Analysis of the Counselling Service Provision to a Specific Client Group
The client group I have chosen for this assignment is Lesbian, Gay, Bisexual and Transgender- People of Colour (LGBTQIA-POC). In this assignment, I will be using the acronym LGBTQIA to represent individuals who identifies as lesbian, gay, bisexual, transgender, queer/questioning, intersex or asexual. People of Colour (POC) is a term used to describe individuals from non-white or non-Caucasian backgrounds/ethnicities (Jackson, 2006).
Common Presenting Issues
According to Meyer (2003), stigma, prejudice and discrimination often create hostile and stressful environments that may cause mental health problems for minorities. LGBTQIA-POC are likely to experience social and psychological issues that are a bit different from those that affect heterosexual ethnic/racial minority individuals or White queers (Akerlund & Cheung, 2000). As LGBTQIA-POC belong to more than one minority group, they may face multiple challenges in a society which often only accepts heterosexuality as an acceptable orientation, and in which people of colour often experience negative social outcomes (Cyrus, 2017; Sutter& Perrin, 2016). Although there is research that shows LGBTQIA identifying individuals have an increased risk for mental health problems and individuals who face racism experience psychological distress, there is very little study done on the intersectionality of these identities and the resulting effects of multiple discrimination on mental health (Ross, 2017; Russell & Fish, 2016). LGBTQIA-POC are at greater risk to experience mental health related problems as the heterosexist stigma is much more prevalent within communities of colour than in White communities (Battle & Lemelle, 2002; Conron et al., 2015; Garnets, 2002; Green, 2000; Lemelle & Battle, 2004; Parks, Hughes, & Matthews, 2004; Parks, 2005). Research suggests that due to the racial, ethnic and/or cultural variations in norms, values, attitudes and beliefs regarding sexuality and gender identity of both minority and mainstream cultures, individuals from the LGBTQIA-POC community are more likely to experience a significant amount of psychological stress that could affect their physical and mental health (Diaz, Ayala, Bein, Henne, & Marin, 2001; Harper & Schneider, 2003; Meyer, 2003; Greene, 1997; Manalansan & Martin, 1996). Studies show that LGBTQIA-POC are subjected to multiple forms of micro aggressions and these individuals often experience unique stressors associated with their dual minority status (Balsam, Molina, Beadnell, Simoni, & Walters, 2011; Sutter et al., 2016). Along with facing cumulative discrimination and social exclusion, LGBTQIA-POC also face racism within the LGBTQIA communities, heterosexism within the ethnic minority communities and racial/ethnic discrimination in dating and close relationships (Ferguson, Carr, & Snitman, 2014; Kudler, 2007; Brown, 2008; Han, Proctor, & Choi, 2014). Some studies also found that LGBTQIA-POC are more likely to be objectified and sexualized by some White LGBTQIA individuals who want to fulfil their exotic fantasies/fetishes (Balsam et al., 2011; Han, 2007; Jones, 2010; Nabors et al., 2001).
Moradi et al. (2010) suggested that because of the inherent conflict and/or differences between ethnic/racial and LGBTQIA identities, the identities of White LGBTQIA individuals have been often construed as different from the identities of the LGBTQIA-POC. Furthermore, due to the intersection of the individual components of these identities, the subsequent identity formed is likely to be more complex, with risk of competition for saliency, conflict over incongruent values and beliefs, and unique lived experiences that are not fully understood by either group (Balsam et al., 2011; Khan, Illcisin, & Saxton, 2017). A study by McQueeney (2009) suggested that LGBTQIA-POC rely more on their ethnic/racial communities than on LGBTQIA communities. This may lead to these individuals endorsing their racial/ethnic communities over their sexual and/or gender identities, thus leading to internalized homophobia and/or concealment of their sexual identity and/or gender (Moradi et al., 2010; Szymanski & Gupta, 2009; Ward, 2005). Studies have found that internalized stigma (used here as an umbrella term for internalized transphobia/genderism and internalized homophobia/heterosexism) is associated with a variety of psychological distress like demoralization, helplessness, depression, anxiety, hopelessness, psychosomatic symptoms, low self-esteem, confused thinking, feelings of guilt, sexual problems, suicidal behaviours and AIDS-related psychological distress (Barnes & Meyer, 2012; Moradi et al., 2010; Newcomb & Mustanski, 2010; Rosser, Bockting, Ross, Miner, & Coleman, 2008; Quinn et al., 2015; Szymanski & Gupta, 2009). Therefore, individuals identifying as LGBTQIA-POC are more likely to experience these mental health related problems as well.
