. For instance name-calling, or constant focus on condemning religious messages about homosexuality, subtle or overt threats to disown someone who identified as
gay, or blaming Jamal for the ways in which he was being bullied, these types of behaviors
could be detrimental. And conversely, if these could be limited it could help Jamal with
whatever he was struggling to understand about his sexuality.
Denise realized that her brothers in particular were engaging in exactly this type of
behavior in their attempts to toughen Jamal. She felt supported by her brothers when
they did this. They were trying to show their love for her but she realized that in doing so
they were making things more difficult for Jamal. Stephanie and she talked about how
Denise might redirect this partly by simply intervening when this happened and asking
them to stop but also by finding opportunities to highlight the ways in which Jamal was
succeeding and thriving. Denise realized during this discussion that she had been overly
focused on the negative and worrisome issues and not balancing this with the many ways
that Jamal was doing quite well.
In these subsequent sessions Stephanie begins to move into difficult dialogs by creating
space for multiple truths and slowly increasing levels of honesty. During these conversations, it is important to recognize the layered and complex issue of coming out in the African American community within a religiously conservative culture. Stephanie led
respectful, authentic communication when Denise asked her about the differences in their
beliefs about sexuality and religion. And she took the opportunity to explain to Jamal
what she believed about gay men. She wanted to give Jamal the message that whatever
his sexuality he would be accepted by her. Importantly, Stephanie was careful not to denigrate or ridicule different beliefs but rather to stay in respectful relationship with these
beliefs. So many young people, especially those from conservative religious backgrounds
and those members of racial minorities, face the pressure to have to choose between vital
pieces of their identity and beliefs (das Nair & Thomas, 2012). They are forced to have to
integrate in their lives dichotomies which are incredibly polarized everywhere else.
Attempting to be an African American gay man who is a Southern Baptist is no small feat.
Stephanie’s stance honors this dilemma and is an attempt to share the burden of bridging
these dichotomies, at least in therapy where the hope is to create a safe space where both
common ground and differences can be acknowledged and allowed to co-exist. Finally, Stephanie is attempting to lessen domination (das Nair & Thomas, 2012) by identifying and
addressing Denise and her brothers’ rejecting behaviors. While these behaviors were
intended to be protective of Jamal as an African American youth they would prove oppressive and harmful to him as an African American gay youth.
Nurturing Queerness
In supervision, Stephanie was directed to begin to integrate pieces of Jamal and
Denise’s life together and connect this with the presenting issue. She began in individual
sessions with Jamal wondering if he had friends he could rely on when he believed his
family was acting strange. He mentioned he had a small group of friends at school but his
mom thought they were “fruity” because they liked to be glamorous and loud with their
dress and attitude. They get together and dance and lip synch and Jamal disclosed “we
are all kind of flaming.” Stephanie expressed her interest in these friends and she invited
Jamal to ask his friends to attend a session. This idea had never occurred to Jamal but
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seemed to excite and invigorate him. There was one particular young man from school
that Jamal was excited to discuss. James was a year older than Jamal in school and
involved in drama club. Jamal seemed smitten and as Stephanie encouraged him to
explore his feelings toward James it became clear that James and Jamal were romantically involved. Jamal’s feelings were tenuous and not clearly articulated. He told Stephanie he could not talk about this with his mother yet.
Uncovering hidden resilience
Stephanie was coached by her supervisor to look for Jamal’s hidden resilience. In the
face of strong pressure from Denise to talk about his sexuality either to confirm his heterosexuality or to change his homosexuality, Jamal remained withdrawn and mostly silent
on the topic. This was curious to Stephanie as it would have been easy for Jamal to allay
his mother’s fears by talking openly with her about sexuality or simply to pretend to be
what his mother was yearning for him to be. He could easily talk more about girls, feign
interest in sports, or be virulently homophobic. But Jamal did none of this. He remained
steadfastly withdrawn which increased tensions with his mother. In some moments when
pressed Jamal denied being “a faggot” because in his mind that meant being immoral, disgusting, and weak, and he trusted he was not those things. He did not try to act more masculine or change anything about the way he looked or acted, which meant that he was still
a target for bullying by peers and now his uncles. It dawned on Stephanie that this stance
was actually Jamal’s hidden resilience, his way of buying himself time while maintaining
a sense of integrity. Stephanie began to move toward reframing Jamal’s silence and withdrawal as strength. She helped first Jamal and eventually his mother see the integrity
and bravery it took for Jamal to be himself in the midst of community and family pressure
to do otherwise.
