The Clinical Corner

The Inaugural Piece of an Ongoing Contribution by Master Clinicians

A forum for discussing clinical issues and cases.

By Gary Howell, PsyD, and Arlene Noriega, PhD

Armand Cerbone , PhDWelcome to The Clinical Corner. This is our inaugural piece of what we hope will be an ongoing clinical contribution to the division. We have uncovered a need for a forum to discuss clinical issues. Our committee will submit cases to one or two master clinicians to review and conceptualize as a way of sharing their wisdom and generativity. Our hope is to capture the essence of those who blazed the trail for our division, and the field, through each of their conceptualizations. We are certain their wisdom will shed some light on your work with others. On behalf of the Clinical Committee, we would like to thank Armand Cerbone, PhD, for his willingness to respond to our first case and hopefully spark some dialogue among our members. The committee would also like to thank Shay Martin for submitting the first case for our Div. 44 masters to review.

Case Scenario presented to Cerbone

Erol is a 63 year old, African-American male who presents to your office complaining of anxiety and depression. He reports the loss of his wife last year after 39 years of marriage. He has recently begun a new relationship with Andrew, a male friend of both him and his late wife, and Erol is struggling with feelings of guilt toward his deceased wife and adult children. He reports feeling as though he is "living a double life" and being unfair to his out partner. He feels uncertain about revealing the relationship to his family but intensely fearful of losing his new partner.

Case According to Cerbone

The case as outlined is complex. I think as a scientist-practitioner, so I formulate hypotheses based on the data provided and try as systematically as possible to gather information from the client that will confirm or disaffirm these hypotheses. Depending on the answers to questions, I will revise hypotheses.

I also reference research and professional consensus frequently with a client to keep the therapy as evidence-based as possible. As a scientist practitioner, I think it important not to assume even the obvious but listen very carefully and caringly to Erol. The first goals are to establish an accepting and affirmative environment. Then, normalize his feelings of distress as much as possible and make sure Erol feels I understand him, as he wants to be understood.

At some point, sooner than later, I would want to know if/how his history as a black male is an important consideration to understanding him. Has he experienced any microaggressions or macroaggressions (racial stigma)? With this in mind, I would ask Erol how it felt to begin counseling with a white male and ask if he would prefer to work with an African-American therapist.

Now to questions I have about Erol and his dilemma:

  • What is the distress he feels in having a relationship with Andrew? When did the relationship become romantic? Was this a surprise for him or had he harbored an attraction for Andrew before his wife died? (His guilt toward his wife may have antedated her death.)
  • How did his wife die? Was it expected? How old was she?
  • What was his relationship with his wife like? Were they happy together? Were they monogamous? Did either of them ever stray? Does Erol believe she was aware or suspect of any same-sex attractions in him or his feelings for Andrew? Of Andrew for Erol? What are/were his attitudes toward same-sex relationships? His wife's? (In later sessions I would gather more extensive information about Erol's courting and marriage.)
  • How has his relationship with Andrew affected his understanding of his sexuality? His sexual identity? Had he had any same-sex feelings before? Before he met/married his wife?
  • How aware does he think his children are of his relationship with Andrew? Why does he fear that he will lose them if he discloses his relationship to them? Are they grounded in family history? Do these fears arise from internalized homophobia?
  • Is Andrew pressing him to disclose? If so, what are its effects on him? Or does his guilt arise from his own expectations of self?
  • Does he want counseling to help him resolve the “double life? Data suggest that coming out improves mental health. Does he know this?
  • How does being 63 affect his feelings of loss and his new relationship with Andrew? How old is Andrew? Are they in the same age cohort? What race is Andrew? How open is Andrew about his sexuality? How long has he been out?

These and a hundred other such questions crowd together and seek answers. The factors generating them arise from experience counseling men in similar circumstances over my many years in practice.

Some of the major factors (in no order of importance) in Erol's case are:

  • Personal beliefs about same-sex attractions and relationships (sexual stigma).
  • Grief over the loss of his wife of 39 years and the life he had expected as they aged together.
  • Coming out challenges, including the loss of a heterosexual identity.
  • Balancing personal needs with those of a new partner, especially about coming out.
  • Age cohort concerns, e.g., aging and the inevitability of his death.
  • Racial stigma.
  • Relationships with his children.

Cerbone's experience working with similar cases is evident in his line of questioning. One of the defining differences between same-sex and heterosexual couples is that of stigma. His questions offer us many options to explore the complexity of this case from a compassionate perspective. His greatest piece of advice: “Don't assume. Listen first.” We encourage dialogue about this case and Cerbone's perspective. If you have an interest in submitting a case or offering a perspective about a future case, please do not hesitate to contact our committee.