To avoid potential discrimination within their ethnic community, some individuals choose to conceal their sexual orientation and/or non-conforming gender identity (Frost, 2011). Concealment of one’s sexual orientation often leads to lower self-esteem, social isolation, mental health problems, substance use, suicide and high-risk behaviours (Ceballos-Capitaine et al., 1990; Frost & Bastone, 2007; Meyer, 2003). A study by Khan et al. (2017) predicted a positive correlation between multifactorial discrimination and poor mental health. The study found that individuals from ethnic/racial background identifying as LGBTQIA were associated with risk factors for severe depression, chronic stress, low self-esteem, anxiety and aggregated mental health scores (Khan et al., 2017). Some of the typical presenting problems that LGBTQIA individuals who are racial, ethnic and cultural minorities may experience include suicide ideations, depression, generalized anxiety, social anxiety, chronic stress, lower self-esteem, alcohol and substance abuse, identity crises, post-traumatic stress disorder, relationship problems and engagement with risky behaviour (Cochran, Mays, Alegria, Ortega, & Takeuchi, 2007; Consolacion, Russell, & Sue, 2004; Dubé & Savin-Williams, 1999; Sutter & Perrin, 2016). Other forms of marginalization related to factors such as age, geographical location, immigration status, English language proficiency, acculturation status, social class and disability (Bieschke, Hardy, Fassinger, & Croteau, 2008; Kertzner, Meyer, Frost, & Stirratt, 2008; Rosario, Schrimshaw, & Hunter, 2004).
Characteristics of Client Group
Individuals who are share one or more variables such as race/ethnicity, gender, age, religion, sexuality and social class are also generally more likely to share similar characteristics with each other (McPherson, Smith-Lovin, & Cook, 2001). LGBTQIA-POC are usually at a high risk of suffering from legal failures such as inadequate workplace protection and unequal pay, along with health and wealth disparities which results in them facing high poverty rates and economic insecurity (Taylor, 2015; Ward, 2008). Due to these barriers, individuals identifying within this group often find it difficult to financially provide for themselves and/or their families (Taylor, 2015). Individuals belonging to this client group are also more likely to face homelessness. Studies show that due to discrimination related to identifying as LGBTQIA in ethnic/racial communities, many adolescents are either thrown out of their homes by their families or they runaway due to the fear of being abused/mistreated at home (Page, 2017; Reck, 2009).
It is argued that LGBTQIA-POC are often pressured into concealing their sexual orientation due to fear or being discriminated against by their racial/ethnic communities (Aranda et al., 2015; Harper, Jernewall, & Zea, 2004; Rosario et al., 2004). A study by Moradi et al. (2010) suggests that LGBTQIA-POC are more likely to demonstrate greater resilience and experience lower mental health problems than LGBTQIA individuals who are from White Caucasian backgrounds. It is possible that LGBTQIA-POC may have learned more ways of coping with discrimination aimed at their sexuality or gender as people of colour are more likely to have experiences in dealing with discrimination based on their ethnicity or race (Cochran et al., 2007; Kertzner et al., 2008; Meyer, Dietrich, & Schwartz, 2009; Moradi et al., 2010; Singh & McKleroy, 2011). Another factor that plays an important role is language, whether it is verbal or non-verbal, spoken or written, it is one of the most important tools in communicating successfully, and often individuals who have grown up in non-English speaking countries often have a challenging time communicating (verbally or non-verbally) in western countries that predominantly speak English (Ikeda & Tidwell, 2009; Spencer-Rodgers & McGovern, 2002).
