Affirmative Therapy for Bisexual Clients: Therapists’ Competence, Self-Efficacy, and Clinical Approaches

The approach that mental health professionals have taken in working with gay, lesbian, and bisexual (GLB) clients has changed dramatically over the past 25 years. Once viewed as being pathological in nature-either a sociopathic personality disorder or a sexual deviation-homosexuality is no long conceptualized as a "disorder" and instead is viewed within the broader context of human diversity. Even with such changes, many mental health professionals nonetheless retain subtle biases against working with gay, lesbian, and bisexual clients, and often lack the necessary information for working with them effectively. This issue of In Session provides a series of articles designed to help practicing therapists to become better aware of those clinical issues if they are to work with GLB individuals-which they are likely to do.

This article discusses some of the key clinical issues for therapists to consider when working with lesbian, gay, and bisexual (LGB) clients. After a discussion of the biases that can influence psychotherapy, guidelines are given for conducting LGB-affirmative therapy that avoids these biases. Issues that therapists need to be familiar with in working with LGB clients include LGB identity development; couple relationships and parenting; LGB individuals as members of families; the unique stressors faced by individuals who are underrepresented in the LGB research literature (e.g., older LGB individuals, ethnic minorities, religious LGB individuals, bisexual individuals); and legal and workplace issues. An examination of the published literature is offered with particular emphasis given to the available empirical research. Lesbian, gay, and bisexual (LGB) women and men utilize therapy at rates higher than the general population (Bell & Weinberg, 1978; Liddle, 1996; Morgan, 1992; National Lesbian and Gay Health Foundation, 1988), and nearly all therapists report seeing at least one LGB client in their practices (Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991). Yet, the mental health professions have historically demonstrated heterocentric and homophobic beliefs, prejudices, and practices against LGB individuals, placing the burden of distress on the client and his or her possession of an illness (Goldfried, 2001). Indeed, some professionals continue to promote cures for homosexuality (Nicolosi & Nicolosi, 2002). Even when homosexuality is not viewed as pathological, mental health professionals need to consider the distress that antihomosexual bias can cause LGB individuals. Disregarding such factors may lead to erroneous and unfortunate attributions of the sources of distress in an LGB person who is seeking therapy. There is a dearth of systematic research on the unique therapy experiences of LGB individuals. Although theoretical work on the nature, etiology, and consequences of LGB identities abounds, little exists in the way of empirical studies on these issues. Thus, it comes as no surprise that when working with LGB clients, we as therapists are often inadequately equipped in our training to handle issues that are unique to LGB individuals (Phillips & Fischer, 1998). As a consequence, LGB clients have a right not only to be skeptical of our competence in handling their LGB-related issues but also to expect that we gain proficiency in handling any such issues that may arise in the therapeutic context. Although guidelines for conducting psychotherapy with LGB clients exist (American Psychological Association, 2000), there is a need for work that explicates these guidelines with the intent of making them more useful for clinicians. Important issues in the lives of LGB clients include LGB identity development, romantic relationships, family relationships, and parenting. There are a number of additional issues and considerations that are important to consider when working with certain members of this population (e.g., specific issues of concern to bisexual, ethnic minority, and older LGB individuals). The primary purpose of this article is to provide an overview of many of the issues we need to know about as therapists when working with LGB clients. As will be seen, some of these issues are based on clinical impressions and some on research findings. We first consider the ways that heterocentrism and homophobia affect LGB individuals and some of the potential therapeutic biases that may arise when working with LGB clients. Toward the goal of encouraging an LGB-affirmative approach to therapy, several of the specific issues confronting our LGB clients are then discussed.

In April 2003 the Alberta government integrated specialized mental health services, formerly organized independently, with the health regions, which are responsible for general health services. The objective of this article is to determine whether the transfer was associated with an increase or decrease in the share of resources in the region allocated to mental health care relative to total spending for health care. The measure of the share for mental health care is the total costs for mental health care resources as a percentage of total health care spending. Resources and spending examined were those that were actually or potentially under the regions' control. Annual costs for mental health services in the province were obtained for a seven-year period (fiscal year [FY] 2000 through FY 2006) from provincial utilization records for all residents in the province. Unit costs were assigned to each visit. The trend in the share measure was plotted for each year. The share for mental health care increased overall from FY 2000 (7.6%) to FY 2003 (8.2%), but returned to pre-FY 2003 levels in the three years after the transfer (7.6%). Despite concerns expressed before the transfer by federal and provincial reports over the level of expenditures devoted to mental health care, the integration of mental health services with other health services did not result in an increase of the share for mental health care.

