Sexual identity and religious ideals: Therapeutic considerations when working with contending areas of diversity
By Angelica Terepka, MA
Psychology as a field has significantly increased its focus on multiculturalism and emphasis on respect for client's rights and dignity in the professional ethical code. Despite these provisions, the path to inclusion remains difficult, especially when two areas of diversity collide; such is the case when working with religious lesbian, gay, bisexual, and transgender (LGBT) clientele. Working with sexual minorities or religious clientele is complicated enough on its own, but what happens when an individual encompasses both identities and finds that they are incongruent? Is one identity compromised while the other perseveres? Is it possible that both identities can be maintained without causing a detriment to the psychological well-being of the individual? The following discussion aims to recognize relevant areas of competency and potential treatment in order to help therapists effectively navigate the often complex set of circumstances present in conducting therapy with religious LGBT individuals.
There are several treatment routes a psychologist may need to consider when treating an individual who presents for therapy experiencing dissonance between their religious beliefs and sexual orientation. The two most popular approaches to treatment, conversion therapy and gay affirmative therapy will be discussed, along with recommendations for psychologist who treat individuals who identify as both LGBT and religious. First, however, psychologists must exhibit respect for their client's right to agency, or autonomy. Autonomy involves recognizing individuals as self-governing agents that are capable of making decisions for themselves regarding their involvement in treatment (Knapp & VandeCreek, 2012). Once a client has made an autonomous decision regarding treatment, psychologists must acknowledge their level of competence in respect to the client's desired therapeutic approach. In addition to competence, therapists should consider their personal views on the potential therapeutic approaches as well as the content matters likely to be included in therapy (i.e., religious beliefs and LGBT issues), matters that further complicate the treatment decision.
With regard to providing therapy to religious LBGT clientele, there is an additional burden placed upon psychologists to reflect on their own views in respect to each of these domains of diversity. Psychologists must consider their own biases for or against religious organizations, as well as their personal perspectives on LGBT issues. On the whole, mental health professionals report lower levels of religiosity compared to the general population (McMinn, Hathaway, Woods, & Snow, 2009). However, a lack of faith amongst psychologists does not relinquish the need for competence and reflection in this area. Therapeutic competencies of religious and spiritual matters in regard to mental health treatment include an understanding of 1) how religion influences mental health and psychopathology, 2) techniques to assess and work with relevant religious beliefs and emotional reactions to religious matters, 3) knowledge about the efficacy of such techniques, and 4) a self awareness of religious bias that may impair therapeutic effectiveness (Fisher, 2013; American Psychological Association, 2007).
Competency in the area of treating LGBT clients includes several important areas common to multicultural training. Psychologists need to be knowledgeable of the most common presenting problems brought into psychotherapy by LGBT individuals (i.e., relationship distress, self-esteem, depression, anxiety, lack of support, etc.). The implementation of a competent skill set, including use of appropriate terminology, comfort in addressing sexuality in therapy, and promoting an environment free of heteronormative bias, is vital when working with LGBT clientele (Lyons, Bieschke, Dendy, Worthington, & Georgemiller, 2010). Lastly, mental health professionals should engage in reflection on personal attitudes toward LGBT culture and consider their own status of sexual identity development.
Conversion or reparative therapies are practices aimed at helping individuals with homosexual urges overcome same-sex attractions through the use of behavioral approaches and aversion techniques. Many conversion programs are founded by religious groups, predominantly fundamental Christian and some Jewish religious organizations (Haldeman, 1994). Overall, research has failed to support the efficacy of such therapies, and in some cases, negative outcomes of conversion therapy may result, including chronic depression, low self-esteem, difficulty sustaining relationships, and sexual dysfunction (Haldeman, 2002). Conversion therapy can also intensify the self-hate and internalized homophobia some LGBT individuals already experience, leading to chronic depression, increased levels of anxiety, self-harm, and even greater instances of suicide exhibited by the LGBT community (Haldeman, 2002). Therefore, use of conversion therapy risks violating professional standards requiring scientific foundations for treatment and may even result in more harm than good to the client.