People of colour who identify as individuals belonging to the LGBTQIA community, typically do not access counselling services due to many reasons. One of the reasons why individuals from this client group may be reluctant to access counselling services, especially ones specific to the LGBTQIA community, may result from the LGBTQIA stigma prevalent in their racial/ethnic communities, and fear of being seen near these services (Frost, 2011). It is also possible that LGBTQIA-POC are more likely to come from ethnic minority communities where there is a high level of stigma attached to mental illness, which is why individuals from these groups choose not to seek out help from mental health services (Gary, 2005). As most services cost money, individuals from low income and financially instable families may not be able to afford the mental health services that may contribute to the decreased likelihood of this group seeking out counselling services (Taylor, 2015; Ward, 2008). Although there may be services available that offer counselling at a lower cost or sometimes even for free, individuals from this group are more likely to not be aware of these resources available to them (Sawrikar, 2016). Another reason why LGBTQIA-POC are less likely to access mental health care providers is because they have difficulty finding services that are sensitive to both LGBTQIA and race/ethnicity issues (Balsam et al., 2011). Studies show that mental health practitioners often fail to incorporate this group’s ethno-cultural worldview and/or their socio-political realities as they often frame LGBTQIA-POC within Eurocentric and heterosexual paradigms (Fukuyama & Ferguson, 2000). Therefore, LGBTQIA-POC are less likely to approach mental health services even when they are in need of support and/or assistance, as they are more likely to experience alienation from counsellors and other mental health providers (Gitterman & Sideriadis, 2001; Stone, 2003; Wynn & West-Olatunji, 2009).
Steps that can be taken to Improve Access to Counselling Services
Stigma towards metal illness and seeking help from mental health services is one of the most cited reasons why people prefer not to seek mental health treatment (Corrigan, 2004). One way in which the service and wider community can help lower the stigma of mental illness in the LGBTQIA-POC community is by designing educational programs targeted towards these populations to help them understand the causes and negative impacts of experiencing mental health issues while also reducing the stigma barriers. People of colour identifying as LGBTQIA may also feel more comfortable approaching services that have counsellors from various ethnic/racial backgrounds who also identify as LGBTQIA (Robinson-Wood, 2016; Wynn et al., 2009). Hence, organizations and services that provide counselling for LGBTQIA individuals or individuals from multicultural backgrounds should also employ counsellors that their client group (LGBTQIA-POC) can identify with. These services could also inform their client group population that they provide counselling for individuals from both, LGBTQIA and ethnic/racial minority communities, as LGBTQIA-POC are often confused or not aware about which counselling service they can seek out for treatment. As mentioned before, LGBTQIA-POC are more likely to face poverty and financial instability, hence it would be helpful if services that cater to this population either provide low cost or free counselling services to individuals who cannot afford it. It is also important for counsellors who work within this client group population to provide interventions that are not only appropriate for LGBTQIA clients, but that are also culturally and racially appropriate as empirical research indicates that although LGBTQIA individuals of colour share similar experiences of being ethnical/racial minorities, in regards to the risks for negative mental health consequences they are not a homogeneous group across race/ethnicity (Harper et al., 2004). As individuals from ethnical/racial minorities are more likely to be non-native English speakers, counselling services should provide clients with translators if needed and/or provide them with counsellors who can speak their language (Walsh, 2014). Furthermore, due to the discrimination against LGBTQIA individuals in many ethnic/racial communities, services that provide counselling for LGBTQIA-POC should also provide their client group with internet and/or telephone counselling that is anonymous, as it would not only help their client group feel safe, but could also be helpful for the individuals who face difficulties in accessing services (Abbott et al., 2014).
Available Service for LGBTQIA-POC
Although there are many services that cater to the LGBTQIA community, there are no organizations in Victoria that have services specific for LGBTQIA-POC. Switchboard Victoria Inc. (2017) is a non-profit organization that provides peer based and volunteer run support services for LGBTQI people and their families, friends and allies. They also provide online and telephone counselling services to LGBTQIA identifying people and their families. This organization has recently started a project called ‘Everybody Under the Rainbow” which aims to improve understanding and support for LGBTQIA people of colour and/or Indigenous people by using approaches taken from Racial Literacy and Anti-racist organizations to improve their services. They are hoping that through this they can better their understanding about the LGBTQIA community from ethnic/racial communities and provide better services to them. Although their service doesn’t provide counselling specifically for LGBTQIA-POC, the organization does have counsellors who are trained in multicultural counselling and/or LGBTQ affirmative therapy.