As discussed earlier coming out is widely viewed as an important milestone of healthy
development for nonheterosexual people. Coming out can also enable a sense of connection
and belonging to the lesbian, gay, bisexual, and transgendered (LGBT) community, which
helps buffer individuals from the negative effects of homophobia and heterosexism. A
well-intentioned clinician might favor and encourage coming out in an attempt to help a
client achieve the psychological benefits of this process. But this is complicated for Jamal
by intersections of race and religion and prescriptions for coming out must be tempered
with an understanding of specifically what is at risk for young racial minorities. Stephanie
and her supervisor realized that Jamal had not resolved how to proceed in the untenable
position in which he was located. Namely he needed to come out to further develop a
healthy identity as a gay man but to do so meant the real risk of rejection from an African
American community whose protection, affirmation, and sense of belonging were also vital
to his identity development. Moreover, as Walker and Longmire-Avital (2013) point out,
conservative religious traditions in the African American community have a long history
of utilizing religious belief to mediate the effects of racism, oppression, and injustice.
Queer youth raised within these traditions are likely to utilize religious belief to cope in
similar ways with the oppression of homophobia. “While religious faith may provide Black
LGB emerging adults with resiliency, if their religious institution uses negative religious
rhetoric regarding same-sex sexual behavior, they may be adding to levels of internalized
homonegativity” (Walker and Longmire-Avital, p. 1727). Finally, coming out is no guarantee that Jamal and other youth of color would feel embraced or protected by the larger
LGBT community. Racism affects this community as much as any other. Coming out then
for youth of color can add to alienation and disrupt feelings of inclusion (das Nair & Thomas, 2012) at a tender and important moment when this connection is most needed as well
as fragile.
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Stephanie and her supervisor recognized Jamal’s dilemma and the unique way he had
found to balance the integrity of his membership in a religious community, his close relationship with his mother, his identity as an African American, and his religious faith along
with the development of his sexuality. Stephanie emphasized a go slow approach which
recognized that Jamal was in the process of finding his own singular way to balance who
he is with who he is becoming. Stephanie knew that therapy must trust and support him
to do this in his own time.
Identifying gifts of queerness
Next Stephanie turned to Denise looking for the gifts that Jamal brought to his family
because of the ways he was different. She asked Denise about Jamal’s “fruity” friends and
Denise described their flamboyant, carrying on behavior where they sing, lip synch, and
dance. Stephanie understood that Denise was uncomfortable with the gender nonconformity of this behavior but also sensed that a part of Denise was entranced and supportive.
She inquired about this and learned that Denise and Jamal danced and played like this
together since Jamal was a young child. When they had bad days they would come home
and turn the music on loudly and “carry on.” Denise a reserved woman would not have
thought to sing and dance with abandon on her own. But Jamal loved to do it. Denise
learned that it brought out something in her that felt healthy, fun, and open. She talked
about these times with sweetness and remembered this way of “blowing off steam” as
something that connected her and Jamal. The flamboyant way that Jamal and his friends
carry on in this same way was seen now mostly through the lens of Denise’s worry, shame,
and homophobia. Stephanie helped Denise remember back to an earlier time when Jamal
first shared with Denise this special way of coping. Stephanie recognized Denise for the
good parenting she did in those moments to affirm and support Jamal as he learned these
coping skills. This led to a broader conversation about other ways that Denise and Jamal
used to connect. Denise admitted somewhat abashedly that she and Jamal used to be
much closer. They would spend hours watching reality TV shows discussing in-detail all
the relationship dilemmas and fashion choices. This discussion included Jamal’s hopes to
be a fashion or interior designer, or artist. Denise enjoyed learning about fashion and art
through Jamal’s eyes and there was a time she was more open and embracing of this. This
enjoyment began to wane for Denise as fears about Jamal’s sexuality came to the forefront. Worried that as a single mom she was feminizing Jamal she began to discourage
these interactions. Stephanie validated Denise for bravely considering how her fears
might have negatively affected Jamal. Stephanie shared that what Denise had described
sounded like “natural gifts” that Jamal has brought to the world from the time he was very
young. Stephanie said, “Could it be that he was sharing with you important parts of
himself and you were simply responding as a loving parent would with investment and
interest?”
