At a time when Lesbian and Gay (LG) equality rights are still being debated by the United Kingdom (UK) Parliament and by several religious organisations, worldwide attitudes towards same-sex relationships remain controversial and ambivalent (Pew Research Centre, 2013). Previous research has identified the existence of such ambivalent attitudes amongst the general population (Herek, 2009; Herek, Gillis & Cogan, 2009), in particular when unconscious (implicit) attitudes are measured and do not always match people’s self-reported (explicit) attitudes (Banse, Seise & Zerbes, 2001; Nosek & Banaji, 2009; Ranganath & Nosek, 2007; Steffens & Jonas, 2010). Equally, attitudes in psychologists seem to follow similar trends (Boysen & Vogel, 2008; Boysen, 2009) where explicit attitudes tend to be positive while implicit attitudes tend to be ambivalent or negative. Such discrepancy between explicit and implicit attitudes can cause internal conflicts in people between their thoughts about, and their behaviour towards, LG people. This can make people come across as ambivalent, distant, and negative (Gawronski & Strack, 2004; 2012) when interacting with LG people.
Research has found evidence that psychologists and psychologists-in-training can show such ambivalence to LG people too (Finkel et al., 2003; O’Brien, 2003; Scher, 2009), including anxiety and avoidance (Gelso et al., 1995), and emotional and social distance (Barrett & McWhirter, 2002; Jones, 2000). Equally, vulnerable clients belonging to minority groups may often be at the centre of unintended discrimination, through ambivalent behaviours, when professionals’ attitudes about clients’ identity are negative or biased. Studies also revealed that psychologists would show less concern for gay clients when their attitudes towards LG people were more negative (Clarke, 2010), consider LG clients riskier and more likely ‘to harm other people’ (Bowers et al., 2005), propose more controlling interventions with gay clients (O’Brien, 2003), be less willing to work with gay clients in therapy (Barrett et al., 2002), regard LG identity as more pathological, and support the use of therapy to change a client’s sexual orientation (Kilgore et al., 2005).
These findings are particularly relevant for clinical psychologists who increasingly may have to see in clinic LG people with psychological and social needs, and to offer them support through direct and indirect clinical work, consultancy and training, supervision and research, and academia-related activities (British Psychological Society, 2006; 2012). Psychologists’ attitudes about clients are then particularly relevant to clinical communication. This is due to the recognition of the potential bio-psycho-social impact that discrimination and prejudice can have on people belonging to minority groups (Meyer, 2003; Davies, 2012). Nonetheless, communication and attitudinal research is a recent emerging phenomena among healthcare professionals (Steffens, 2005; Steffens & Jonas, 2010), remains scarce and is further needed at the centre of clinical psychology practice.
The current research investigated communication patterns on a sample of UK clinical psychologists-in-training toward simulated ‘gay clients’ (professional actors), and how participants’ demographic characteristics and attitudes towards LG people may be related to their behaviour in session with a ‘gay client’ either with depression or with anxiety. The study also looked at changes in clinical communication over time, so each 10-minute ‘session’ was video-recorded to be analysed with two communication measures. ‘Gay clients’ also provided their satisfaction score at the end of each session for each psychologist. Results suggested that the current sample of psychologists-in-training show discrepancy between positive self-reported (explicit) attitudes and slightly negative and ambiguous unconscious (implicit) attitudes towards LG people. The attitudes of the current sample were equivalent to those found in earlier studies (i.e. Boysen et al., 2008; Banse et al., 2001) thus showing a prevalence of unconscious social prejudice and distance towards sexual diversity. These attitudes did not change after six months of clinical training and placement experience.
Furthermore, clinical communication scores revealed that participants interacted professionally with ‘gay clients’ but showed less empathy and interest in client’s concerns and worries. ‘Clients’ also felt overall dissatisfied with their sessions and did not feel a connection with their ‘psychologist’. In particular, psychologists who had more avoidant characteristics had more difficulty in communicating with ‘clients with depression’, did not explore clients’ feelings as often, and gave ‘clients’ less opportunities to speak about their worries. Whenever clients gave hints to the psychologist that they wanted to talk about their concerns, most of the time these were not noted or followed-up by the psychologist. ‘Clients with depression’ felt less satisfied with their session than ‘clients with anxiety’ and findings were similar after six months of clinical training and placement. However, after six months of training, psychologists’ communication scores improved slightly and ‘clients with depression’ felt slightly more satisfied with their session.
