John R. Stafford
Brandman University
Abstract
Couples therapy provides unique situations for any therapist. Each couple has a different dynamic, interpersonal relationship, and individual personality traits that either exacerbate or alleviate the daily stressors that a couple experiences. However, other couples encounter more than the every-day nuances of negotiating a healthy relationship. LGBTQ couples face the same issues like any other couple, but their societal status produces additional stressors that many other couples may never encounter.
Keywords: LGBTQ, LGBTQ Couples Therapy, Couples Therapy
LGBTQ Couples Therapy: The Additional Problems Therapists Encounter
One of the most significant societal expectations is that we, as humans, mature and find someone to couple with and start a family. From a young age, children are molded by experience and natural instinct to seek a mate. Once a suitable mate is found, the couple begins to blend their individual lives into what they hope will be a cohesive family unit. It sounds easy, but combining two different entities is not as easy as it may seem. Moreso than not couples, both new and seasoned find internal and external forces introduce speedbumps into the relationship. Whether it be the simple act of moving in together and merging belongings, the birth of a child, or the death of a family member, each new experience is bound to result in some level of relational change.
Issues for LGBTQ Couples
Outside of the nuclear family model, which most couples and family therapy techniques developed, there are alternative family models that do not adhere to the baseline assumptions at the root of family and couples therapy (Sue, & Sue, 2016). For decades, LGBTQ couples hid, and continue to conceal their relationships from society. Many same-sex couples derived elaborate stories that resulted in the creation of a false relationship portrayed to friends, family, co-workers and the general public. Additionally, the experiences LGBTQ people experience in day-to-day life may introduce personal psychological issues that result in relationship problems. Mental stress related to abuse, alienation from family and friends, job discrimination, denial of essential services, and even exposure to medical conditions like HIV/AIDS create unique issues that get introduced to the relationship dynamic.
Relationship Facades
It was not uncommon for two men or women engaged in an intimate relationship to form a façade of being roommates when moving in with one another. They would set up two separate bedrooms to serve as an indicator to family and friends that they were in fact, just friends sharing a living space (Niolon, 2011). The fake family status created by gay and lesbian couples is only one detrimental aspect placing additional pressures on LGBT households. Societal acceptance of gay and lesbian people, in general, adds stress to the individuals in a relationship because he or she may experience issues of violence, prejudice, and discrimination in the workplace, or in obtaining essential services (Kessler, & Yalom, 1996).
Gay and lesbian individuals may also have problems stemming from their family of origin that carry over into their relationship (Sue, & Sue, 2016). He or she may have experienced abuse, both physical and psychological, or abandonment from parents and other family members (Kessler, & Yalom, 1996). Some LGBTQ men and women may not have experienced any of these issues at all. Individuals who came out to friends and family and received full acceptance will not have an understanding of a partner’s fears of being outed. Additionally, an individual employed in an environment that promotes equality may equally find it hard to understand why a partner in a more conservative work environment does not invite him or her to company parties or events in fear of being discovered (Kessler, & Yalom, 1996; Sue, & Sue, 2016).
Marriage Equality
Over the decades, LGBTQ people have received more recognition in society. Countries around the world have enacted laws protecting LGBTQ people from discrimination in the workplace, housing, and access to essential programs. Many nations have adopted laws recognizing same-sex unions, while others have made advancements in legalizing marriage equality. Although these improvements indicate a changing landscape for LGBTQ people, they do not suggest that societal acceptance is advancing in the same strides. While it may be legal for a gay or lesbian couple to marry, many may not because of issues related to acceptance of family or societal concerns. An excellent example of these matters in America is the growing movement to legally discriminate against LGBTQ couples based on a religious objection, also known as the First Amendment Defense Act (H.R. 2802, 114th Cong., 2015).
Raising Children
Raising children is considered by society to be a marker of adulthood and a successful relationship. However, for the LGBTQ couple, this widely accepted marker of success poses unique problems. Studies evaluating the academic performance, cognitive and social development, psychological health, and early substance abuse and sexual activity of children raised in same-sex households indicate no variation when compared to children raised in different-sex households (Crowl, Ahn, & Baker, 2008; Manning, Fettro, & Lamidi, 2014). In one study at the University of California-San Francisco, Gartrell, & Boss (2010) concluded that adolescent sons and daughters of lesbian parents rated higher in academic, social, and total competence, and lower in social problems, aggressive and externalizing problems, and rule-breaking than their age-matched peers.
