NCE STUDY – Understanding LGBT Clients…

(((I am currently studying for a licensure exam & completing an internship.  This blog post is intended as a study exercise.)))

PART ONE: A Literature Review Paper…

According to research, higher rates of mental health diagnosis, substance abuse and suicidal ideation exist within the LGB by community (Biescheke, et al, 2007, Hays & Iwasama 2006; Herek & Greene, 1998).   With mental health diagnoses concentrated in the areas of anxiety, depression, and suicidal ideation, it is important to note these issues are commonly correlated with “minority stress” in research, (Biescheke, et al, 2007, Hays & Iwasama 2006; Herek & Greene, 1998). Defined as a form of social stress related to stigmatized minority status, it will be essential to start off with a discussion of this concept. (Meyer, 2003, p675).

In this paper, I begin by discussing the concept of “minority stress”. I then discuss key issues common within the LGB community: identity development, coming out, and internalized homophobia. I conclude by providing a summary of how these key issues affect LGB youth and how to develop a treatment plan with these factors in mind.

Minority Stress.

In attempting to understand the concept of minority stress, it is vital to understand how discrimination exists as its cause. With social discrimination bringing about a stigmatized status amongst LGB minorities, the result is the minority stress they are forced to contend with (Herek & Greene, 1998; Meyer, 2003)

Discrimination as Cause.

Firstly in contextualizing the nature of minority stress, it is important to understand the nature of the discrimination they encounter. In a book titled “Stigma and Sexual Orientation” there is a brief review of research that examines the underlying motivations of assaultive acts against LGB victims. The conclusions made from this research are that assaults on LGB individuals can be seen as resulting from motives best defined as “a learned form of social control of deviance”, (Herek & Grene, 1998, p7). In this respect the motives aren’t entirely personal in nature, but simply an extreme form of gender norm reinforcement, (Herek & Greene, 1998).

“To reconcile the apparent contradiction between the socially normative attitudes held by assailants and the visciousness and brutality of their behavior….during the course of my research I came to conceptualize the violence not in terms of individual hatred but as an extreme expression of American cultural stereotypes and expectations regarding male and female behavior…From this perspective, assaults on homosexuals and other individuals who deviate from sex role norms are viewed as a learned form of social control of deviance rather than a defensive response to personal threat.” (Herek & Greene, 1998, p7)

Stigma as Cause of Minority Stress.

With this perspective in mind it is important to note that the definition of stigma is simply a “characteristic of persons that is contrary to a norm of social unity”, (Herek & Greene, 1998, p108). Key aspects of the underlying causes of stigma exist external to the individual. Additionally, when you note that such a stigma is associated with an elemental component of one’s overall identity, the result is minority stress. Understanding the nature of this minority stress as comprising an array of interrelated individual and social factors is essential, and will be discussed next.

The Nature of Minority Stress.

It is clear, when taking time to understand the nature of minority stress, it exists as an interrelated set of social, group, and individual components, (Meyer, 2003). For example, society is comprised of social structures that appear to stand against an LGB minority lifestyle. Additionally, the social environments in which an LGB individual lives often create a meaning system that completely negates their experience (Meyer, 2003).   Against these social factors, are other variables such as family dynamics, social environment, and individual factors that also play a part. For example, individual factors such as methods of handling stress and forms of cognitive appraisal influence the nature these social factors have on a person:

“The more an individual identifies with, is committed to, or has highly developed self-schemas in a particular life domain, the greater will be the emotional impact of stressors that occur in that domain.” (Meyer, 2003, p678)

Distal / Proximal View of Minority Stress

In attempting to bring some clarity to the interrelated factors that comprise minority stress, a research article I found (Meyer, 2003), describes an interesting perspective of stress worth mentioning. Firstly, this research proposed that stress is comprised of three components as discussed in the following quote:

“I have previously suggested three processes of minority stress relevant to LGB individuals. From the distal to the proximal they are (a) external, objective stressful events and conditions (chronic and acute), (b) expectations of such events and the vigilance this expectation requires, and (c) the internalization of negative societal attitudes. (Meyer, 2003 p676)”

While well beyond the scope of this paper, the article then goes on to provide some discussion of how such factors are interrelated.   The crux of this theory’s proposed stance is that such abstract social concepts become relevant psychological through the manner in which we decide to cognitively appraise them (Meyer, 2003, p676).