Mental and Physical Health Needs of Lesbian, Gay, and Bisexual Clients in Substance Abuse Treatment

Aim: Professional therapy organisations promote the importance of working with difference, yet subtle negative biases towards lesbian, gay, and bisexual (LGB) clients continue. Issues of competence in this area have only recently been addressed. This research aims to study the effectiveness of training to support therapists working with LGB clients in Britain. Method: Students (past and present) of an integrative counselling diploma course completed questionnaires including: background details, a Sexual Orientation Counselor Competence scale (Bidell, 2005), and two qualitative questions about previous learning relating to LGB issues. Quantitative analysis utilising a one way ANOVA test was used to compare the levels of competence at different times in training, and grounded theory to analyse the qualitative responses. Results: Results show that students have a high level of awareness, although a lower level measured in year two of the programme. The qualitative results indicate the learning value of personal experiences. Further themes describe the ways in which students learnt about LGB issues. Discussion: The reduction in scores for awareness may indicate that training facilitates a deeper understanding of self. Key themes indicate the importance of challenging old internal working models of sexual orientation. Implications for practice: The results will enable competences and effective learning experiences to be mapped in the curriculum.

Objective: COVID-19 restrictions precipitated rapid work practice changes for family and mental health practitioners, including care via telehealth and secondary exposures to COVID-19 induced violence in client. This descriptive study aimed to examine stress and health among practitioners during COVID-19 restrictions. Method: Participants, recruited via professional networks, were 320 maternal and child health (MCH), child and youth mental health (CYMH) and adult mental health (AMH) practitioners from Victoria, Australia. Participants reported family violence among cases, workplace stress, and mental and physical health problems during COVID-19 restrictions, via an online survey. Results: Rising family violence incidence, including emotional abuse and serious threats against a woman (>25%), child emotional abuse/neglect, and child exposure to family violence were reported. Higher violence was reported by CYMH and AMH than MCH practitioners. We found increases in practitioner stress due to workplace practice changes and exposure to family violence. Highest stress was among CYMH and AHM practitioners. Participants reported worsening mental (63.2%) and physical (51.2%) health. Negative affect was higher among CYMH than MCH participants. Conclusion: Findings demonstrate pressure on family and mental health workforces during COVID-19. Provision of training and support to manage secondary stress from exposures to trauma and changing workplace practices is indicated. KEY POINTS What is already known about this topic: (1) Family and mental health practitioners’ mental health is below normative levels due to exposure to secondary traumatic stress exposure and associated compassion fatigue. (2) Periods of natural and community disaster elevate pressure and distress among mental health professionals and contribute to risk for workforce attrition and among client families are also associated with increased risks for intimate partner violence due to financial pressures and inadequate and confined housing. (3) Concerns about family violence during COVID-19 lockdown restrictions have arisen from publicly available reports of increases in emergency department domestic violence-related injuries and urgent applications to the Family Courts, but research data pertaining to levels of family violence during COVID-19 are scarce. What this study adds: (1) Family and mental health practitioners, especially those in child/youth and adult mental health sectors, reported increased proportions of caseloads in which incidents of family violence occurred during stage-3 COVID-19 lockdown restrictions in Victoria, Australia, contributing to exposure of practitioners to secondary trauma. (2) Practitioners reported higher workplace stress (due to changed work practices and family violence) during COVID-19 restrictions and greater stress was related to greater negative affect, sleep problems, headaches, and gastrointestinal problems. (3) Urgent attention to training and support of family and mental health workers providing care to distressed families during periods of community and natural disaster is indicated.

Policy Recommendations to Promote Integrated Mental Health Care for Children and Youth.