In a multicultural perspective however, conversion therapy upholds the religious values of an individual and respects their desire to live a life congruent with the morals delineated by religious views. More broadly, conversion therapy supports the freedom, autonomy, and self-determination of clients, an argument termed as the “Right to Choose” debate (Yarhouse, 1998). The APA Ethics Code (1992) states that clients have the right to choose treatment and to be informed of various treatment modalities and alternatives to treatment as part of the informed consent process. However, some professionals would argue that individuals do not act in an autonomous manner when choosing this treatment because environmental stressors and oppression resulting from social norms can greatly influence distress regarding sexual orientation, thereby influencing their decision to seek sexual conversion (Silverstein, 1972). The social forces guiding individuals to choose a heterosexual lifestyle are particularly exacerbated for religious individuals for whom ingrained religious morals denouncing homosexuality conflict with their sexual orientation.
The gay-affirmative approach to therapy is defined as “the integration of knowledge and awareness by the therapist of the unique development and cultural aspect of LGBT individuals, the therapist's self-knowledge, and the translation of this knowledge and awareness into effective and helpful therapy skills at all stages of the therapeutic process” (Bieschke, Perez, & DeBord, 2007, p.408). In gay-affirmative therapy, mental health professionals are encouraged to combat heterosexist norms, acknowledge and combat personal internalized homophobia, recognize internalized homophobia in their clients, and understand heterosexual privilege and its effects in their clients' lives (Kort, 2008). There is a small number of existing studies supporting the efficacy of gay-affirmative therapy (Johnson, 2012), however, the approach has yet to be widely researched.
An affirmative therapy approach to LGBT populations seems congruent with the multicultural stance the APA encourages (Johnson, 2012). As such, gay-affirmative therapy upholds professional standards, particularly regarding respect for sexual orientation. Additionally, this approach allows professionals to counter heterosexual social norms and gay prejudice by affirming all variants on the spectrum of human sexuality. However, psychologists need to be especially careful to not renounce the religious values of their clientele which may result in harmful effects for the client such as a spiritual or religious confusion, loss of their meaning-making model, loss of religious social support, anger toward their religious affiliation, and perhaps anger toward or even loss of their relationship with God (Pargament, 1997).
Ethically Navigating a Complex Intersection
In the specific case of treating individuals who identify as LGBT and acknowledge religious beliefs, choosing just one of these treatment avenues may harm the individual and lead to a violation of ethical standards. “If one attempts to minimize one's sexual nature, one risks giving up a profound avenue of connection with, and growth through, another human being; if one attempts to minimize one's religious orientation, one risks losing the community which one has found nurturance, meaning, and a sense of belonging” (Bartoli & Gillem, 2008, p.204). It is suggested that psychologists do not assume a dichotomous perspective on this dilemma but rather work on integrating these disparate elements of the human experience. It is recommended that professionals obtain competence in both domains of diversity, including appropriate training and self-reflection in both areas. However, even adequate competency in each domain may leave psychologists at a loss when faced with a client whose sexual orientation is at odds with his or her religious values.
When working with religious LGBT, it is recommended that psychologists first assess their client's religious values and sexual orientation, as well as the intersection between the two (Lasser & Gottlieb, 2004). Important areas of assessment include potential sources of distress such as conflicting religious beliefs, social stigma, internalized homophobia, social support, and treatment goals. Following assessment, it is recommended that the therapist reflect on their level of competency in conducting therapy with the individual, as well as personal biases that may inhibit their ability to help the client attain their treatment goals. Feelings of incompetency may stem from a lack of knowledge regarding a particular religious orientation; these may be assuaged through professional consultation or collaboration with appropriate religious clergy. Personal biases that may inhibit professionals from helping their clients may include the therapists' own anti-gay religious beliefs deterring a gay-affirmative therapeutic approach, or valuing social equality and dissuading a reparative approach to LGBT orientations. In the case of either incompetency or incongruence with personal values, it is recommended that psychologists refer the patient to a more appropriate treatment source.