Common LGB Issues

In attempting to further put into perspective key issues common within the LGB community, a few key observations can be made that help put them into context.   In this section I discuss three key issues in the LGB community: (1) identity formation, (2) coming out, and (3) cognitive appraisal.

Identity Formation.

“In social identity theory and identity theory, the self is reflexive in that it can take itself as itself as an object and can categorize, classify, or name itself in particular ways in relation to other social categories or classifications.” (Stets & Burke, 2000, p224).

As the above quote indicates a person’s identity is essentially an internalized subjective construct of “you”. (Stets & Burke, 2000). In this respect, it can be thought of as a byproduct of our interpretations. For individuals with a sexual minority status, developing a positive identity is problematic as a result. (Bieske, et al, 2007, p19).

Before going further it must be noted briefly, that much in-group diversity exists within the LGB community. For example, contextual factors such as cultural background, sexual preference, and gender orientation influence individual LGB identities. Adding to these factors is the historical context within which a person lives.   Finally, adding to the confusion is the fact that the three components of sexual orientation (same sex identity, same sex behavior, same sex attractions) don’t exist in equal degrees with all LGB identifying persons, (Hays & Iwasama, 2006). Finally, while stage theories help to conceptualize the identity formation process, it must be noted, that identity development isn’t necessarily experienced like that first-hand. Instead often described as a fluid and abstract notion, it is more accurately understood as a lifelong process.

Coming Out.

It is important to note, that unlike many minority groups, LGB individuals have the option of concealing this stigmatized status (Hays & Iwasama, 2006). Early on in the process of LGB identity development, this concealment is often an essential coping mechanism. Having said this it should also be noted that coming out “is associated with lower psychological stress” (Hays & Iwasama, 2006, p224).

Internalized Homophobia.

Another key factor to note, that makes the LGB community unique amongst all minority groups, is their status is often not shared within the family (Hays & Iwasama, 2006). As a result, LGB individuals are often raised within a cisgendered, heteronormative environment to varying degrees (LGBTQA, 2014). The consequence of this is a learned belief system defined as “internalized homophobia” (Hays & Iwasama, 2006). Overcoming this is key in the coming out and identity formation process for LGB individuals.

Counseling LGB Youth.

In taking time to consider what the concept of minority stress means in the daily lives of LGB youth during key developmental years, concepts such as Marsha Linehan’s “invalidation” and Brene Brown’s “shame” come to my mind.

LGB youth, in the early developmental stages of form an adult identity, often deal with the issues above as an internal struggle without little outside guidance.   In doing research for this paper, I found two great resources that were helpful in allowing me to develop a rudimentary understanding of how to begin to formulate a treatment plan for this community of individuals. In providing counseling for any LGB youth, the eclectic counseling perspective mentioned in our Hays textbook, (2006), would be my starting point. Key insights, such as what I discuss from these resources, will be helpful in the ongoing case conceptualization and treatment formulation process.

Early LGB Identity Development.

The first key insights I found beneficial were within the video link provided in the assignment description for this week. Titled, “Working with Gay/Lesbian Youth Clients”, this video provides samples of counseling scenarios with LGB youth clients. What I found most interesting were the varied stages of development displayed within each counseling session.   With each stage of development there exists a unique set of characteristics, and counseling considerations with each stage. I discuss each of these stages briefly below.

Identity Confusion Phase.

During this early phase of LGB identity development, the client is experiencing a growing internal awareness that is not well defined.   As noted earlier, the majority of LGB individuals often hold this minority status alone in the family. Without any family or friends to provide guidance, the growing internal awareness can be experienced at first as just “being different somehow” (Sage Productions, 2014). Often understood within a heteronormative family environment, the growing awareness of homosexuality exists against within an array of denial strategies.   Often not ready to admit such feelings outwardly, or put labels to things, ongoing self-rejection is an early core issue. Key goals during this stage include: (1) empathetic listening, (2) building trust, (3) validating confusion, (4) assessing suicide risk potential, and finally (6) probe for greater specifics regarding situations and associated feelings, (Sage Productions, 2014).