Moving toward transformation
A cornerstone of our model of therapy is that nurturing queerness leads to transformation and not only for nonheterosexual youth but also for their families as well. For Denise,
the idea that she was actually being a good parent when she danced with her son or listened and invested in his nontraditional hopes and dreams was novel and antithetical to
her worries that she was somehow a flawed, unsuccessful parent. The intersections of
Denise’s own life had powerfully influenced her. She had internalized racist, misogynistic,
homophobic beliefs that as a Black woman, and a single mother of a son, her parenting
was inherently flawed. Stephanie asked Denise to consider what she and Jamal may have
lost out on because her fear, shame, and self-doubt interfered. This was powerful for
Denise as she understood the ways her own voice as a parent had been lost, overshadowed
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by cultural messages that activated her shame and worry. In this way, therapy became a
place where Denise’s shame could be transformed and she could be reconnected with her
abilities as a good parent and allow herself to be reacquainted with her son. As a result
their relationship improved, the tension dissipated, and they began to share more of themselves. Jamal did eventually come out to his mother. But by the time he did much of the
energy and angst had been leeched out of the process. Both he and his mother were more
grounded and resolved. For his part Jamal continued to stay connected to his church community while his mother protected and helped him negotiate this. She was able to intervene or redirect conversations when her brothers made disparaging remarks or tried to
goad Jamal into being more masculine. Jamal developed his identity as a gay man with
James, with his friends, and in therapy. Stephanie and he worked on connecting him to
LGBT affirming churches recognizing the importance of alternate religious views that did
not condemn him as a gay man.
COMPOSITE CASE EXAMPLE CHARITY AND FAMILY
Charity Pham was 18 years old when she was first referred to a Mental Health Clinic
so that she could be assessed for hormone therapy (see Coolhart, Baker, Farmer, Malaney,
& Shipman, 2013, for details about the assessment process). Charity stayed in treatment
after she began taking hormones to work on family problems that had plagued her for
years due to her gender nonconforming behavior. Charity was the youngest of four children born to Vietnamese refugee parents who met in a settlement community in the United States in the late 1970s. Charity’s family became very involved in the Catholic Church
when they moved to the United States, which became a sanctuary for her parents and siblings and an ongoing point of contention for Charity. One of Charity’s earliest memories
was dressing up in her sister’s hand-me-down dress for church one Sunday and her
father’s outrage at her mother for causing this catastrophe. This set up an ongoing triangle where any time Charity showed nontraditional boy behavior, her father would blame
his wife and verbally and physically abuse her for Charity’s behavior. Charity’s rage at
her father goaded her to flaunt her gender performance provocatively as often as possible
in front of her father. When Charity became a teenager, she became the direct target of
her father’s physical abuse.
High school was as unwelcoming of Charity’s gender atypical behavior as her family
environment. Her family had settled in a depressed community with few jobs and limited resources. Charity’s high school had a 50% graduation rate, was plagued by gang
violence, and teachers were too preoccupied or overwhelmed in the classroom to notice
or intervene in the bullying that Charity endured. Charity tried to mitigate her
isolation by connecting with an online community of trans individuals and when,
finally, her father’s rage became life threatening, Charity left home and found refuge
on the couch of a 40-year-old man in a community 45 minutes away. For the next
2 years, Charity moved from couch to couch, making ends meet by having sex with
people to pay for food, rent, drugs, and alcohol. She was finally caught by the police
and when she called her mother to see if she could come home, her mother told
Charity it was not safe.
The police connected Charity to a transitional living house in our community whose
staff are trained in LGBTQ-affirmative theory and techniques. Charity enrolled in high
school and she came to the clinic for hormone assessment and therapy. She was living full
time as female, going to school, and was working part time at the mall. She hesitantly
made an appointment for therapy and was assigned to Mike, a young and engaging
African American out gay man.
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Creating Refuge
At first, Charity was reluctant to engage in the therapy process and was resentful that
she had to come to therapy to take hormones. She was angry at the world and all the
people in it. Mike listened with patience and compassion, periodically affirming Charity’s
disappointment and holding hope that things would get better for her. Eventually, with
enough respect, affirmation, and curiosity, her therapist joined with Charity and a trusting relationship developed. To be eligible to receive hormones, the World Professional
Association for Transgender Health’s Standard of Care suggests that a mental health professional write a letter of recommendation before hormones are given. A thorough psychosocial history was taken and Charity was open with information about her past
experiences with her family and her self-awareness of her gender identity at a very early
age. A turning point in therapy came when Mike told Charity that he was almost finished
writing her letter of recommendation and wanted to go over the letter with Charity. As
Charity reviewed the letter, she started to cry. Mike was shocked as he had never seen
any emotion from Charity besides rage and anger and he was concerned he had hurt her.