Health Care Reform and Care at the Behavioral Health--Primary Care Interface

The purpose of this study was to explore (a) faculty members' beliefs about the ethics of reparative therapy and referring lesbian, gay, and bisexual (LGB) clients, (b) course content related to reparative therapy and referral of LGB clients, and (c) positions taken by programs associated with reparative therapy and referral of LGB clients. A total of 117 faculty members from accredited family therapy programs completed an online survey for this study. While the vast majority of faculty members reported that reparative therapy is unethical, there was less agreement related to the ethics of referring LGB clients, which may highlight the need for clearer ethical guidelines to regulate this potentially harmful practice. Implications for clinical training and future research are discussed.

Health Support Directed at Lesbian, Gay and Bisexuals: Socio-demographic Context and Education

Older lesbian, gay, and bisexual (LGB) adults face a unique set of challenges that intersect with both their sexual identities and the aging process. While society has made significant progress toward accepting diverse sexual orientations, older LGB individuals often remain marginalized and underserved. This narrative review explores the contextual factors that contribute to these challenges, including ageism, discrimination in health care, financial insecurity, mental health concerns, social isolation, intimacy, sexual health, and bereavement. The article highlights how these issues can be compounded by the historical stigmatization of LGB identities, creating barriers to receiving appropriate care. Additionally, it emphasizes the importance of culturally competent therapeutic approaches that address the specific needs of this population. The goal is to provide clinicians with strategies for offering affirming, compassionate care to older LGB adults, ensuring that their mental, physical, and emotional health needs are adequately met.

Responding to the Child Mental Health Emergency: Future Pediatricians to the Rescue?

A Multilevel Approach for Reducing Mental Health and Substance Use Disparities Affecting Bisexual Individuals

This new column provides an overview of mental health reforms in Latin America and the Caribbean. Progress has been particularly visible in countries that have implemented policies with strong political support (Brazil, Chile, and Belize, among others). However, lessons may be learned from the collective experience of a region that has faced multiple obstacles to reform. Available resources are still insufficient and inequitably distributed, reform implementation is not complete in most countries, and high levels of unmet need exist. Countries face new challenges related to growing psychosocial problems affecting children and adolescents and increasing violence, which require new responses from mental health services.

The rising prevalence of mental health conditions continues to place significant pressure on general practitioners (GPs) and general practice. Despite their critical role in managing mental health conditions, GPs and practice staff face substantial barriers in providing effective mental health care, such as time and financial constraints. A new mental health model of care (Link-me+EMPHN) aimed at engaging and building capacity in GPs and practice staff for the provision of mental health services is being designed and implemented in a Primary Health region in Victoria, Australia. This protocol describes formative research that aims to support the implementation of the Link-me+EMPHN Mental Health Model of Care in general practice, focusing on identifying current gaps in GP mental health training, assessing barriers and facilitators to implementation, exploring stakeholder perceptions and experiences, and determining needs and priorities for successful integration into routine practice. The formative research involves a multimethod approach comprising (1) a desktop audit of currently available mental health training and guidelines for GPs; (2) up to 20 semistructured interviews with GPs and practice nurses; (3) an online survey exploring current mental health care practice of GPs and practice nurses; (4) two co-design workshops with people with lived experience of mental health care help-seeking in general practice and four expert working group workshops with a multidisciplinary primary-care team; and (5) testing of the model of care in a simulated practice setting with GPs, patients, and Care Navigators. The desktop audit, online survey, and interviews will be mapped to the Theoretical Domains Framework to systematically identify gaps in GP knowledge and skills in providing mental health care. Thematic analysis of the interviews will provide context for the gaps found in current mental health care and training so that we can begin to address these. Findings from each of the co-design, expert working group, and simulation sessions will be thematically analyzed and will include key themes, insights, and any practical implications. The formative research received funding in May 2024, with the formative research components taking place from May 2024 to July 2025. As of June 24, 2025, a total of 5 people participated in co-design, 14 in semistructured interviews, 28 in simulation sessions, 30 completed the online survey, and 4 working groups have been held. The desktop audit yielded 270 results. The findings of the formative research are tentatively planned for publication in 2026. This formative research will generate a robust understanding of the factors influencing GP and practice engagement in mental health care and will provide practical solutions to improve implementation of the mental health model of care. The findings will contribute to creating a sustainable and scalable model that improves mental health outcomes for patients and supports GPs. DERR1-10.2196/79560.