Early Identity Acceptance.

During the early identity acceptance stage there exists a clear awareness of the nature of one’s attraction. With a greater degree of awareness, there still exists much internal confusion and heightened degrees of anxiety in moving forward.   Key goals during this stage include: assessing the use of support systems and providing tools with which to address anxiety in a healthy manner (Sage Productions, 2014).

It is useful to note, in concluding my remarks on this stage with a brief quote from another resource that sheds light on the importance of a support system for LGB youths:

“Through reappraisal, the in-group validates deviant experiences and feelings of minority persons….It is important to distinguish between group-level and personal resources because when group-level resources are absent, even otherwise-resourceful individuals have deficient coping. Group-level resources may therefore define the boundaries of individual coping efforts.” (Meyer, 2003, p677)

Late Identity Acceptance.

With greater internal clarity and awareness of oneself, the process of coming out to oneself and others becomes the overarching goal during this stage. Continuing to assess the degree of clarity, helping clients to forge a new positive identity will be important focuses during this stage of the counseling process.

In concluding this brief discussion on LGB Identity formation, it must be noted that much in-group variation exists. An in depth discussion of this matter is well beyond the scope of this assignment. Therefore, this discussion is just a brief cursory overview that is helpful for me as a useful as a form of rudimentary case conceptualization.

Addressing Key Stressors For LGB Youth.

“Four stressors are of particular importance to lesbian, bisexual and gay youth, (a) overt acts of abuse, harassment, and violence, (2) development of one’s identity as a sexual minority person and related internalized homophobia, (3) disclosure of sexual orientation to others and related lack of adult social support, and (4) development of platonic and romantic relationships with other lesbian, gay male, and bisexual peers.” (Safran, et al, 2001, p217)

Understanding key issues associated with a stigmatized sexual minority status as an LGB youth is one critical matter that cannot go without mention. When you consider the overt expressions of hatred, heteronormative environments along with a scarcity of social support, the heightened risks to an individual’s well being become clear. An article titled “Cognitive Behavioral Therapy with Lesbian, Gay and Bisexual Youth”, lists stress reduction, anxiety, and depression as three key issues for individuals in this community, (Safran, et al, 2001).  I discuss each of these in turn briefly below:

Depression & CBT.

As per the cognitive behavioral perspective, stigmatizing experiences alongside negative environment factors and a “dysfunctional attribution style” are what lead to feelings of hopelessness in LGB a youth (Safren, et al, 2001). Utilizing CBT techniques such as cognitive restructuring are useful in addressing negative preconceptions of any same-sex attraction, (Safren, et al, 2001, p221).   Alleviating thinking errors such as “catastrophizing” (Safrem, et sl, 2001), and self-blame, can help with depressive systems. The importance of this consideration becomes clear in light of the higher rates of substance abuse and suicide associated with the greater prevalence of depression,

Anxiety & CBT.

It’s not surprising that LGB youth experience higher rates of social anxiety when you consider the lack of social support they often receive. In fact, preconceived “what if’s”, (often in the form of worst case scenario conceptions), frequently underlie this anxiety, and can produce an avoidance-based coping style. Ultimately, this fear of self-disclosure and social situations can only limit normal adolescent development.   Assisting LGB youth through cognitive restructuring and varied forms of social support can give these individuals a new frame of reference with which to move forward (Safran, 2001).

Stress Reduction & CBT.

“It is not the stressors themselves that cause depression but that one’s cognitive interpretation plays a mediating role. From a cognitive-behavioral perspective, external acts of homophobia, if occurring chronically, uncontrollably, or unpredictably, can lead to internalized homophobia, as well as helpless or hopeless attributions.” (Safram, 2001, p222).