Psychologists are also encouraged to help their client explore the social factors contributing to their distress. In addition to the religious beliefs prohibiting a homosexual lifestyle, clients may benefit from identifying cultural norms and attitudes regarding sexual orientation. The client may find some relief in understanding the social factors driving their distress. Additionally, understanding the underlying social factors may influence the individual's therapeutic treatment goals. Finally, psychologists are encouraged to present all the potential treatment options available to their clients, emphasizing benefits and detriments of each, so as to provide adequate informed consent before beginning treatment. Psychologists who do work with individuals for whom sexual orientation conflicts with religious ideals may find it beneficial to connect their clients to social supports that are both religious and inclusive of sexual minorities where available.
Overall, psychologists must remember that “the greater the conflict between sexual and religious identities, the more difficult their integration and the greater the perceived loss in choosing one over the other” (Bartoli & Gillem, 2008, p.204). From a professional stance, adhering to one set of ethical recommendations and affirming religious values over sexual orientation or vice versa does not constitute a solution to this problem, and instead exacerbates the conflict between religious beliefs and LGBT orientations. Instead, the profession should aim to integrate these two realms of diversity, and in doing so, move toward the greater goal: not changing either religious beliefs or sexual orientation but rather, seeking integration for the betterment of our clients and society.
American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3 rd ed., revised). Washington, DC: Author
American Psychological Association (2002). Ethical principles of psychologists and code of conduct. American Psychologist, 57, 1060-1073.
American Psychological Association (2012). Guidelines for psychological practice with lesbian, gay, and bisexual clients. American Psychologist, 67 (1), 10-42
American Psychological Association (2007b). Resolution on religious, religion-based and/or religion- derived prejudice. Washington, DC: American Psychological Association.
Bartoli, E. & Gillem, A. R. (2008). Continuing to depolarize the debate on sexual orientation and religion: Identity and the therapeutic process. Professional Psychology: Research and Practice, 2, 202-209.
Bieschke, K J., Perez, R. M., & DeBord, K. A. (Eds.). (2007). Handbook of counselingand psychotherapy with lesbian, gay, bisexual, and transgender clients (2nd ed.). Washington, DC: American Psychological Association
Fisher, C. B. (2013). Decoding the ethics code: A practical guide for psychologists (3 rd ed.) . Thousand Oaks, CA: SAGE Publications
Haldeman, D. C. (2002). Gay rights, patient rights: The implications of sexual orientation conversion therapy. Professional Psychology: Research and Practice, 33, 260-264.
Haldeman, D. C. (1994). The practice and ethics of sexual orientation conversion therapy. Journal of Consulting and clinical Psychology, 62, 221-227.
Johnson, S. D. (2012). Gay affirmative psychotherapy with lesbian, gay, and bisexual individuals; Implications for contemporary psychotherapy research. American Journal of Orthopsychiatry, 82, 516-522.
Knapp, S. J. & VandeCreek, L. D. (2012). Practical ethics for psychologists: A positive approach (2 nd ed) . Washington, DC: American Psychological Association.
Kort, J. (2008). Gay affirmative therapy for the straight clinician: The essential guide . WW Norton & Company.
Lasser, J. S. & Gottlieb, M. C. (2004). Treating patients distressed regarding their sexual orientation: Clinical and ethical alternatives. Professional Psychology: Research and Practice, 35, 194-200.
Lyons, H. Z., Bieschke, K. J., Dendy, A. K., Worthington, R. L., & Georgemiller, R. (2010). Psychologists' competence to treat lesbian, gay, and bisexual clients: State of the field and strategies for improvement. Professional Psychology: Research and Practice, 41 , 424-434.
McMinn, M. R., Hathaway, W. L., Woods, S. W., & Snow, K. N. (2009). What American psychological association leaders have to say about psychology of religion and spirituality. Psychology of Religion and Spirituality, 1 , 3-13.
Pargament, K. I. (1997). The psychology of religion and coping: Theory, research, practice. New York: Guilford Press.
Silverstein, C. (1972). Behavior modification and the gay community. Paper presented at the annual convention of the Association for the Advancement of Behavior Therapy, New York City, October 1972.
Yarhouse, M. A. (1998). When clients seek treatment for same-sex attraction: Ethical issues in the “right to choose” debate. Psychotherapy: Theory/Research/Practice/Training, 2, 248-259.