Beyond Acceptance: Utilizing Empathy to Diagnose and Treat Internalized Homophobia in LGBTQ+ Clients

Eli Sharon

School of Government & Society, Family Studies, The Academic College Tel Aviv-Yaffo, Israel

Faculty of Health Professions, Ono Academic College, Israel

Abstract

This article asserts that effective therapy with LGBTQ+ clients should evolve beyond basic "gay friendly" practices to require deeper clinical engagement. It argues that therapists can actively cultivate precise empathy, which is predicated on a more detailed familiarity with the client's unique experiences, particularly those shaped by internalized homophobia. This skillful approach involves refining a therapist's cognitive complexity and utilizing relevant diagnostic tools to accurately diagnose and treat the often-subtle, debilitating impact of minority stress. Ultimately, this targeted, empathetic strategy is vital for establishing and strengthening the therapeutic alliance.

Introduction

APA guidelines¹ and other relevant associations address a therapist’s attitude towards diversity and their familiarity and knowledge of characteristics related to an LGBTQ client’s life. Alongside with familiarity of LGBTQ lifestyle and being 'gay friendly' another dimension vital for working with an LGBTQ client is creating an effective therapeutic alliance that calls for garnering empathy unique to an LGBTQ client’s experiences. Living as a non-heterosexual in a heteronormative sexist society results in a unique emotional experience^2,3,4,5,6,7. Creating this dimension of working alliance can be challenging as feelings of empathy habitually arise when a person sharing the experience meets similar or identical emotional dimensions in a listener.

LGBTQ clients' experience in a heterosexual society

Experiencing internalized homophobia - A person who experiences self-homophobia inevitably feels damaged, deviant and sick because of what they aspire to, because of what they feel and experience emotionally in contrast to their human environment. Scheibe and his colleagues⁸ describe the difficult effects of non-conformity an LGBTQ individuals experience due to their gender. Rejecting those longings and aspirations may lead an individual, especially in the early stages of building a life guided by autonomous goals, affect difficulties up to lose of the will to live. Reactions can range from undermining a chosen sense of direction for self-actualization, diminished feelings that incentivize activity and self-actualization according to personal ideals, nest feelings of despair, non-fulfillment, lack of futility and purpose, and diminish a sense of resilience in the face of failures and unrealizable challenges. From here the path to symptoms of depression, anxiety and the like is easy to understand as researchers describe^9,10,11,12.

Stigmas rooted in homophobia place non-heterosexual people in greater demand for help from agencies offering emotional support services^{13,14,15,16,17}. That is primarily because LGBTQ clients necessarily live as a minority that has internalized elements of homophobia that exist in society^18,19. However, clients report dissatisfaction vis-a-vis support services due to what they experience as a lack of understanding and knowledge among therapists^20,21. Greatly needed is familiarity with an LGBTQ client’s emotional inner world that emphasizes cultural context^{22,23,24,25,26}. Concurrently, therapists report challenges working with non-heterosexual clients because of a lack of familiarity with cultural aspects of LGBTQ life, including injurious emotional experiences^25,27,28,29. Some therapists fear that they may harm their non-heterosexual client³⁰.

Among the many studies addressing mental symptoms and intrapersonal effects caused by internalized homophobia^31,32,33, there are fewer that address a diminished sense of self-worth rooted in the inadequacy of longing and striving for life goals. These experiences shape an individual’s sense of value and mental well-being. Kasser and Ryan³⁴ point to the gap between internal and external goals in an individual that may lead to increased anxiety, depression and other symptoms. Researchers such as Kasser and Sheldon³⁵ and Emmons³⁶ posited that the illusion in adopting and maintaining the external goals as objects of longing when, in the end, they do not improve, at best, an individual’s situation.

An LGBTQ individual who comes to therapy needs first and foremost ‘cleansing’ and regulation of the dimensions/aspects of his internal homophobia so that he can garner the strength and capability to pursue a healthy life experience. According to this approach, the difficulty with which the individual comes is not due to the attitude of others towards him, although the difficulty was apparently caused because of this, but rather it is due to a feeling that something inside him, in who he is in his life goals, in his aspirations and experiences, is ‘not right’, ‘sick’, ‘broken’. On the face of it, it is understood that these sorts of dimensions of self and life experiences are not commonplace for a heterosexual therapist, yet those therapists will need to show accurate empathy for the client’s feelings.