Addressing one’s ability to cope with daily stressors is yet a final key priority that cannot go without mention. In fact, I find this notion of internalized homophobia as a root cause especially troubling. It will be useful to conclude this paper by discussing internalized homophobia (and the stress that comes with it), from within the framework of the earlier discussion.

Firstly, it is important to note that LGB discrimination is best understood as “a learned form of social control of deviance”, (Herek & Greene, 1998, p7). Stigma resulting from this is simply due to holding a characteristic which “is contrary to a norm of social unity”, (Herek & Greene, 1998, p108). Based on these definitions, internalized homophobia can be thought of as a stigmatized self-concept based on discriminatory experiences. This internalized homophobia, influencing ones identity and belief systems, produces minority stress as a result, (Herek & Greene, 1998; Meyer, 2003).

Having said all this, I conclude with the thought that it seems once belief systems of ourselves become internalized they exist as self fulfilling prophecies. We become what we believe we are and get what we are told is possible. CBT a can become a much-need coping tool in this by helping LGB youth understand they always have the ability to choose otherwise.

PART TWO: Exploratory Exercise Paper….

((ABSTRACT – In this paper I provide a summary of my experiences in joining in with an LGBTQI University Organization Meeting.  I start with a review of relevant literature and end with a discussion of insights gained.  From this experience I have concluded that continued service within this community is essential in order to serve it effectively as an LGBTQI ally.))

Initial Thoughts

Approximately, 33% of females and 37% of males have had a climax with somebody of the same sex after 18 (Rosenthal, 2005).  Additionally about 10% of the U.S. Population identifies as gay & lesbian (Rosenthal, 2005).  A quick literature review shows a higher rate of mental health diagnosis, substance use, and suicide within the LGBT community as a whole (Biescheke, et al, 2007; Herek & Green, 1998).    Additionally, mental health diagnoses heightened in the areas of depression and substance use (Biescheke, et al, 2007; Herek & Green, 1998).  Additionally, a book titled “Stigma & Sexual Orientation (Herek & Green, 1998), makes it clear that discrimination (and the stigma that exists as result) are predominant causes of these high rates of mental health and substance abuse problems.

To understand this discrimination as cause, it is important to step back and understand the concept of identity a bit.  As the above quote alludes to, identity is an internalized construct of the self, based on an interaction with others and the environment.  When you consider how discriminatory acts against one’s very identity, I can only imagine how stigmatizing and shame-inducing and invalidating this might be. Defined as “a characteristic of person’s that is contrary to a norm of social unity” (Herek & Green, 1998, p. 108), stigma can produce a highly problematic identity formation process.  When taken alongside ostracizing reactions of family and friends LGBT individual’s internalized homophobia, transphobia and minority stress are often the norm (Herek & Green, 1998).

Summary of my Experience…

(((Here I provide just brief excerpts from my paper, in order to show, that there is much left to learn.  As I have discovered, intention means little if there is no action to back it up.  Understanding the privilege that comes with being a cisgendered heterosexual is critical.  Ignorance is never an excuse for any shortcomings in my desire to act as an LGBTQI ally as a future counselor)))

The Importance of Community….

“An element included in virtually all sexual-orientation models is finding and developing some sort of connection to the LGBT community. Community is important in helping break the sense of isolation and despair that can occur from being different, which is an early piece of identity development, (Biescheke, et al, 2007, p. 213).”

The first thing that struck me was how welcoming and friendly everyone was.  While I am a cisgendered heterosexual, I felt an immediate belonging and camaraderie within the group.  As a bullied child with few friends, I also struggled in my teens and 20’s.  It is for this reason, that I immediately appreciated the efforts of this organization to provide members a chance to interact with others who implicitly understood them.  The interaction was light-hearted and fun.  We decorated cookies while watching a movie and engaged in casual conversation.

In-Group Trust.