These findings are important since previous research has found that practitioners often struggle more when working with clients with depression (e.g. Gonzalez et al., 2013; Annen et al., 2012; Lyons & Janca, 2009). These clients are often perceived as unmotivated and disengaged, and consultations are more difficult to conduct. However, most of the time clients with depression are unsure if they can trust their therapists with their problems and just want to be asked the right questions. When applying such results to LG clients, a study by Newman and colleagues (2010) uncovered that gay men with depression often withheld information about their worries and concerns until they feel that their therapists are trustworthy, ethical, encouraging, knowledgeable, supportive and, most of all, are open and clear. These are important areas to highlight, due to the dual stigmatisation that gay men may face when also diagnosed with a mental illness.
Quality of life, therapeutic outcome and client satisfaction can be greatly improved when there is tailored client participation and decision-making and good clinician communication skills (Vogel, Leonhart & Helmes, 2009). So there is an urgency to ensure that psychologists are trained to provide therapy in a safe and affirmative environment with the right communication skills, even if at first they may feel deskilled to working with LG people. There is also a need for psychologists to revisit their assumptions of sexual orientation through specific sexual diversity training, to prevent cultural and personal bias from transpiring to the therapeutic relationship. In particular, future research could explore the impact of such training on attitudes and clinical communication with gay clients with depression when comparing to heterosexual clients with depression to evaluate if there is any difference in the interaction.
Annen, S., Roser, P., & Brune, M. (2012). Nonverbal Behavior During Clinical Interviews: Similarities and Dissimilarities Among Schizophrenia, Mania, and Depression. Journal of Nervous & Mental Disease, 200(1): 26-32.
Banse, R., Seise, J., & Zerbes, N. (2001). Implicit attitudes toward homosexuality: reliability, validity and controllability of the IAT. Zeitschrift fur Experimentelle Psychologie, 48(2): 145-160.
Barrett, K. A., & McWhirter, B. T. (2002). Counselor trainees’ perceptions of clients based on client sexual orientation. Counselor Education & Supervision, 41: 219-232.
Bowers, A. M. V., & Bieschke, K. J. (2005). Psychologists’ clinical evaluations and attitudes: an examination of the influence of gender and sexual orientation. Professional Psychology: Research and Practice, 36(1): 97-103.
Boysen, G. A. (2009). A Review of Experimental Studies of Explicit and Implicit Bias Among Counselors. Journal of Multicultural Counseling and Development, 37: 240-249.
Boysen, G. A. & Vogel, D. L. (2008). The relationship between level of training, implicit bias, and multicultural competency among counselor trainees. Training and Education in Professional Psychology, 2(2): 103-110.
British Psychological Society (BPS) (2006). Core competencies – clinical psychology – a guide. Leicester, UK: BPS.
British Psychological Society (BPS) (2012). Guidelines and literature review for psychologists working therapeutically with sexual and gender minority clients. Leicester: British Psychological Society.
Clarke, C. P. (2010). Exploring the relationship between heterosexual therapists’ attitudes toward gay men, their self-reported multicultural counseling competency, and their initial clinical judgments. Dissertation Abstracts International, 70, 12-B, PsycINFO, EBSCOhost [accessed 25 September 2012]
Davies, D. (2012). Sexual orientation. In C. Feltham & I. Horton (eds) The Sage handbook of counselling and psychotherapy, 3rd edition, pp. 44-48. London: Sage Publications.
Finkel, M. J., Storaasli, R. D., Bandele, A., & Schaefer, V. (2003). Diversity training in graduate school: an exploratory evaluation of the Safe Zone Project. Professional Psychology: Research and Practice, 34(5): 555-561.