He moved closer to her and quietly gave her a tissue and asked what the tears were about.
Charity said, “This is the first time I’ve ever read anything about myself, or actually ever
heard anything about myself that was positive. I f’ing hate myself and my life so to see
that someone likes me, it’s just new, that’s all and it made me cry. You f’ing called me
brave, mo-fo, you f’ing called me brave.” Mike said, “Charity, I am in awe of your courage
and I really want to continue to work with you so that a little bit of what I think and feel
about you moves into that fabulous brain and heart of yours so we can begin to counteract
all the negative voices. Those voices that don’t belong there, they are from people whose
own demons keep them from seeing you and all your loveliness.”
Difficult Dialogs
Charity was in constant phone contact with her mother, Mai, and they both missed each
other terribly, though Charity never shared her sadness and loneliness with her mother.
Charity also had Internet chat contact with her sister, Cam, who would give Charity
updates about how bad life was at home and the rages that her father continued to engage
in whenever things did not go his way. Mike broached the subject of bringing Charity’s
family into therapy. This became a difficult dialog. When Mike first brought up the subject, Charity became rigid and quiet. They sat in silence for a long time. Mike asked Charity what was going on and she refused to answer. When the session was almost over, Mike
said, “Charity, I suspect you are mad at me and think I don’t understand how terrifying it
would be for you to have your family come here to meet with us.” Charity interrupted Mike
and said, “Not my family, that a-hole.” Mike said, “I stand corrected, you probably think I
don’t have any understanding about how terrifying it would be for you to have your father
come here to meet with us.” Charity remained silent. Mike said, “I get it, Charity, as much
as I possibly can. I just wonder, and I have actually witnessed this happening before, if we
all got together with a third party watching and supporting you, whether some members
of your family might actually be open to the possibility of hearing your perspective and
supporting you.” Charity was not willing to entertain the possibility and left the session
with a hostile attitude.
Charity did not see Mike again for another month. They had a regular standing
appointment and each time Charity did not show up for the appointment, Mike left a voice
message on Charity’s phone letting her know that he missed her and looked forward to
her coming to the next appointment which he kept scheduled for her. When she finally
returned, Mike enthusiastically welcomed her back and after discussing what had transpired since they last saw each other, Mike brought the family topic up again.
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Mike
So have you thought about the last difficult dialogue we had the last time we
were together?
Charity
Yes and I’m still pissed at you about it (Mike acknowledged the anger). He’s
poison Mike and he doesn’t deserve to be in relationship with me and I
refuse to see him.
Mike
OK. I get it. I really get it. So I can hold the hope that someday, not someday
soon, but someday in the future, things will be different and you will be able
to tell him all the awful things he did to you and how it has impacted how
you felt about yourself and how you have to work hard to recover from the
toxic messages he sent you, and he will, well, maybe never apologize, but sit
and listen, and you will unburden yourself. You may never forget but my
hope is that someday you can understand and then forgive the hardness of
his heart. And I totally understand and respect why you do not want to see
him. OK? (Charity nods). So since I can’t stop, how about your mother and
sister? (Charity and Mike look at each other and smile).
Mike then encouraged Charity to bring her mother and sister in for a few family therapy
sessions to see if he could help Charity use them more effectively for emotional, financial,
and social support and a year into therapy, Charity agreed.
Midway through the second session when Charity was attempting to share some of the
traumatic life experiences that had occurred since leaving home, Cam asked Charity if she
was living with other “trannies.” Charity, quick to temper, told Cam to go fuck herself and
shut down. Mike knew Charity was offended by the label and asked her if he could take a
minute and talk about language with Cam and their mother, while Charity used some of
her self soothing skills to calm herself down to come back to engaging in this wonderful
but difficult dialog. Charity agreed.