Implicit social norms existed that presumed an understanding of relevant social norms.  These implied social norms appeared to allow a heightened level of trust to exist amongst participants regarding things such as proper rules of preferred pronoun usage for example.   As somebody mentioned to me at one point: “It is simply nice to just hang out and have fun”.  This comment really struck me as I came to appreciate in that moment the privilege of cisgendered heterosexual.   I was able to just be me unselfconsciously.  For example, the idea of being “clocked” as a trans person, puts you constantly on edge.  I came to realize how luck I was to not know what this is like.  The idea of in-group trust stands out as a essential from this perspective.  Community organizations such as this provide participants a chance to be themselves “unselfconsciously” as I live my life 100% of the time.

I left the experience wondering if my own ignorance regarding the LGBTQI community reflected what I’ve witnessed within the extended family as a biracial child.  While I cringed at the thought of this, I reminded myself that all I can do by denying this fact is perpetuate it.  Self-awareness, on the other hand, is ultimately empowering if it leads to change and growth.

“privilege also tends to isolate people, cutting them off from information and experiences related to specific minority groups that could be helpful and enrich their lives…privileged areas are often in those areas in which people hold the least awareness.” (Hays, 2008, p. 42).

Identity as a Foundation of Self

During this meeting I became aware elemental sexual preference and gender identity are as fundamental aspects of daily living.  While conceived of in black and white terms for the cisgendered heterosexuals,  these concepts in reality are much more fluid. This fact helped me understand better why LGBT community in Omaha was so protective.   I left this experience with a profound realization of how being LGBTQI can potentially affect  all aspects of your life.

In-Group Diversity

The LGBTQI community is very diverse and is an umbrella term that comprises many sub-groups.  For example, sexual orientations vary greatly from lesbian, gay, bisexual, and even asexual.  Additionally within the trans community you have concepts such as FTM, MTF, bigender, gender, trans, and genderqueer.

**Here’s a link to a list of terms that I could useful.
**Here are some tips to being a better LGBTQI ally.

In conclusion, it appears there is much left for me to learn.  Developing multicultural competency will be a life-long commitment & personal journey as I increase my understanding of those communities I hope to serve within.  


Bieschke, K.J., Perez, R.M., & DeBord, K.A. (2007). Handbook of Counseling and Psychotherapy with Lesbian, Gay, Bisexual and Transgender Clients. Washington D.C.: American Psychological Association.
Bilodeau, B.L. & Renn, K.A. (2005).  Analysis of LGBT Identity Development Models and Implications for Practice. Gender Identity and Sexual Orientation: Research, Policy and Personality. 111, pp. 25-39.  
Hays, P. (2008). Addressing cultural complexities in practice. (2nd ed.) Washington, D.C.: American Psychological Association.
Hays, P., & Iwasama, G.Y. (2006). Culturally Responsive Cognitive-Behavioral Therapy: Assessment, Practice, & Supervision. Washington, D.C.: American PsychologicalAssociation.
Herek, G.M. & Green, B. (Eds.) (1998). Stigma and Sexual Orientation. (Vol. 4). Thousand Oaks, CA: Sage Publications.
Johnson, R. (2013) Forensic and Culturally Responsive Approach for the DSM-5: Just the Facts. Journal of Theory Construction & testing. 17(1), 18-22.
LGBTQI (2014). About LGBTQI+ In Lincoln, Nebraska. Lincoln, NE: University of Nebraska Lincoln.
Mays, V.M., Cochran, S.D. (2001). Mental health correlates of perceived discrimination among lesbian, gay and bisexual adults in the United States. American Journal of Public Health. 91(11). 1869-1976.
Meyer, I.H. (2003). Prejudice, social stress and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin. 129(5). 684-697.
Rosenthal, H. (2005). Vital Information and Review Questions for the NCE and State Counseling Exams. Routledge.
Safren, S.A., Hollander, G., Hart, T.A., & Heimberg, R.G. (2001). Cognitive-behavioral therapy with lesbian, gay and bisexual youth. Cognitive and Behavioral Practice. 8. 215-223.
Sage Productions. (2014) Working with Gay/Lesbian and Youth Clients. Retrieved from:
Stets, J. E., & Burke, P. J. (2000). Identity theory and social identity theory. Social Psychology Quarterly, 63(3), 224-237. Retrieved from






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