Case Illustration

Primarily, adaptation of CT for LGB patients consists of the therapist being self-aware about his/her biases and aware of contextual factors that contribute to the patient's depression. Sexual orientation is often not an issue for patients. However, as the following case illustrates, a patient may have a long and arduous struggle reconciling sexual orientation with opposing values. The patient held a negative view of himself as a gay man, and his belief that he would never find true love or happiness resulted in behavior that exacerbated his depression. He had developed a self-defeating pattern of engaging in anonymous sexual encounters that were immediately reinforcing but ultimately confirmed his self-effacing beliefs.

The patient, Lance, represents someone struggling to reconcile his sexual orientation with his religious upbringing. Lance, a 27-year-old male, was referred for CT by his primary care physician, who thought that he needed treatment for depression or possible dysthymic disorder. Lance was gainfully employed in the computer industry and lived alone in a small condominium that he owned. The youngest of four children, Lance's parents were still married and were regular church attendees in a conservative Christian denomination, as were his three older siblings. All of his older siblings were married with children. None of his family lived in the same city as Lance. He was in regular communication with his parents and kept in contact with his nieces and nephews by sending birthday, Easter, and Christmas gifts. Lance did not feel particularly close to any of his siblings, and he reported that his relationship with his father was better than that with his mother. He had told his parents about his sexual orientation, and whereas his father had told Lance that he loved him "no matter what," his mother said, "I don't want to know these things, and I'll pray for you. The Lord will heal you." Neither response felt particularly comforting to Lance, although he thought his father was certainly more accepting than his mother had been.

Another contextual factor affecting Lance's case was that his mother had apparently been depressed during a period of Lance's youth. He stated that when he was in the seventh or eighth grade, she had stopped attending church for about a year, spent most of her days lying on the couch, and was very irritable with the four children. He recalled his father telling the children that she was "ill," and he and his siblings made a special effort to be quiet and well behaved. Because his parents never talked openly about such things, Lance could not be sure whether his mother was depressed but he thought she very well might have been.

Lance almost married a woman to whom he was engaged for 1 year, when he was 24 years old. His decision to tell her that he needed to break the engagement because he was gay prompted his coming out to his parents. Notably, his siblings were still unaware of his sexual orientation, and Lance did not tell them because he feared they would not let him be in contact with his nieces and nephews. He believed his parents were keeping his dis closure to them confidential. Lance identified as gay. He said that he used to believe that everyone was heterosexual, and that some people were simply heterosexual and ill. After trying to change his sexual orientation and to become erotically attracted to women through a variety of methods, including prayer and counseling, Lance recognized that his sexual orientation was a part of him and that his efforts to change had been in vain. It was at this point that he broke his engagement with his fiancée and told his parents that he was gay.

From this account it is clear that significant public pressure to be heterosexual and a history of subjection to negative bias played a role in Lance's beliefs about himself. Lance wanted to have a fulfilling relationship and grieved over not having a family and children. He believed that men did not really love one another, rather, they used one another for their own gratification. He occasionally had anonymous sex with men for physical release but never dated. He felt extreme guilt after every sexual encounter. Lance had considered committing suicide. He had a BHS score of 18 when he began therapy and a BDI-II score of 42. He denied a plan or intent to commit suicide and stated that for religious reasons he would not kill himself.

In this case it was important that the therapist not only take an affirming and nonjudgmental stance, but also that Lance's struggles over his sexual orientation be considered an important part of the case conceptualization. Therapists can err by either colluding with a patient in pathologizing nonheterosexual sexual orientation or by being overly affirming and invalidating the patient's struggle. The therapist used a case formulation approach that included developing a problem list (Persons, 1989), as well as a cognitive conceptualization (J. S. Beck, 1995).

The problem list included frequent absences from work due to depression, negative beliefs about self, anonymous sexual encounters, and feelings of guilt, shame and social isolation.

The cognitive conceptualization included:

Core belief: "I am defective."

Intermediate beliefs: "Because I am gay, I will always be alone. I should be heterosexual."

Samples of automatic thoughts were as follows:

Situation: A man gives Lance his telephone number at the gym.

Automatic thought: "He thinks I am just interested in sex."

Feeling: Sad, anxious.

Situation: Lance's nephew calls to tell him that he was selected for the little league team.

Automatic thought: "I'll never have a family."

Feeling: Sad, despondent.

In spite of the distress Lance experienced over his sexual orientation, one of his stated therapy goals was to be comfortable as a gay man. This was an essential goal for the therapist to understand. Some patients experience tension between religious beliefs, cultural allegiance, and sexual orientation. The patient's goals for therapy help the therapist to understand how best to assist in resolving this tension. Lance did not believe the tenets of his religious upbringing, although he expressed a desire to regain a sense of spirituality. His shorter-term goals were to feel less depressed, to reengage with life, and to maintain consistent work performance, so that his job would not be jeopardized.

The therapist first worked on behavioral activation strategies to break the patterns of avoidance that were developing. Lance scheduled routine activities such as cleaning his condominium, calling his parents, and attending mandatory meetings at work. His inertia and avoidance regarding work were complicated by the fact that he was allowed to work remotely from home in his company and frequently used this as an excuse to remain in his pajamas all day long, occasionally responding to e-mail but doing very little else. Thus, the activity scheduling included actually going to the office, regardless ofhow he felt or whether he could successfully work from home.

Lance was also keeping data about his general activities and using thought records to record automatic thoughts. He began to make a connection between his belief that he was defective and would never have a family, and his anonymous sexual encounters that left him feeling guilty. The first belief that he began to test was that men did not have loving relationships with one another. His therapist recommended a book on male couples, and Lance agreed to do a behavioral experiment to locate and interview men who were in couples. He was to ask how long they had been together, what their living situation was like, and what they believed was positive about their relationship. A small dinner party hosted by a lesbian friend provided the opportunity for Lance to do the experiment, because there were two male couples in attendance.

A second behavioral experiment was attempted to assist Lance in reclaiming his "spiritual self." It had been his belief that all Christian churches condemned LGB people or, alternatively, those that did not were not really Christian. His assignment was to locate and attend churches that were openly affirming of LGB members. Some of the churches he attended had predominantly LGB members, and others were mainline denominations that publicly expressed inclusivity. Lance discovered that several churches were similar to the church in which he had been raised but included LGB people as active members of the congregation. He decided to attend one in particular and joined a Bible Study class that met once a month at the home of one of the gay male church members. Attending such a group, according to Lance, was a complete contradiction of his belief that it was impossible to be gay and spiritual.

Lance completed therapy after 25 sessions. His BDI scores had dropped significantly over the course of therapy, and by Session 25, his scores had been below 9 consistently for three sessions. He still had not met a partner, and wished to do so. He had begun to develop close friendships with several men and women from his church. He was making better choices about sexual behavior, getting acquainted with men prior to becoming sexual, and felt much less guilt about his choices. He had begun to integrate sexuality as an important part of his life and stated to his therapist, "It is time for me to claim my right to have a full life, and I think that I can finally enjoy this life that I've got."

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