Dimensions of empathy required for LGTBQ

Accurate empathy - Empathy is fundamental in establishing a therapeutic relationship and in treatment outcome^37,38,39,40. Rogers⁴¹ defined empathy as “the therapist’s sensitive ability and willingness to understand the client’s thoughts, feelings and struggles from the client’s point of view. This "ability to see completely through the client’s eyes, to adopt his frame of reference (p. 85)....it means entering the private perceptual world of the other...being sensitive, moment by moment, to the changing felt meanings which flow in this other person... It means sensing meanings of which he or she is scarcely aware....” (p.142).

Empathic accuracy is likely to be shaped by the listener’s early experiences, thoughts, and personality^42,43. Emotional recharge in an empathic process is shaped by a viewer’s feelings more than by a narrator’s feelings⁴⁴. People ‘enter into’ an emotional state when they listen and follow what another person is saying, paying attention to body posture, facial expression, the ‘music’ with which things are delivered. These elements lead to an emotional response on the part of the listener⁴⁵. A listener’s response to another person’s feelings and experiences is described as ‘joint activation’ of empathy that involves self-processes of felt emotion and sense of body. A listener’s emotional state, their earlier experiences from the past and otherness they feel about the narrator may shape the quality of empathic accuracy^46,47.

Therapists can have an empathetic experience and convey this experience to a client, yet that may be limited due to their personality, contextual factors, fatigue and burnout. Other limitations may arise due to a lack of clarity or complexity that could lead to enmeshment where a therapist’s feelings intermingle with the experiences of clients, possibly blurring the quality of empathy. A more precise empathic attitude can be acquired when viewed as a process that requires knowledge, self-awareness, and skill⁴⁸. One needs to differentiate between self and other self by distinguishing between representing their own feelings, actions, reactions, and emotions and those of the other⁴⁹.

Living as a non-heterosexual person within heterosexual communities uniquely impacts upon LGBTQ experience and reality^50,51,52. A model that can shed light on this experience is the ‘minority stress model’³² that offers dimensions of being rejected and not accepted in families of origin which may lead to traumatic experiences of abuse, sexual exploitation in childhood, absorbing insults, etc. Internalized self-homophobia can lead to feelings of guilt, shame, low self-esteem and other emotional challenges⁵³. Homophobia feeds on heterosexist attitudes that rest upon what Herek, et al.⁵⁴ call an ideology that translates into practice based on the assumption that people are heterosexual and those who are not become invisible and are subsequently treated as sick or ‘not according to nature’. These attitudes constitute the basis for emotional and behavioral challenges^{55,56,57,53,58,59}. To lessen and avoid pointing arrows of stigma on themselves, these individuals adopt distortions of sense and expression as well as inauthentic behavior⁶. Notably, therapists can hone and deepen their empathy skills^{60,61,62,63,64}. In the case of LGBTQ clients, it is necessary to first identify the content focal points of homophobia: namely, the rate, depth and dimensions it holds on a client’s experience of self. There are some applicable ways to diagnose the rate and dimension of internalized homophobia, including: Herek’s tool⁶⁵ of attitudes towards lesbians and gay men (ATLG) Scale; Wright et al.’s tool⁶⁶ that examines negative attitudes towards LGBTQ. Also possibly relevant are measuring tools by Milhausen, et al.⁶⁷ the index proposed by Hudson and Ricketts’ Index of Attitudes Toward Homosexuals (IAH)⁶⁸. Mayfield⁶⁹ also proposes an index of internalized homonegativity comprising 23 items loaded on 3 subscales, labeled ‘Personal Homonegativity, Gay Affirmation, and Morality of Homosexuality’. An initial step can be to review possible dimensions of internalized homophobia as enumerated by Fassinger⁷⁰ who notes factors and dimensions of life experience in a heterosexual society for those who are not heterosexual employing dimensions of the cultural-social and interpersonal context.