Ethical and Legal Issues
LGBTQIA-POC come from religious backgrounds where there is still stigma about LGBTQIA sexualities and/ or gender (Washington, 2001). Due to the still prevalent biases and misinformation about non-conforming sexual identities and/or genders in these communities, LGBTQIA-POC are more likely to seek help to change their sexual orientation (Tozer & Hayes, 2004). This may lead to not only ethical but also legal issues for counsellors as conversation therapy is banned in Victoria, Australia (Health Complaints Act, 2016). Sexual and physical abuse is higher amongst LGBTQIA-POC, and counsellors may face various ethical and legal dilemmas around reporting sexual and physical abuse cases (Balsam, Lehavot, Beadnell, & Circo, 2010; Harper et al., 2004; Stotzer, 2009). Ethically and legally counsellors are required to report all cases of child abuse/violence, but depending on the client’s age and family situations, reporting this to authorities may be a bit complicated if the clients are around the ages of 15 or older and/or reporting may cause them more difficulties. If a client is a minor i.e. below the age of 18 years, the counsellor may be ethically and legally required to keep the client’s parents informed about the process by sharing information about the sessions, but this could prove to be challenging if the client is an older teenager (14 years and above) who has sufficient understanding and intelligence to fully understand their circumstances and make their own decisions. Hence, informing the client’s parents about their child’s sexual/gender identity could get complicated as it can be unethical to go against the client’s (the child’s) wishes, especially if they do not want their parents to know, and depending on their family circumstances (family and cultural beliefs around LGBTQIA) it can sometimes cause them more harm than good. Counsellors may also overgeneralize their client’s problems based on their ethnicity, race or cultural and sexual identity and/or gender, and may fail to understand the challenges that integration of multiple identities could pose for their LGBTQIA-POC clients (Balsam et al., 2011; Fukuyama et al., 2000; Haldeman, 2012). As the LGBTQIA-POC community is niche population, various confidentiality issues and ethical dilemmas may arise (Koocher & Keith-Spiegel, 2013; Lonborg & Bowen, 2004). The counsellor is likely to experience confidentiality and boundary issues if a client starts to talk about another client that also comes to the service for therapy or maybe even someone who the counsellor may know outside of work really well. Another challenge that a counsellor might face often is transference and countertransference. The counsellor is likely to respond to their client’s transference with unhealthy and/or harmful countertransference if their own boundaries are not firm (Howard, 2000).
Specific Training that Might be Helpful or Necessary
Training in culture-centered therapy and gay (LGBTQIA) affirmative therapy might be helpful and even necessary when working with clients from LGBTQIA-POC populations (Davies, 1996; Arredondo, McDavis, & Sue, 1992). When working with LGBTQIA-POC, counsellors should have knowledge and understanding of the non-heterosexual and non-Eurocentric worldviews as well as an awareness about the socio-political realties of LGBTQIA life, to be able to provide effective counselling to this client group (Wynn et al., 2009). The intersection of ethnic, racial and/or cultural identities with sexual and/or gender identities often present distinctive problems that require cultural knowledge when accessing and intervening with LGBTQIA individuals who are from ethnically diverse communities (Israel & Selvidge, 2003; Wynn et al., 2009). Studies show that training in culture-centered counselling can help provide counsellors with a framework that can accurately conceptualize the presenting issues of ethnically/racially diverse clients, leading to positive outcomes (Israel & Selvidge, 2003; Wynn & West-Olatunji, 2008; Wynn et al., 2009). As most individuals’ identities and perspectives on mental health issues are formed based on their cultural orientation, using the culture-centered counselling approach with diverse LGBTQIA clients would help provide counsellors with an alternative framework that would not only help them conceptualize their client’s needs, but also facilitate appropriate interventions for their clients (Sue & Sue, 2008; Wynn et al., 2009).
Studies show that training in gay (LGBTQIA) affirmative therapy has helped mental health professionals who may be subjected to biases and prejudices about LGBTQIA culture because of the heterosexist society they live in, clarify their negative attitudes about non-heterosexual orientations while also positively enhancing their knowledge and skills (Boysen & Vogel, 2008; Israel & Hackett, 2004; Mathews, 2007; Rutter, Estrada, Ferguson, & Diggs, 2008). Affirmative therapy can be used to address the negative impacts that homophobia, transphobia and heterosexual may have on LGBTQIA clients while also helping them embrace a positive view of their identities, sexualities and relationships (Bigner & Wetchler, 2012).