Although these studies provide supporting evidence for the stability of children raised in same-sex households, they also offer indicators that children can be negatively affected by socioeconomic circumstances, lack of opportunity and support for same-sex parents (Crowl, Ahn, & Baker, 2008; Gartrell, & Boss, 2010). In addition to the stressors related to parenting, the lack of opportunity and support, and other socioeconomic issues, same-sex parents and their children also face problems related to discrimination in school administrations, teasing from peers, and alienation from specific social activities (Manning, Fettro, & Lamidi, 2014).
Extended Family Issues
The extended family of LGBTQ couples may pose additional stressors in the relationship. These problems could be related to alienation of one or both of the partners from their family of origin or from hiding the relationship from family and friends. Another factor for extended family issues is the circle of friends one or both of the partners may have. Because many LGBTQ couples are alienated or estranged from the family of origin, friends of one or both partners become surrogate family members in which they can share experiences like holidays and other relationship milestones. While friends do sometimes make acceptable surrogates for the family of origin, they are not without pitfalls.
Every couple is destined to contend with death in the extended family. As the couple matures, family members age and eventually die. With the introduction of HIV/AIDS in 1981. The LGBTQ community landscape changed. People were dying at wholesale rates (U.S. Department of Health & Human Services, n.d.). A friend someone saw at a party a couple of weeks previously was now dead. Although treatment had advanced and improved the lifecycles of those infected, the rate of death in the LGBTQ community remains high. For couples who are extended family consists of friends, the grief of loss may be more of a typical occurrence than those in close contact with their families of origin (Kessler, & Yalom, 1996).
HIV, Intimacy, and Relationships
One of the leading issues in relationships is intimacy. Couples experience a myriad of problems including loss of sexual desires, sexual dysfunction due to injury or other causes, and daily issues that restrict quality alone time for the couple. LGBTQ couples experience these same problems, however, many couples today face another challenge with intimacy. With the widespread epidemic of HIV in the LGBTQ community, it is not uncommon for one or both partners in a relationship to be HIV positive. Advancements in HIV treatments have enhanced and expanded the life expectancy of those infected with HIV, and studies indicate that more people with HIV are 50 years old and growing (Psaros, Barinas, Robbins, Bedoya, Safren, & Park, 2012).
Although medical advancements have improved the quality of life for HIV patients, difficulties arise in couples where one partner is HIV positive, and the other is not. The HIV negative partner may express concerns about accidentally forgetting to use protection in the heat-of-the-moment, or in some cases may express a desire to become HIV positive as to avoid having to be concerned about using protection. Both of these situations present emotional concerns for both partners because the HIV positive partner may be overly worried about his partner’s health, or may feel regret and distress that his partner may wish to contract HIV to remove a barrier between them (Rhodes, & Cusick, 2000). Additionally, the HIV negative partner may push harder on issues like creating wills and making funeral preparations earlier than other couples or attempting to increase the number of experiences the couple shares out of fear the HIV positive partner may die prematurely (AIDSmap, n.d.).
Roles and Role-Models
Roles and role-models for same-sex relationships present unique problems. Society places role expectations on people based on an archaic belief that women are nurturers and child bearers and men are hunters and protectors. This view instills into society a biased view of masculinity and femininity as it relates to gender orientation. Gay and lesbian children raised with these biased opinions may experience difficulties in their relationship. However, using these assumptions, therapists can understand, and help clients understand psychological feminity and masculinity roles within each other ( American Association for Marriage and Family Therapy, n.d.).
Consequently, society emphasizes the nuclear family concept. This outdated notion maintains that a proper family unit is most likely a white, opposite-sex couple with two children, a husband that works and provides for the family, and a stay-at-home mother responsible for maintaining the household and family. This ideal, to this day, dominates mainstream entertainment outlets and marketing channels, leaving same-sex couples little to model their family structure. Additionally, because same-sex relationships remained mostly hidden in society, many young same-sex partners lack not only societal but also personal role models (Kessler, 1996).