The degree of internalized heterosexist attitudes and internalized self-homophobia can be evaluated using Ross and Rosser’s⁵ tools as well as that of Currie and others⁷¹. A comprehensive tool for internalized homophobia is Nungesser Homosexuality Attitudes Inventory⁷² comprising 34 items that relate to an individual’s self-perception and thoughts in a socio-cultural context. Despite some reported weakness⁷³ for therapists, it sheds light into an LGBTQ client’s experience in a heterosexist society. An overview of other available tools can be found in³. A therapist who is not LGBTQ can use these questionnaires and scales on themselves to gauge dimensions of internalized homophobia.

Discourse that facilitates therapist empathy – Carkhuff⁷⁴ mentions ‘active listening’ in which dimensions of emotion can be tracked that a client has not transcribed or seen before. Carkhuff’s⁷⁴ scales were used in the 1970s and 1980s as a key metric in training therapists on empathy⁷⁵. Bowland et al.⁷⁶ noted a need for an ‘open’ dialogue that raises questions and musings for a client in light of a complex life, intertwined with dialectics. As long as the so-called ‘real relationship’⁷⁷ exists, the emotional sharing and sense of reciprocity will deepen with dimensions of sincerity^78,79,80.

Language is metaphorical⁸¹. Its use in a deliberate way can enrich and deepen the shared experience of discourse as each person brings their world into the metaphorical space. It also helps activate new areas of brain pathways and facilitates novel perceptions⁸². The use of images and metaphors generates dimensions of thought and emotion that occur simultaneously in an individual; they ‘perceive’ emotional dimensions alongside cognitive dimensions⁸³.

Cognitive complexity rests on the interaction between approach, memory, learning, thinking, emotion, etc. and on complex perception of situations⁸⁴. Cognitive complexity requires a degree of separation and constitutes a fundamental dimension to it⁸⁵. It is a fundamental aspect in the empathic experience^44,86,87. Because cognitive complexity is a situational factor, it can be perfected and studied. Those endowed with it possess can engage in relational thinking and may better understand the complexity of situations raised by a client, with a strong capacity for empathy^79,88,89.

Summary

It is possible to improve and grow one’s capacity for empathic accuracy. It is central and fundamental to therapeutic work. We highlighted internalized self-homophobia in a client who lives in heterosexist society as a unique challenge a therapist might be unfamiliar with, having had no firsthand experience as someone who is not LGBTQ. We propose adopting a stance that acknowledges gaps in knowledge and proposes the use of experience, scales and questionnaires that help increase empathic accuracy among caregivers of LGBTQ clients. Clinicians may embrace a "not knowing" stance with a curiosity that places the client as the expert on their unique experience of being LGBTQ, rather than relying on generalized clinical knowledge or assumptions. This directly combats the potential for heteronormative interpretations. As previously mentioned, they can enhance empathic accuracy through the systematic use of scales and questionnaires. This involves routinely incorporating validated, culturally sensitive tools to assess the client's experience of sexual minority stress and internalized prejudice. Additionally, it is important to develop skills in recognizing and interpreting nonverbal communication cues related to shame, concealment, and distress, which are often present in clients facing internalized sexual stigma. Empathic accuracy frequently entails accurately identifying subtle expressions of vulnerability.

We recommend that future research explore how unique empathic skills develop and inform training programs and therapeutic approaches. Specifically, it would be valuable to examine how distinct dimensions of empathy in working with the LGBTQ population influence the therapeutic alliance between sexual minority clients and their therapists. Enhancing therapists' empathic skills through a focus on nonverbal communication, systematically integrated into training programs, will enable them to respond more effectively to clients' unspoken emotions. Additionally, innovative training methods and new technologies could better equip therapists to engage with clients from diverse backgrounds. Future studies in this area may help establish evidence-based practices that promote client well-being. Such research can also refine educational curricula, ensuring that future clinicians are well-prepared to meet the needs of their clients.

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