Mike talked with the family about labels. He wondered what Cam meant by using it
and if she understood what this label felt like to Charity? He explained how labels like
“tranny” are powerful and driven by ideas that are culturally constructed most often by
heterosexual, White, western culture. For GLB and transgendered ethnic minority people
like Charity, these labels can be doubly alienating. First because they are often not seen
as being full members in the communities to which labels refer though they are still tormented with the animus intended by the labels. Moreover, there are many diverse, multicultural knowledges about sexuality not captured well or simply not captured at all (das
Nair & Thomas, 2012) in these labels. So it is important to address language and we do it
most often by looking for opportunity to create space for more complexity around language. Mike took the opportunity to ask Cam about what this label meant for her, and a
discussion ensued with everyone about which labels fit and a discussion on what each
woman understood about how Vietnamese culture imagines gender and sexuality. This
opened space for the possibility that there are meaningful and important sexual minority
experiences that deserve being explored and might be helpful for the intersecting identities that Charity embodies. It also opened up a great dialog about the gender roles in the
Pham family and the possibility of challenging some of the dysfunctional ones.
Nurturing Queerness
Mike met with Charity, Mai, and Cam off and on for the remainder of therapy with
Charity. Part of the conversation was devoted to working through Charity’s disappointment with her mother while she was growing up and her mother’s attempt to understand
some of Charity’s behavior.
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Mai
I understand that you wanted me to be more supportive but it was difficult
for me when you were so disrespectful to your father.
Mike
Mai, can you give me an example of a typical interaction?
Mai
Charity would come down for breakfast before school wearing blue eye
shadow. Now, with her hair long, and her nails and all, she looks like a
woman but back in high school, she was Chien (Charity’s birth name) and it
would make her father so mad. Charity knew her father would be mad and I
would beg her to wait until she got to school to act up because she knew her
father would flair up and throw her around. I just don’t understand why she
couldn’t wait.
Charity
That was the point, ma, I didn’t give a f’ about him. He disrespected me and I
disrespected him. He didn’t deserve my respect.
Mike
You know something, Charity; I think you’re selling yourself short. I think
you cared a lot about what he thought and you still do. I think your eye
shadow was an act of defiance and I mean that in a good way. I think you
were saying, “dad, I am here and I am queer (everyone giggled) and I wish
you would see me and love me dad, (everyone got more somber) actually I still
do but I am not going to disrespect myself just because you disrespect me.”
Charity
Ma, Mike and I have been talking in therapy about my crazy behavior and
how prideful I become when someone disses me and how that’s a good thing
and a bad thing. When I hurt myself because I have been hurt, like from
your husband (Charity refused to call him her father) then it is a bad thing
but when I am prideful because I am a woman, well, that’s a good thing, a
strength, and that is the part that I wish you had gotten when I was coming
up.
Mai
Well I get it now, Charity, at least I am trying really hard.
Mike
And you are doing an absolutely fabulous job.
Mai eventually helped Charity move into her own apartment and helped her find a job
through connections she had with the community. Mai became out and proud and one of
Charity’s greatest advocates. She believed her husband was immovable so gave up
attempting to gather his support; instead, she took pride in her own initiative. At one of
the last family sessions, Charity’s mother said, “I learned from Charity that sometimes
you have to do what your heart leads you to do even if it means you have to fight old traditions. Just because some things are always one way, doesn’t mean they are the right way
or the only way.”
CONCLUSION: ENCOURAGING TRANSFORMATION
Informed by queer theory, intersectionality, and family systems theory, we have been
evolving a model of therapy that mines for resilience; expecting, finding, and unlocking
the natural agency and mastery in queer youth and their caregivers. We recognize and foster this resilience so that queer youth and their loved ones can begin to recognize both
their vulnerability and their beauty and are better able to manage the multiple layers of
oppression they will face. The target of change in therapy is simultaneously the queer
child, the parenting subsystem, and all of the relational processes of the family system.
These elements reinforce one another and as one is transformed it creates the opportunity
for all to be transformed.
