Therapists working with LGB patients can readily use the same case conceptualization (Persons, 1989) they would use with non-LGB patients. Given the impact of minority stress on LGB patients (Meyer, 1995), however, therapists need to consider carefully the social context in which their patients live. Therapists should consider not only the social support the patient receives but also the social stress under which the patient lives (Smith & Ingram, 2004). Patient presentation is likely to vary dramatically depending on the patient's identification with a particular ethnic group, the geographic region in which therapy is taking place, the degree to which the patient is public about his/her sexual orientation, and his/her spiritual or moral values. Many of these factors will also covary. For example a male, European American middle-class patient from a large, liberal, coastal city may feel completely comfortable being open about his sexual orientation, may work in an environment that includes sexual orientation in antidiscrimination policies, and may have a very supportive gay community in which he participates. In contrast, a Mexican American woman working as an aide in a day care center, who strongly identifies with her family traditions and religion may experience a great deal of conflict over same-sex attractions, may find emotional support from family but not particularly feel supported over her sexual orientation, and may feel overwhelmed with stress about being lesbian or bisexual.
Many therapists see patients who engage in same-sex behaviors but do not identify themselves as lesbian, gay, or bisexual. For example not all African American men who have sex with men identify as gay, and they may in fact primarily identify with the African American rather than the gay community (Mays, Cochran, & Zamudio, 2004). In some cultures, such as Latino culture, men are identified as homosexual only if they are an anal-receptive partner in sex (Zamora-Hernández & Patterson, 1996). Much of the research on coming out and becoming involved in LGB communities has been based on samples of white LGB people, and therapists should expect great variety in the experience of patients from different cultural backgrounds (Smith, 1997).
When patients do not disclose their sexual orientation, there is not yet information that provides guidelines for what therapists might observe that would alert them to the fact that patients may have intimate relations with others of the same gender. Simple questions (e.g., "Do you date or have sex with women and men?") during intake can help. Such questions show the therapist's openness to the issue of patients having sex with people of the same gender or with both genders. Not all patients will see this as an innocuous question, however, and therapists may get an angry or puzzled response from some. Such a response can give the therapist further information about the patient's worldview that may be useful in case conceptualization. Some therapists may feel uncomfortable asking patients such questions in an initial interview. If so, keep in mind that asking questions is not imposing values on a patient; it is just information gathering. Most therapists would not find it embarrassing to ask a gay male patient, for instance, if he has sex exclusively with men. Therapist and patient discomfort with the reverse, asking a straight man if he has sex exclusively with women, comes from living in a society that has consistently represented homosexuality as deviant. In reality, the question is no different than asking someone whether they sleep 8 hours a night, and whether they wake during the night. It is information that therapists need to understand their patients fully.
A standard cognitive therapy (CT) case conceptualization is useful with LGB patients. Several specific areas of concern need to be addressed, however, that may not be considered with all patients presenting for therapy. It is important, for reasons I stated previously, to know how public the patient is about his/her sexual orientation and what descriptors the patient uses for self-definition. If the patient has "come out," then the age at which he/she did so may be relevant for a number of reasons. A patient who only recently has begun to acknowledge that he/she is LGB may still have conflict about his/her sexual orientation. Patients who have been out a long time may be well integrated into an LGB community, celebrate their sexual orientation, and be completely comfortable in their own skin. Given the homonegative environments in which most LGB people are raised, however, there may be residual negative beliefs. A common example is when a gay male patient specifies that he doesn't like "effeminate" men, or when a bisexual woman says she is not attracted to "butch dykes." They may be self-conscious about their own behavior and hold rigid beliefs about proper gender expression.
Case-conceptualization with LGB individuals is based on the method proposed by Persons (1989). In formulating a problem list to address in therapy, it is a good idea for the therapist to assess for problems in several specific areas. Following are some of the areas that should be considered in formulating the treatment plan.
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