Although, most of these studies focus on LGBTQIA-POC, there are some limitations that need to be taken into account when generalizing and interpreting their findings. Most of the sample sizes were not sufficient to examine the differences between race/ethnicity as well as gender and/or sexual identity in relation to experiences of discrimination and its effect on mental health. There was also little to no research done on how socio-economic status and/or age would affect the individuals presenting issues. It is also apparent that there is limited empirical research on LGBTQIA-POC and that most of the published studies related to this population are only theoretical in nature. Moreover, it is possible that individuals who participated in these studies may differ in more systemic ways from those who did not participate. For example, participating individuals may be more open about their sexualities, more aware of the stigma they face or may even be more connected to LGBTQIA communities, and hence these factors may limit the generalizability of the findings. Additionally, the probability of being able to determine a generalized explanation of how discrimination and stress can affect mental health outcomes is low, as the LGBTQIA-POC has a significant amount of diversity within the group itself. Sample composition should also be taken into account when interpreting the generalizability of the research findings. Most of the studies had samples composed of adolescents, young adults and adults and African-Americans, Latin-Americans and very few Indians and Chinese, hence further research would be needed to be able to evaluate the applicability of the results to LGBTQIA-POC from other ethnicities/races and age groups (for e.g. Individuals from Japan, Pakistan, etc. and children and older adults). Similarly, these studies also had limited representation of individuals who identified as bisexual, asexual, intersex, pansexual or Indigenous Australian. Lastly, as most of these studies were conducted on populations in America, there may be a difference in the presenting issues of the LGBTQIA-POC in Australia, due to cultural and social differences between America and Australia.
As a pansexual Indian, I do identify with the LGBTQIA-POC client group. Identifying with a client group can have both benefits and drawbacks for the counsellor. One of the benefit’s is that ethnically similar clients may feel that I can relate to their circumstances and issues and also understand their problems better as they may assume that shared commonalities in cultures and values are important elements in minority mental health (Zane et al., 2005). Clients who share the same ethnicity as me may also feel that they can express themselves better as I would be able to better understand their non-verbal (body) language. As I am multi-lingual, clients who speak the same language as me may feel more comfortable as they can express their feelings in their language, especially if their English language proficiency is not good. Belonging to a multiple minority group, I would be able to better understand the discrimination that LGBTQIA-POC experience in LGBTQIA communities and also their own ethnic/racial communities, and this knowledge would help me counsel them more efficiently.
However, I could also over identify with LGBTQIA Indians and their problems which could hinder the therapeutic relationship and lead to inefficient counselling. Over identifying with a client could lead to countertransference and transference possibilities. Although I am a minority, I still may not be able to identify with all minorities, as each ethnicity, race and/or culture are very different from each other and so are their issues and problems (Modood, 2013). Due to the various biases and prejudices prevalent within the racial/ethnic minority and LGBTQIA communities, I may stereotype my clients or they may come into counselling with stereotypes about me, a non-heterosexual Indian female (Hagendoorn, 1995). This may lead to some transference and countertransference which could disrupt the client-counsellor relationship. For example, I may have a client from African ethnicity who identifies as gay and due to the pre-existing stereotypes I may have about gay African men, I may unconsciously transfer my feelings and thoughts onto him and this could lead to him reacting negatively to my misplaced emotions or visa-versa. As sexuality is very complex and everyone understands it differently, I may also face challenges in trying to keep my emotions in check when a client’s opinions and understanding of sexuality and gender it is very different from mine (Harper et al., 2013). Another kind of transference that would be problematic is erotic transference. If a client is facing relationship problems, it is possible that he/she may develop fantasies about their therapist, i.e. me, that are romantic, intimate and/or sexual (Devi, Manjula, & Math, 2015; Milton, Coyle, & Legg, 2005).
To work with this client group, I would need to do additional training in multicultural and LGBT affirmative therapy. I also think it would be helpful to have additional education, training and experience in areas such as: (a) multidimensional models of human sexual orientation; (b) effects of stigmatization on LGBTQIA-POC; (c) career and workplace issues experiment by LGBTQIA-POC; (d) types of non-traditional relationships and families; (e) challenges with religion, spirituality and culture for LGBTQIA-POC; (f) effects of intersection of multiple identities, i.e. sexual orientation, race, ethnicity and culture, gender, social class, and disability.
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