Gawronski, B., & Strack, F. (2004). On the propositional nature of cognitive consistency: Dissonance changes explicit but not implicit attitudes. Journal of Experimental Social Psychology, 40, 535–542.
Gawronski, B., & Strack, F. (Eds.). (2012). Cognitive consistency: A fundamental principle in social cognition. New York: Guilford Press
Gelso, C. J., Fassinger, R. E., Gomez, M. J., & Latts, M. G. (1995). Countertransference reactions to lesbian clients: the role of homophobia, counsellor gender, and countertransference management. Journal of Counseling Psychology, 42: 356-364.
Gonzalez, A. V., Siegel, J. T., Alvaro, E. M., & O’Brien, E. K. (2013). The Effect of depression on physician–patient communication among Hispanic end-stage renal disease patients. Journal of Health Communication: International Perspectives, Feb 14. DOI:10.1080/10810730.2012.727962
Herek, G. M. (2009). Understanding sexual stigma and sexual prejudice in the United States: a conceptual framework. In D. Hope (Ed.), Contemporary perspectives on lesbian, gay and bisexual identities: the 54th Nebraska Symposium on Motivation (pp.65-111). New York: Springer.
Herek, G. M., Gillis, J. R., & Cogan, J. C. (2009). Internalized stigma among sexual minority adults: Insights from a social psychological perspective. Journal of Counseling Psychology, 56: 32-43.
Jones, L. S. (2000). Attitudes of psychologists and psychologists-in-training to homosexual women and men: an Australian study. Journal of Homosexuality, 39(2): 113-132.
Kilgore, H., Sideman, L., Amin, K., Baca, L., & Bohanske, B. (2005). Psychologists’ attitudes and Therapeutic approaches toward gay, lesbian, and bisexual issues continue to improve: an Update. Psychotherapy: Theory, Research, Practice, Training, 42(3): 395-400.
Lyons, Z., & Janca, A. (2009). Diagnosis of male depression – does general practitioner gender play a part?. Australian Family Physician, 38(9), 743-746.
Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129: 674-697.
Newman, C., Kippax, S., Mao, L., Saltman, D., & Kidd, M. (2010). Roles ascribed to general practitioners by gay men with depression. Australian Family Physician, 39(9), 667-671.
Nosek, B. A., & Banaji, M. R. (2009). Implicit attitudes. In P. Wilken, T. Bayne, & A. Cleeremans (Eds.), Oxford Companion to Consciousness (pp. 84-85). Oxford, UK: Oxford University Press.
O’Brien, K. (2003). Patient sexual orientation and clinical intervention: A study of psychoanalytic psychologists’ biases and countertransference enactments with the gay male patient. Dissertation Abstracts International, 63, 7-B, PsycINFO, EBSCOhost [accessed 25 September 2012].
Pew Research Centre (2013). The global divide on homosexuality: greater acceptance in more secular and affluent countries. Available online from: http://www.pewglobal.org/2013/06/04/the-global-divide-on-homosexuality/ [accessed 6th June 2013].
Ranganath, K. A., & Nosek, B. A. (2007). Implicit attitudes. In R. Baumeister & K. Vohs (Eds.), Encyclopedia of Social Psychology (pp.464-466). Thousand Oaks, CA: SAGE.
Scher, L. J. (2009). Beyond acceptance: An evaluation of the safe zone project in a clinical psychology doctoral program. Dissertation Abstracts International, 69, 10-B, PsycINFO, EBSCOhost [accessed 25 September 2012]
Steffens, M. (2005). Implicit and explicit attitudes towards lesbians and gay men. Journal of Homosexuality, 49(2): 39-66.
Steffens, M. C., & Jonas, K. J. (2010). Implicit attitude measures. Journal of Psychology, 218(1): 1-3.
Vogel, B., Leonhart, R., & Helmes, A. (2009). Communication matters: The impact of communication and participation in decision making on breast cancer patients’ depression and quality of life. Patient Education & Counseling, 77(3), 391-397. doi:10.1016/j.pec.2009.09.005
Trainee Clinical Psychologist, University of Liverpool