The Great Mirror of Same-Sex Love - Prose - 32. Robert Fish “Keith asked a number of questions”

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from Coming Out Issues for Gay and Lesbian

Mental Health Professionals in Voluntary and Involuntary Settings

Unlike racial minorities, who are usually recognized by common physical characteristics, most Gay and Lesbian individuals are challenged continuously with whether to self-disclose their orientation (come out) in almost every social, and in many professional, situations. The Gay or Lesbian therapist faces a decision other minority-group therapists do not confront, that of whether to disclose their orientation to colleagues, consultees and patients.

On a community level, coming out is an important act because it helps to break down societal prejudices against Gay and Lesbian people by forcing heterosexuals to compare their stereotypes of “h*m*s*x**ls” to an actual Gay and Lesbian person whom they already know, love, and / or respect. In large part, the re-conceptualization of being Gay within psychiatry from pathology to a normal variant of human behavior was due to Gay and Lesbian therapists coming out to their colleagues and demanding recognition of a growing body of evidence that demonstrated no relationship between orientation and psychopathology (McHenry & Johnson, 1993). While high levels of discrimination against Gay men and women still exist, the coming out of increasing numbers of them is believed to have significantly ameliorated heterosexuals’ negative stereotypes of Gay men and Lesbians (Barbone & Rice, 1994).

The author made the decision to be open about being Gay with all mental health colleagues in all the settings where I have worked as a professional. Being out with colleagues makes the work situation more rewarding and also serves to challenge stereotypes and advocate for non-biased treatment of Gay and Lesbian patients by the mental health profession. However, this chapter proposes that the decision about whether or not a [therapist should] come out to patients is more complex and should be in the best welfare of the patient considering the patient’s level of functioning, the patient’s cultural background, the type of intervention, and the setting within which the patient is being seen. The unique challenges of providing consultative and therapeutic services in institutions also make the decision to come out in institutional settings more complex than more traditional treatment settings. Mental health professionals are increasingly called upon to provide consultation and treatment to patients in situations different from the traditional outpatient and hospital inpatient settings. This chapter will examine this issue in relationship to the author’s experience working in […] a shelter for abused and neglected children and adolescents. […]

Theoretical Orientation and Relationship to Therapist Self-Disclosure

Attitudes toward self-disclosure vary depending on the therapist’s theoretical orientation, ranging from the classical psychoanalytic advocates of the therapist as a “blank screen,” to some humanists, exemplified by Jourard (1971), who advocated that the therapist adopt an attitude of “transparency.” Behaviorists generally favor self-disclosure when the disclosure permits the patient to model desirable behavior exemplified by the therapist’s disclosure (Weiner, 1978).

Studies on Therapist Self-Disclosure

Much of the early research in self-disclosure was based on the research and theories of Jourard (1971). Jourard postulated that since “disclosure invites or begets disclosure” (Jourard, 1971, p. 14), and since disclosure by the client was necessary for therapeutic change, therapists should share with clients experiences similar to those with which the client was struggling.

Jourard’s approach was based on a good deal of his own research (Jourard, 1971), and some subsequent studies have supported his position. For example, two analogue studies of undergraduate students’ perception of a therapist who disclosed either personal therapy experience (Fox, Strum, & Walters, 1984), or personal life experiences similar to those of the patient (Lundeen & Schuldt, 1989), found that subjects rated the self-disclosing therapist more favorably on personal and therapeutic characteristics than the non-disclosing therapist.

However, other research has indicated that the relationship between therapist self-disclosure and client behavior is more complicated than Jourard (1971) anticipated. For example, Wetzel and Wright-Buckley (1988) found that for Black female undergraduates disclosure by a Black therapist increased the number of client disclosures, while disclosure by a white therapist decreased the number of client disclosures. […]

Benefits and Risks of Coming Out to the Gay, Lesbian or Bisexual Patient

The effect of coming out to the Gay, Lesbian, or Bisexual patient depends on both the patient, the timing and how the self-disclosure is worked through. Three possible benefits have been identified with coming out to patients. The first benefit is based upon the fact that many Gay and Lesbian people early in the coming out process lack positive role models (Rochlin, 1981; Troiden, 1988). The knowledge that someone like their therapist, whom they hopefully respect and look up to, is Gay can allow the patient to establish a positive identification (Schwartz, 1989). The second benefit is that by coming out the therapist may reassure the Gay and Lesbian patient that their therapist does not devalue or judge them because of their orientation. The third benefit is that by coming out, it “increases the likelihood that the therapist will, at some point, become the focus for projection, displacement, and stereotypical perceptions . . . this creates the opportunity for interpretation, cathartic attenuation, and cognitive reworking of these attitudes and introjects” (Malyon, 1981, p. 64).

