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.

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Miguel Montenegro
Trainee Clinical Psychologist, University of Liverpool

September 2013