Adaptation of Standard CT for Depression

Given the invalidating climate in which LGB individuals typically are raised, it is imperative when working with this population that therapists not assume that all negative thinking is indicative of a cognitive distortion. Perhaps this is the greatest adaptation one needs to make when working with LGB patients. While attesting to the fact that lesbian and bisexual women generally have the same types of problems as nongay women, Wolfe (1992) suggested that irrational beliefs about need for the approval of others and fair treatment may lead to anger and discomfort for many lesbian and bisexual women given the continuing disapproval that they face from society at large. Therapists must recognize that the beliefthat others react negatively to an LGB person may in fact be true, and should be careful to follow the patient's lead regarding self-disclosure in various settings, while helping to evaluate the evidence for such beliefs. Patients who believe that people are hostile toward them at work may be seeing the world through a negative self-schema, or they may be accurately assessing their environment. There may be obvious distortions (e.g., a patient saying, "She walked right past my desk this morning and didn't say hello. I know it is because she doesn't like the fact that I'm lesbian") in which a patient clearly ignores the many rea sons that a person might neglect to say hello in the morning, regardless of their views about one's sexual orientation. However, other automatic thoughts may be less obviously distorted and might reflect actual experience, even if they sound outlandish on the surface. Consider, for example, a patient who said the following:

"I was talking with a representative from my high school class who had called to invite me to our 10-year reunion. She was very excited to hear about what I had done since graduation, and we caught up on some old friends. Several times she said she couldn't wait to see me. When I told her that I had been in a relationship for 3 years with [a partner of the same sex] she got very quiet and then said, 'I guess you are probably going to be really busy and unable to come.' I got the message loud and clear that I had just been uninvited, in a sense."

Given the classmate's initial interest and encouragement of the patient to attend, followed by an abrupt change of message after the patient disclosed the sex of the partner, it is very rational to conclude that the classmate was disapproving and withdrawing her invitation to the reunion, even though she did not say as much.

In cases when the patient does indeed have evidence for lack of approval, unfair treatment, or outright harassment from others, the therapist can take several steps to help. First, particularly with depressed patients, the therapist can discuss the meaning of the maltreatment for the patient. For example, some patient's believe that they deserve to be overlooked for jobs or promotions, because they have come to believe the negative information about LGB people and have negative schema that they are inferior. Others may not internalize the negative beliefs but may express hopeless thoughts that the world is not likely to change and that there is little place for LGB people to live happy lives. The therapist uses Socratic questioning, behavioral experiments, and other standard CT techniques to help the patient to see him/herself or his/her world more broadly. It is indeed true that the world can be a hostile place for LGB people, and it is also true that there continues to be progress toward understanding and acceptance of LGB people worldwide, however slowly that progress may occur. Second, the therapist can help the patient with problem solving, discussing possible ways to deal with the negative treatment, and help the patient to evaluate the pros and cons of the various options.

Safren and Rogers (2001) suggest several guidelines for conducting cognitive-behavioral therapy with LGB patients. First, therapists should identify their own assumptions and beliefs about LGB people. As in all cul turally competent therapy, therapists need to recognize their own blind spots or biases toward people different than themselves. This is especially important when a therapist holds negative beliefs about a patient. Therapists who believe that the only normal variant of human sexual behavior is heterosexual are likely to express that bias with LGB patients either overtly (offering a "cure") or covertly (ignoring conversation about same-sex sexual behaviors). On the other hand, therapists may assume that there are no differences at all between their LGB and their heterosexual patients, erring on the side of overconfidence in their skill in working with sexual minority patients.

Second, therapists need to assess how the patient's sexual orientation fits into the case conceptualization. This is extremely important to prevent the therapist from assuming that sexual orientation is a major factor in the patient's presenting problem when it is not, or alternatively, not seeing a relationship between the patient's sexual orientation and his/her presenting problem when clearly there is one. For example in the case of a male patient having unsafe sex with multiple male and female partners both sexual orientation and sexual behavior may be important considerations in the case conceptualization. On the other hand, in the case of a male patient in a long-term relationship who is open and "out" to his family, friends, and cowork-ers, and who presents with reactive depression following the death of his father, sexual orientation may play a negligible role in the case conceptualization.

The third recommendation is that therapists need to acknowledge the impact of societal norms on the negative beliefs a patient may hold about same-sex sexual attraction. This can become complicated for the therapist who wishes to work collaboratively with patients without promoting his/ her own agenda. For example, a patient may hold negative beliefs about his or her sexual attractions because of deeply held religious beliefs. Although the therapist would not attempt to question the religious beliefs, it would still be important to understand that, apart from the societal proscriptions, the patient might be quite happy being attracted to persons of the same sex. The imposed societal norms and mandatory heterosexuality may be at the heart of the problem. Fourth, it is important for therapists to assess the extent of social support the patient receives.

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