However, there are at least three risks to coming out to patients if the Gay, Lesbian or Bisexual patient is deeply conflicted over his or her orientation. The first risk is that it may prompt the patient to devalue the therapist or the therapy (Malyon, 1981; Schwartz, 1989). The second risk is that the conflicted patient will interpret the disclosure as a pressure toward the therapist’s orientation (Sophie, 1987). And the third risk is that the patient can interpret the therapist’s self-disclosure as a seductive move (Sophie, 1987). All of these negative reactions can impede therapeutic progress or result in premature termination. […]

Self-Disclosure in an Institutional Setting […]

Because I believe caution should be exercised in self-disclosing to severely disturbed patients, I chose not to disclose my orientation (or any other personal data such as religious beliefs, age, or marital status) while working in institutional settings. However, I believe that the Gay or Lesbian therapist should never deceive the patient, directly or subtly, into believing that the therapist is heterosexual. Often, patient uncertainty about orientation or other personal aspects of the therapist is helpful in exploring the patient’s conflicts. Genuineness does not require that the therapist disclose everything; only that what he or she does disclose is real and not phony (Patterson, 1974).

The utility of not answering the patient’s question is illustrated by the following case example. The example is drawn from work with an adolescent at a children’s shelter setting and illustrates the potential benefit of not responding in some cases to direct questions and instead working through the reasons for the patient’s question.

Case Example

Keith, a 17-year-old African American male, had recently failed, for the second time, placement at a group home for Gay and Transgender adolescents due to periodic episodes of assaultive behavior towards peers and staff, serious rule infractions, and sexual acting out in the placement. Keith had been in placement for several years due to a history of being abused and neglected by both parents. In the first therapy session, Keith asked a number of questions about the author’s personal life, including whether I was Gay, was I married, and had I been abused as a child. I chose not to answer any of these questions and questioned whether answers to any of these questions would help Keith decide whether or not to trust me. I also affirmed for Keith that his suspiciousness of me and other adults was rational and understandable in that he had been let down repeatedly by adults in the past. Keith persisted in demanding this information, alternating between questioning my competence and rationale for not answering, trying to trick me into answering, and trying to make me feel guilty by stating that if I really wanted to help him I would answer all of his questions. Exploration of what it would mean to Keith if I were straight or Gay yielded important insight into Keith’s conflicts by the end of the first session. Keith disclosed that he didn’t want to be Gay, that he believed that being Gay was a sin. Further, he often fantasized that “God will deliver me from the evils of h*m*s*x**l*ty.” Further exploration in subsequent sessions revealed that Keith projected his own self-hatred onto out Gay peers and staff at his prior placement and devalued them instead of utilizing them as role models. Because of this, he would then emotionally isolate from Gay or Lesbian staff and peers or pick verbal or physical fights with them.

When a patient asks a personal question of a therapist, it is most often a way of the patient asking if the therapist can understand and help with his or her problems. The client is asking “can I trust you?” While a therapist may choose not to answer the patient’s question directly, the therapist has to directly address the underlying question of trust or therapeutic progress will be halted. In addressing the issue of trust, the therapist should accept that he or she is not entitled to the patient’s trust, but must earn it.

The proper stance of the therapist when choosing not to disclose his or her orientation to the patient is not to covertly or overtly convey to the patient that the therapist is heterosexual. Instead, when the therapist intentionally leaves his or her orientation in question, the patient is allowed to project his or her feelings toward being Gay onto the therapist, and this facilitates the exploration of these feelings in therapy. Achieving ambiguity regarding orientation often comes naturally for male therapists, as the therapist’s emphasis on feelings and relationships is incongruent with the culturally based gender-role expectations of many patients.

An additional consideration in working with patients in institutional settings is that therapeutic contact is usually brief and crisis-focused. The focus typically for patients is on stabilization of psychiatric symptoms while in the institution and linkage with community services upon discharge for long-term treatment. Because of these limitations, therapist self-disclosure typically needs to be cautiously employed as the self-disclosure may have limited relevance to the patient’s current crisis and time for the disclosure to be worked through may not be available.

—Robert C. Fish,[i]

1997