Fam. Proc., Vol. 54, September, 2015
416 /
FAMILY PROCESS
We work hard to create safe, respectful spaces that can tolerate increasing honesty, difficulties, and complexity. We intentionally nurture the powerful potential in queer sensibilities that often go unrecognized, undeveloped, and unexplored. When we nurture
queerness, we uncover hidden resiliencies, helping youth as well as their loved ones
acknowledge both the unique vulnerabilities and singular gifts they have to give. Some
families, or members of some families, may leave therapy still unable to accept the gift
that queer youth have to offer. We may have to work with youth in less than optimal families and contexts. We never underestimate the power of our loving acceptance in a youth
and a family’s developmental trajectory and while we are not enough, we are often sufficient. We have seen dramatic change in families and communities we have been involved
with and we share this finding with families who are experiencing despair. We have
walked families through the process of rejection to acceptance to transformation enough
times to know that all people are capable of change. Therefore, we are always working
with half a mind toward the possible future. We are uninterested in group-think or political correctness but invested in seeding the potential in families and communities to evolve
in dramatic moments and also in subtle, almost imperceptible movements away from
domination and toward increasing ability to recognize, care for, and fully love their queer
children. This transformation in our minds is worth working for, as it will make all of us,
youth, parents, communities, clients, and therapists, less constrained, more flexible, and
more creative.
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Contemp Fam Ther (2016) 38:307–317
DOI 10.1007/s10591-016-9389-3
ORIGINAL PAPER
MFT Program Policies on Referral of LGBT Clients
Hoa N. Nguyen1 • Erika L. Grafsky1 • Fred P. Piercy1
Published online: 3 August 2016
Springer Science+Business Media New York 2016
Abstract The purpose of this exploratory study is to examine
program policies that govern whether or not student therapists
can refer lesbian, gay, bisexual, transgender, and queer clients,
based on the therapist’s religious beliefs. We conducted a
qualitative survey with program directors of Commission on
Accreditation for Marriage and Family Therapy Education—
accredited marriage and family therapy programs to ask what
policies monitor client referrals that are solely based on the
therapist’s beliefs toward sexual orientation and gender
identity. Implications revolve around finding congruency
between the program’s philosophy, policy, expectations for
students, and ethics. We provide recommendations for
addressing these issues early on in the recruitment process.
Keywords Client referrals LGBTQ policy MFT
programs
Introduction
On June 26, 2015, the Supreme Court ruled in favor of
legalized same-sex marriage in the United States (Obergefell
vs. Hodges 2015). Supporters of LGBTQ rights celebrated this
decision while recognizing the need to address other issues in
the community such as transgender rights, workplace protections, homelessness, substance use, suicide, violence, hate
crimes, and inclusivity of non-binary sexual and gender
identities. With the growing acceptance of diverse sexual
orientations and gender identities, LGBTQ individuals may be
& Hoa N. Nguyen
hoa@vt.edu
1
Marriage and Family Therapy Program, Department of
Human Development, Virginia Tech, Blacksburg, VA, USA
more likely to seek therapy (Israel et al. 2008; Malley and
McCann 2002). This calls for greater sensitivity to LGBTQ
mental health and increasing therapists’ clinical competence
with LGBTQ-related issues. Changes in larger societal
acceptance toward LGBTQ individuals may also influence
how programs will address their policy on LGBTQ client
referrals. The purpose of this exploratory study is to investigate policies and expectations that marriage and family therapy (MFT) program directors have for their student therapists
regarding whether or not they can refer lesbian, gay, bisexual,
transgender, and queer (LGBTQ) clients solely based on the
student therapist’s religious beliefs.
Section 1.1 of AAMFT’s code of ethics states, ‘‘Marriage
and family therapists provide professional assistance to persons without discrimination on the basis of race, age, ethnicity,
socioeconomic status, disability, gender, health status, religion, national origin, sexual orientation, gender identity or
relationship status’’ (AAMFT 2015). While referrals based on
competency is reasonable, referrals based on discrimination
are not. One issue we will discuss is whether allowing therapists to refer a client based on their religious beliefs is considered discrimination toward LGBTQ individuals or
protection of religious freedom. Given the AAMFT code of
ethics and the importance of non-discriminatory practices
toward LGBTQ individuals, we hope to begin to address the
complexities of these issues in this paper.
Mental Health Organizations
Mental health organizations have taken stances against
discrimination and toward inclusivity. In 2004, National
Association of Social Workers (NASW) reaffirmed:
… the Association’s support for same-sex marriages,
and strongly opposes any attempt to pass federal
123
308
legislation or amend the United States Constitution to
discriminate against same-sex couples or prohibit
governmental recognition of these relationships.