Therepeutic Implications
Couples present to therapy for a wide variety of concerns that range from learning how to negotiate arguments to dealing with infidelity. The crucial function of the therapist, while varied by the dominant theory applied, is to be a facilitator to help the couple resolve dysfunction within the relationship. Although most people seek couples therapy to address dysfunction and improve the quality of their relationship, others may enter treatment to help end the relationship in an amicable manner (Gurman, 2008). No matter the presenting problem, the therapist is placed in a position that demands specific attributes. First, the couple may present a problem that reminds the therapist of his or her own experiences. In this situation, the therapist must be aware of counter-transference. While many therapists find it inappropriate to share personal experiences, others may find it beneficial to divulge just enough to help the couple understand that he or she is capable of relating to their problem (Gurman, 2008). Therapists may also become exposed to situations that conflict with personal values, which place implications of ethical interactions with the client if the therapist is not able to see past his or her own biases (Sue, & Sue, 2016).
Working with LGBTQ Couples
Most therapists will find that working with same-sex couples is similar, if not identical, to working with couples of the opposite sex. Many of the presenting issues will be the same, and the treatment paths will be the same. However, there are also issues that same-sex couples will encounter that differ from opposite-sex couples and others that are unique to same-sex couples. One of the problems related to working with same-sex couples is the bias related to studies of gay and lesbians in couples therapy. In a compelling article in the Journal of Family Therapy, Ussher (1991) argued that couples therapy, at the time, was widely unavailable due to a lack of referrals and that therapists were ill-equipped both psychologically and by lack of understanding the dynamics of same-sex couples to provide adequate treatment. Acknowledging this pitfall also provided compelling arguments “that established forms of intervention are effective with gay clients, provided that the specific needs and problems of the gay and lesbian community are addressed by the therapist” (Ussher, 1991 p.1).
Therapeutic Techniques
As referenced earlier, most standard therapeutic techniques used with opposite-sex couples will work equally as well with same-sex couples. The issues that a same-sex couple will present for treatment are most likely to be the same as those of any other couple, and the process of treating the presenting problem the same as well (Ussher, 1991). Accounting for issues considered unique to same-sex couples, the therapist may use Structural Couples Therapy or Cognitive Behavioral Couples Therapy, or a combination of these or other therapeutic models he or she is most comfortable with.
Structural Couples Therapy
Structural Couples Therapy (SCT) is a product of Structural Family Therapy developed by Salvador Minuchin. SCT focuses on systemic issues in a relationship based on the assumption that each member of the family plays a role in the family system and subsystem (Gurman, 2008). Using SCT, clinicians can assess the family system, subsystem[s], and external contexts that impact same-sex couples (DeDiego, 2016). For example, a gay couple preparing to start a family may experience difficulties based on the lack of traditional “mother and father roles.” Under SCT, the clinician addresses issues of hierarchy and power boundaries by refocusing family roles beyond the traditional gender roles (DeDiego, 2016).
Cognitive Behavioral Couples Therapy
Cognitive Behavioral Couples Therapy (CBCT) focuses on educating clients on the biological and psychological processes in the relationship, and how couple interactions become ineffective (Hubbard, 2016). Using this baseline, clinicians can work with couples to assess how their interactional patterns interfere with the relationship and provide opportunities to practice troubled areas like communication and challenge disruptive thoughts and behaviors that are causing relationship dysfunction (Gurman, 2008; Hubbard, 2016). CBCT can be helpful when working with LGBTQ couples where one partner’s low self-esteem or self-worth are causing dysfunction in the relationship by enhancing the couple’s ability to communicate more efficiently while challenging the feelings of the individual. For example, a couple presenting about constant arguments in the household. During the assessment, the clinician discovers that one partner has low self-esteem because his family of origin degraded him and eventually alienated him for coming out. Using CBCT, the clinician can address the communication problems while at the same time, challenging the feelings of low self-esteem of the partner. This process not only helps the individual begin to change how he sees himself but also helps the other partner understand how these feelings can cause problems.
