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Cognitive-Behavioral Therapy With Lesbian, Gay, …

215 Cognitive-Behavioral Therapy with Lesbian, Gay, and bisexual Youth Steven A. Safren, Massachusetts General Hospital~Harvard Medical School and Fenway Community Health, Boston Gary Hollander, University of Wisconsin Medical School Trevor A. Hart and Richard G. Heimberg, Temple University The purpose of the present paper is to sensitize cognitive -behavior therapists to issues that are faced by many lesbian, gay, and bisex- ual youth. Little information is available to Cognitive-Behavioral therapists about same-sex sexual attractions in lesbian, gay, and bi- sexual youth, or how to incorporate these concerns into one's functional analysis and treatment plan.

215 Cognitive-Behavioral Therapy With Lesbian, Gay, and Bisexual Youth Steven A. Safren, Massachusetts General Hospital~Harvard Medical School and Fenway Community Health, Boston

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Transcription of Cognitive-Behavioral Therapy With Lesbian, Gay, …

1 215 Cognitive-Behavioral Therapy with Lesbian, Gay, and bisexual Youth Steven A. Safren, Massachusetts General Hospital~Harvard Medical School and Fenway Community Health, Boston Gary Hollander, University of Wisconsin Medical School Trevor A. Hart and Richard G. Heimberg, Temple University The purpose of the present paper is to sensitize cognitive -behavior therapists to issues that are faced by many lesbian, gay, and bisex- ual youth. Little information is available to Cognitive-Behavioral therapists about same-sex sexual attractions in lesbian, gay, and bi- sexual youth, or how to incorporate these concerns into one's functional analysis and treatment plan.

2 Howeveg, lesbian, gay, and bisexual youth may be at risk for a variety of clinical problems amenable to Cognitive-Behavioral Therapy . We provide necessary information for the incorporation of issues concerning same-sex sexuality into one's case formulations when working with lesbian, gay, and bisexual youth, illustrated by case examples and clinical vignettes. AY, LESBIAN, and bisexual youth are a subpopulation of youth at risk for a variety of clinical difficulties, including depression, substance abuse, and suicidality, as well as homelessness, school problems, and family discord (see Anhalt & Morris, 1998; Moscicki, Meuhrer, & Potter, 1995; Safren & Heimberg, 1999; Savin-Williams, 1995; Savin-Williams & Cohen, 1996).

3 While there is no reason to believe that Cognitive-Behavioral Therapy would be less ef- fective with bisexual , gay, and lesbian youth than with het- erosexual youth, little has been written about how to inte- grate issues of sexual orientation into Therapy with younger individuals. However, there are unique clinical issues that should be incorporated into a thorough case formulation and functional analysis when working with adolescents struggling with same-sex sexual attractions. The purpose of the present paper is to sensitize cogni- tive-behavior therapists to issues that are faced by many lesbian, gay, and bisexual youth.

4 We provide initial neces- sary information for the incorporation of issues concern- ing same-sex sexuality into one's case formulations, illus- trated by case examples and clinical vignettes. The scope of clinical work with gay, lesbian, and bisexual youth is large, and therefore, no single article can address every issue that members of this population may face. Thus, as always, Cognitive-Behavioral therapists should employ id- iographic assessments and be sensitive to internal and ex- ternal factors that may or may not be outlined in the present discussion (see Persons, 1989).

5 Despite increased distress among gay, lesbian, and bi- sexual youth, and the critical importance of providing CognRtve and behavioral Practice 8, 215-223, 2001 1077-7229/01 Copyright 2001 by Association for Advancement of Behavior Therapy . All rights of reproduction in any form reserved. L~ Continuing Education Quiz located on p. 279. Cognitive-Behavioral Therapy in an affirming way when approaching work with this population, clinicians do not have sufficient knowledge of, and training programs do not adequately prepare psychologists for work with , sex- ual minority populations.

6 Anhalt and Morris (in press) surveyed graduate students in behaviorally oriented clin- ical psychology doctoral train- ing programs, who overwhelm- ingly reported minimal training in gay, lesbian, and bisexual issues and feelings of inade- quacy in working with lesbian, gay, and bisexual individuals. Garnets, Hancock, Cochran, Godchilds, and Peplau (1991) reported on the American Psy- chological Association's Com- mittee on Lesbian and Gay Concerns study, which re- vealed that psychologists vary widely in their adherence to the standards of unbiased practice with gay men and lesbians .

7 From this survey of 2,544 psycholo- gists, the committee learned There is no empirical evidence linking youth's sexual orientation per se to either the experience of emotional or behavioral problems or to the efficacy of Cognitive-Behavioral treatment. of high levels of bias in Therapy as demonstrated by mul- tiple episodes of automatically assuming a client is het- erosexual, assuming that problems are a result of sexual orientation, focusing on sexual orientation when not rel- evant or neglecting it when it is, derogating homosexu- ality, and underestimating the importance of same-sex relationships.

8 In utilizing Cognitive-Behavioral techniques with dis- tressed gay, lesbian, and bisexual youth, it is critical to un- derstand that there is no evidence linking youth's sexual orientation per se to either the experience of emotional or behavioral problems or the efficacy of Cognitive-Behavioral 216 Safren et al. treatment. Direct and indirect effects of homophobia and related stresses are believed to be the root of diffi- culties that may be more prevalent in youth with same- sex sexual attractions (see Garnets & Kimmel, 1993; Safren & Heimberg, 1999).

9 Therefore, a useful way to ap- proach treatment of distressed gay, lesbian, and bisexual youth is to acknowledge the different cultural experi- ences of these youth and heterosexual youth. Purcell, Campos, and Perilla (1996, p. 391 ) developed this idea by stating, " lesbians and gay men present unique political, social, interpersonal, and Direct and indirect effects of homophobia and related stresses are believed to be the root of difficulties that may be more prevalent in youth with same-sex sexual attractions. personal qualities that define culture.

10 " Accordingly, culture influences the impact of con- tingencies of reinforcement and the shaping of behavioral re- sponses. Clinicians working with this population will be most effective when they are aware of the different experiences, language, and "culture" asso- ciated with being a gay, lesbian, or bisexual youth. Similar to issues of cultural diversity, it is also important to consider the heterogeneity of experiences that exist within a minority population as well as stressors experienced by many members of the population. Al- though a great number of lesbian, gay, and bisexual youth experience the types of difficulties that are presendy dis- cussed, many do not.


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