They may be micro but their impact isn’t: Sexual orientation microaggressions in psychotherapy

- by Stacey Prince

I recently read an excellent article in the Journal of Counseling Psychology, entitled Sexual orientation microaggressions: The experience of lesbian, gay, bisexual and queer clients in psychotherapy. I will briefly describe it here but I hope this will entice some of you to read the article in its entirety; it’s a great read for psychotherapists, healthcare providers, case managers and anyone working with LGBQ clients.

The article begins with the assertion that, while general affirmation and acceptance of LGBQ individuals has increased, psychotherapy clients still all too frequently report experiences of discrimination and hostility in the therapy setting. Overt forms of discrimination such as the practice of conversion or reparative therapy have declined, but more subtle forms of heterosexism seem to persist. This parallels findings in the area of racial oppression, which have shown that while overt racism has decreased, more subtle and insidious forms of modern racism are still prevalent. Led by psychologist Derald Sue and colleagues, this substantial body of research documented the prevalence of racial “microaggressions,” the term used to describe these more subtle injustices of modern racism.

Microaggressions are described as communications of prejudice and discrimination, expressed through seemingly meaningless or even well-intentioned tactics but that actually deliver a hidden message of hostility, denigration, or invalidation. Examples include a white person stating to a person of color “you are so well-spoken” (indicating that their intelligence and articulateness is surprising or an exception), asking an Asian American individual “where are you from?” (assuming foreignness), or stating that he or she is “color blind” (denying the realities of personal and systemic oppression). Microaggressions differ from overt racism in multiple ways, including the fact that they are contextual, more difficult to identify, and that while there may be legal recourse for someone who experiences overt racially based discrimination, it is much more difficult if not impossible to document and take action against microaggressions.

The article I am describing today attempted to expand the microaggression literature to microaggressions that are based on sexual orientation rather than ethnicity. Further, it explored the negative impact of sexual orientation based microaggressions on the psychotherapy process. Psychotherapists are not immune to heterosexism and homophobia, having been indoctrinated in the same societal stigmatization of LGBQ individuals as everyone else, and therefore may unintentionally perpetuate negative bias toward their LGBQ clients. Although previous research has explored homophobia and heterosexism in psychotherapy, this study was, I believe, the first to try to identify and describe microaggressions based on sexual orientation. It utilized focus groups to explore the experiences of 16 self-identified LGBQ individuals in psychotherapy. Using a series of questions informed by the literature on racial microaggressions and previous work on heterosexism in psychotherapy, investigators identified themes, channels, and impact of sexual orientation microaggressions as they had occurred in participants' therapy experiences.

Several themes representing different types of sexual orientation microaggression emerged from the analysis of participant responses. These included assuming that sexual orientation was the cause of all of the client's presenting issues, even when the client was seeking help for unrelated problems; avoiding discussion of sexual orientation (such as avoiding use of gendered pronouns when referring to partners), avoiding discussion of the negative impact of rejection and internalized heterosexism, overidentifying with LGBQ clients, making stereotypical assumptions about LGBQ clients, expressing heteronormative bias, assuming that LGBQ clients need continued treatment even when clients felt ready to terminate; and suggesting that LGBQ clients should expect conflict and discrimination due to their sexual orientation.

The study also investigated channels of communication on which sexual orientation microaggressions were expressed in the therapy setting. Paralleling the research on racial microaggressions, results indicated that sexual orientation microaggressions occurred on multiple channels, including verbal (direct and indirect comments), behavioral (e.g., body language, silence, demeanor), and environmental (e.g., waiting room literature only relevant to heterosexual individuals and couples).

What was the impact of these sexual orientation microaggressions on the therapeutic process? Findings again paralleled research on racial microaggressions in psychotherapy, revealing that clients had a range of affective responses such as feeling uncomfortable, confused, rejected, invalidated, and angry. They were less likely to disclose issues related to sexual orientation out of a fear of being viewed as abnormal. They reported feeling more doubtful about their therapists' competence and the effectiveness of therapy, and were more likely to terminate therapy prematurely.

The authors ended with some recommendations for addressing sexual orientation microaggressions. These included responding in a nondefensive and transparent way if a client raises concerns, processing the impact of microaggressions on the client rather than focusing on therapist intentions (which may have been positive or neutral), and admitting heterosexism to oneself (thereby increasing self-compassion and openness to feedback) rather than maintaining that one is bias-free. They also described limitations of the study, including the somewhat skewed sample (predominantly white, highly educated) as well as all of the fallacies that are associated with retrospective self-report. Another important limitation not mentioned was that neither transgender individuals were not included in the sample; this is an important area for future investigation and my guess is that transgender clients in psychotherapy may experience many microaggressions similar to those described here, as well as perhaps some additional themes surrounding gender expression and transitioning.

In conclusion, even well intentioned psychologists who aspire to provide culturally competent services to marginalized populations are indoctrinated in racist, heterosexist, classist, and otherwise oppressive belief systems. Further, such views may be outside of one's immediate awareness, inhibiting the ability to recognize and redress microaggressions. The power imbalance inherent in the therapist-client relationship, internalized oppression, clients granting and therapists claiming "expert" status, and a host of other variables curtail clients' ability to recognize and call out such experiences when they do occur. The onus is therefore on practitioners to learn about, self-identify, and rectify incidents of microaggression as they occur in treatment. If therapy is going to be liberatory it at the very least has to be non-oppressive, and understanding and owning one's own microaggressions is an important step in practicing ethical, competent, empowering psychotherapy with members of marginalized groups.