The American Psychological Association (APA) stated that
the organization, ‘‘supports legalization of same-sex civil
marriages and opposes discrimination against lesbian and
gay parents’’ (APA 2005), and the American Psychiatric
Association also supported, ‘‘the legal recognition of samesex civil marriage with all rights, benefits, and responsibilities conferred by civil marriage, and opposes restrictions to those same rights, benefits, and responsibilities’’
(APA 2004). In 2005, AAMFT adopted the following
stance:
AAMFT believes that all couples who willingly commit
themselves to each other, and their children, have a right
to expect equal support and benefits in civil society.
Thus, we affirm the right of all committed couples and
their families to legally equal benefits, protection, and
responsibility.
Consistent with AAMFT’s stance, the Commission on
Accreditation for Marriage and Family Therapy Education
(COAMFTE)—accreditation standards require MFT trainees to learn how to work with diverse clients and attain
the necessary multicultural competencies. Students enrolled in MFT training programs may not be aware of the
expectations around treatment or referral of LGBTQ individuals in their family therapy program. In light of the
revised AAMFT code of ethics (effective January 1, 2015),
faculty members need to take these guidelines into consideration when creating program policies.
LGBTQ Individuals and Mental Health
Like other clients, LGBTQ individuals seek therapy for
various reasons, most unrelated to their sexual orientation
and gender identity. In an exploratory study of 42 LGBT1
clients, presenting problems in therapy (from most to least
common) included relationships, depression/suicidality,
career, sexual orientation/gender identity, anxiety/stress,
family, medical health, and mandated therapy (Israel et al.
2008). Family therapists, among other mental health professions, are likely to encounter LGBTQ clients in their
clinical practice. More than two decades ago, therapists in
one study reported that one tenth of their clinical practice
involved gay or lesbian clients (Green and Bobele 1994).
These numbers are consistent with a more recent study, in
which 91 % of 741 AAMFT members reported having
1
We use different acronyms, LGBTQ, LGBT, or LGB, to clearly
identify the demographic referred to.
123
Contemp Fam Ther (2016) 38:307–317
worked with at least one lesbian or gay client (Henke et al.
2009).
Henke et al. (2009) found that MFTs, on average,
reported feeling fairly confident about their ability to work
with gay and lesbian clients. This is an improvement
compared to Doherty and Simmons’ (1996) study which
found approximately 54 % of the clinicians surveyed felt
they were not competent enough to work with gay and
lesbian clients. At the same time, therapists also reported
that they only have ‘‘somewhat’’ of an awareness about
lesbian and gay experiences, mental health needs, and
heterosexism (Henke et al. 2009). This suggests a difference between therapists’ confidence and clinical
competence.
Both clients and experts on LGBTQ issues considered
knowledge/understanding of heterosexism, cisgenderism,
homophobia, transphobia, and LGBTQ-related issues to be
key components in providing helpful, effective therapy for
LGBTQ individuals (Blumer et al. 2013; Blumer and
Barbachano 2008; Godfrey et al. 2006; Israel et al. 2008).
Ford and Hendrick (2003) surveyed 314 APA and AAMFT
members on how they handle conflicts between therapist
and client values, and found that 40 % chose to refer, 25 %
talked with their client, 18 % consulted another professional, 4 % examined their values and explored the client’s
perspective, 2 % engaged in personal therapy, and 1 %
helped clients explore the issue. The remaining 20 % stated
‘‘other’’ or ‘‘not applicable’’. With 40 % choosing to refer
their client and only 4 % engaging in self-examination and
considering the client’s position, it is important to consider
whether therapists are willing to acknowledge their values
and bias.
Therapists may be learning how to work with LGBTQ
clients, but most of them do so through clinical experiences
after they graduate, rather than during their training. A
sample of 208 AAMFT clinical members showed that
95 % of the therapists learn about gay and lesbian clients
through clinical work and 46 % through graduate supervision (Green et al. 2009, 2010). Further, student therapists
reported relatively low levels of competence on conducting
therapy with LGB clients, and 60 % indicated they have
received no training on affirmative clinical practices (Rock
et al. 2010). Research suggests that clients find LGBTaffirmative practices to be helpful in their therapy experiences (Blumer and Murphy 2011; Israel et al. 2008).
Clinical training often excludes information regarding
the needs of transgender clients, and despite increasing
visibility of transgender individuals, clinical literature
tends to focus on sexual orientation and rarely centers on
gender identity (Benson 2013; Blumer et al. 2013; Carroll
et al. 2002). Since therapists are likely to work with
LGBTQ clients, therapist competence in regards to serving
LGBTQ individuals is important. At the same time, beyond
Contemp Fam Ther (2016) 38:307–317
counseling skills, therapists that express openness and
positivity toward LGBT clients with some knowledge and
focus appropriate to LGBT issues were found to be particularly helpful from the client’s perspective (Israel et al.
