Adapting cognitive therapy for depression: Managing complexity and comorbidity (2008) pp. 373-393 Published by Guilford Press
By all accounts, being lesbian, gay, or bisexual (LGB) is not a symptom of any underlying pathology or failure of development (Gonsiorek, 1991). Yet, LGB people exist in a different context than that of their heterosexual counterparts--one that is often invalidating and stressful. Societal values shift between prohibition and acceptance of homosexual or bisexual identity and same-sex partnerships. There are dramatic differences in the treatment of LGB people, and their ability to live openly in their communities, depending on the geographic area in which they live. Within religious denominations there are progressive voices that call for the open reception of LGB people in the congregation and there are vocal, intolerant, condemning attitudes that promote religiously directed prohibition of LGB people. The stressors begin early in life for LGB people. LGB youth face increased harassment and victimization (D'Augelli, 1998), and have higher rates of attempted suicide than their heterosexual counterparts. Some clinicians within the field of clinical psychology have recommended treating gay or lesbian people who want to change their sexual orientation (Adams, Tollison, & Carson, 1981), whereas others recognize that such self-denigrating desires result from living as part of an oppressed group. Treating LGB people to change their sexual orientation has been criticized on ethical grounds (Davison, 1976; Schroeder & Shidlo, 2001); its treatment effectiveness has been challenged (Haldeman, 1994, 2002) and so-called "conversion therapy" has been rejected or discouraged by most professional mental health organizations (e.g., American Psychiatric Association, 2000; American Psychological Association, 1998). The idea that gay or bisexual men and lesbian or bisexual women are able to change their sexual orientation with help persists, couched in the guise of allowing patient autonomy in decision making. Such an argument overlooks the enormous pressure to be heterosexual that is placed on LGB people from birth forward. The literature suggests that most LGB youth and adults are well adjusted and manage to cope effectively with the stresses of being members of a sexual minority. Nevertheless, LGB youth are at greater risk for depression and suicidality, and LGB adults are at greater risk of depression and anxiety disorders than their heterosexual counterparts. It appears that mediating factors other than sexual orientation significantly contribute to this finding. LGB patients who receive more social support from family and community are better protected from depression and other emotional difficulties. Family reactions to disclosure of an LGB sexual orientation may be particularly important to LGB youth in both positive and negative ways. In general, it appears that accepting one's sexual orientation and disclosing it openly to others is associated with better emotional well-being. This is not the case with every LGB patient, however. Therapists need to allow patients to determine how they identify and how public they wish to be about their identity, while supporting those patients who may wish to disclose to others but do not do so out of fear. The sections of this chapter discuss the following topics: Conceptualization of depression with LGB women and men; Level of openness about sexual orientation; Level of acceptance of or resistance to negative societal views about homosexuality; Stage of "coming out"; Problems of therapeutic bias; Assessment of depression with LGB women and men; Treatment of depression with LGB women and men; Adaptation of "standard" CT for depression; and finally, A case illustration.
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