Conclusion
Clinicians working with couples are sure to experience a myriad of issues that are as unique as each couple, as well as presenting problems that share a commonality. No matter how many clients a clinician has worked with, knowing exactly how to contend with the next client has an air of uncertainty. Although traditional opposite-sex couples share some commonalities, this is never something that can be assumed. Besides the conventional nuclear family couple, some couples do not fit this mold, and who present issues that may be outside the usual box. Same-sex couples for example not only share the standard problems like any other couple, but also experiences that add a new layer of complications to a relationship. For clinicians to work efficiently with same-sex couples, he or she needs to be aware of not only personal biases that could interfere with the clinician-cleint relationship but also aware of the unique issues that LGBTQ peope experience in life and bring into the relationship.
References
AIDSmap. (n.d.). HIV & sex - Relationships with an HIV-negative partner. Retrieved October 10, 2017, from http://www.aidsmap.com/Relationships-with-an-HIV-negative-partner/page/1637216/
American Association for Marriage and Family Therapy. (n.d.). Therapeutic Issues for Same-sex Couples. Retrieved October 10, 2017, from https://www.aamft.org/iMIS15/AAMFT/Content/Consumer_Updates/Therapeutic_Issues_for_Same-sex_Couples.aspx
Crowl, A., Ahn, S., & Baker, J. (2008). A Meta-Analysis of Developmental Outcomes for Children of Same-Sex and Heterosexual Parents. Journal of GLBT Family Studies,4(3), 385-407. doi:10.1080/15504280802177615
DeDiego, A. C. (2016, September 28). A systemic perspective for working with same-sex parents. Retrieved October 10, 2017, from https://ct.counseling.org/2016/09/systemic-perspective-working-sex-parents/
Garanzini, S., Yee, A., Gottman, J., Gottman, J., Cole, C., Preciado, M., & Jascula, C. (2017). Results of Gottman Method Couples Therapy with Gay and Lesbian Couples. Journal of Marital and Family Therapy,43(4), 674-684. doi:10.1111/jmft.12276
Gartrell, N., & Boss, H. (2010). US National Longitudinal Lesbian Family Study: Psychological Adjustment of 17-Year-Old Adolescents. Pediatrics,126(1), 28-36. Retrieved October 10, 2017, from http://pediatrics.aappublications.org/content/126/1/28
Gurman, A. S. (2008). Clinical handbook of couple therapy(4th ed.). New York: Guilford Press.
Hubbard, B. (2016). CBT for Couples Marital Therapy. Retrieved October 12, 2017, from http://cognitive-behavior-therapy.com/relationship-couples-marital-therapy/
KESSLER, H., & YALOM, I. D. (1996). Treating couples. San Francisco: Jossey-Bass.
Manning, W. D., Fettro, M. N., & Lamidi, E. (2014). Child Well-Being in Same-Sex Parent Families: Review of Research Prepared for American Sociological Association Amicus Brief. Population Research and Policy Review,33(4), 485-502. doi:10.1007/s11113-014-9329-6
Niolon, R. (2011, August 02). Issues for Same-Sex Couples | PsychPage. Retrieved October 10, 2017, from http://www.psychpage.com/family/library/gay-lesbian.html
Psaros, C., Barinas, J., Robbins, G. K., Bedoya, C. A., Safren, S. A., & Park, E. R. (2012). Intimacy and Sexual Decision Making: Exploring the Perspective of HIV Positive Women Over 50. AIDS Patient Care STDS,26(12), 755-760. doi:10.1089/apc.2012.0256
H.R. 2802, 114th Cong., Www.congress.gov (2015) (enacted).
Rhodes, T., & Cusick, L. (2000). Love and intimacy in relationship risk management: HIV positive people and their sexual partners. Sociology of Health & Illness,22(1), 1-26. Retrieved from http://onlinelibrary.wiley.com/doi/10.1111/1467-9566.00189/pdf
Sue, D. W., & Sue, D. (2016). Counseling the culturally diverse: theory and practice(7th ed.). Hoboken, NJ: John Wiley & Sons, Inc.
U.S. Department of Health & Human Services. (n.d.). A Timeline of HIV and AIDS. Retrieved October 10, 2017, from https://www.hiv.gov/hiv-basics/overview/history/hiv-and-aids-timeline
Ussher, J. M. (1991). Family and couples therapy with gay and lesbian clients: acknowledging the forgotten minority. Journal of Family Therapy,13(2), 131-148. Retrieved from http://onlinelibrary.wiley.com/doi/10.1046/j..1991.00418.x/pdf