2008). In a sample of 741 clinicians, McGeorge et al.
(2015a) found that therapists who had higher negative
beliefs about LGB individuals were more likely to refer
clients on the basis of sexual orientation. They were also
more likely to view referrals of LGB clients as ethical.
Policies in Family Therapy Programs
MFT programs vary in how they incorporate sexual and
gender diversity in their curriculum and training. Some
programs employ a feminist-informed social justice model
to guide the culturally sensitive and affirmative training of
their student therapists (Carlson et al. 2006). Scholars have
written about how to train student therapists to work with
LGBTQ clients through experiential tasks to enhance cultural sensitivity (Laszloffy and Habekost 2010) and specific
tools such as critical incident journaling to address cultural
bias (Lee and Vennum 2010). Other strategies include
attending LGBTQ workshops, inviting guest speakers on
the topic, reviewing taped sessions with LGBTQ clients,
and inviting student therapists to openly share and explore
their values, beliefs, and bias about sexual orientation and
gender identity (Aducci and Baptist 2011; Long 2000;
Long and Serovich 2003). There are also inventories to
assess trainees’ clinical competence and beliefs about LGB
individuals (Carlson et al. 2013; McGeorge et al.
2015b; Nova et al. 2013). Program faculty continue to
develop ways to train their students, to increase their
confidence and ability to work with LGBTQ clients.
Not as many studies directly address the role of policies
in their program training, and academic literature on issues
of therapist conscience in family therapy is limited
(Caldwell 2013). What are family therapy program
expectations around working with or referring LGBTQ
clients? What policies do they have in place to train their
student therapists and increase their level of competence
and sensitivity toward LGBTQ clients? McGeorge and
Carlson’s (2014) study of 117 faculty members specifically
assessed the LGB affirmative policies in program environments. They found that most participants could not
identify specific LGB affirmative policies and often
described a non-discrimination policy that may not necessarily include sexual orientation or gender identity. In a
study of 56 MFT faculty members, researchers found that
49 % of participants in their sample worked in programs
that established policies beyond the standard non-discrimination policy, 9.8 % were neutral, and 41 % did not have
one (Edwards et al. 2014).
309
The issue of client referral has occurred in some counseling programs. In one case, counseling student Julea
Ward, from Eastern Michigan University, felt that she
could not work with a gay-identified student, stating that
she could not ‘‘affirm a gay lifestyle’’ because of her religious beliefs (Ward 2009). Subsequently, disciplinary
actions were filed against Ward, noting that the American
Counseling Association (ACA) Code of Ethics stated that
mental health professionals were not allowed to discriminate based on sexual orientation (Section C.5; ACA 2005).
The case resulted with the university paying a settlement,
but the program did not change its practices (Caldwell
2011). Leigh Greden, director of government and community relations for Eastern Michigan University maintained that, ‘‘The underlying lawsuit is not about religion
and not about homosexuality. It’s about the right of university to insist that their students complete their academic
assignments’’ (Sands 2012).
Though courts are generally reluctant to interfere with
the academic decisions and professional guiding code of
ethics, the appeals court in Ward’s case indicated, ‘‘the key
problem … is that the school does not have a no-referral
policy for practicum students’’ (Ward v. Wilbanks 2010,
p. 3). At the same time, the ACA Code allows for referrals
when the treatment issue is outside the professional’s scope
of competence (Section C.2; American Counseling Association 2005). Arguments supporting Julea Ward’s client
referral was based both on the protection of religious
freedom and scope of competence. The ACA Code, similar
to the AAMFT code, includes two clauses that may contradict each other in this circumstance: one that supports
non-discrimination in treatment, and the other that supports
not treating clients beyond the professional’s scope of
competence.
Kaplan (2014) details multiple facets of the case, stating
that the ACA code of ethics does have one exception that
allows referrals on the basis of the therapist’s personal
values—when helping terminally ill clients with end-of-life
decisions such as physician-assisted suicide conflicts with
the therapist’s moral and personal values. The code also
mandates that therapists can refer on the ‘‘inability’’ rather
than the...
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