Pride focus: Delighting in difference
Therapy Today, June 2024

As a profession that values empathy and connection many of us strive to hold a thoughtful middle ground in an increasingly fractured and polarised world, both in and out of the consulting room. But we are not immune from the human pull to tribalism. Territorial disputes within the profession over what constitutes ‘proper’ therapy have traditionally been fought between modalities. More recently, a split between affirmative and exploratory approaches has developed along ideological fault lines, descending into a civil war of sorts.

I occupy a curious position in relation to this split as an experienced psychodynamic psychotherapist – in other words, trained to explore – who is also a gay man working with LGBTQ+ clients. Exploration and affirmation are at the heart of my work, but I’ve noticed therapists from either side of the divide attempting to discredit the other. But what if affirmation and exploration, rather than being mutually exclusive, represent the disavowed shadow of the other – projected parts that, once reclaimed, can enrich and improve our work with this community? Perhaps it’s time to address this split and choose understanding over shutting down.  

Affirmative therapy has its roots in social justice, particularly in work with LGBTQ+ communities, as a response to the pathologising of sexual and gender minorities. The starting point for affirmative therapy is that sexual and gender diversity do not represent mental health conditions in themselves. In affirmative therapy we allow clients to define themselves without pre-judgment or attempts to change them to fit our theories or world view. 

For some, the idea of affirmative therapy conjures up the cosy platitudes of self-help books, or therapist as cup of tea-wielding best friend and champion. The reality is far more nuanced – the stance of the affirmative therapist is: you are welcome as you are. We invite clients in and, as the relationship deepens, we help them to understand themselves in the context of the world in which they live. In other words, we explore. 

Explorative

Explorative therapists often seek to examine the unconscious and trace historic relational patterns that might be causing current difficulties. They use the therapeutic relationship itself as an agent for change – through transference, countertransference, rupture and repair. It can and should be challenging, pushing us to confront ourselves. It is this aspect of therapy that excited me, and made me want to become a therapist. 

But the legacy of harmful conversion therapies has understandably left some wary of exploratory therapy. The historic pathologising of homosexuals is echoed in that of transgender and gender-expansive people today by some in our profession. Conversion therapy in its overt, well-documented form can include those damaging faith-based ‘pray away the gay’ therapies, thankfully far less common in the UK than other countries.¹ But more covert conversion practices can occasionally be found within our profession, where at times exploratory therapy might collide with inflexible ideologies around gender and sexuality. In the wrong hands, a person struggling to come to terms with their sexual or gender diversity might face a ‘corrective’ exploratory therapy. 

However, most exploratory therapists are not enacting conversion therapy, and discouraging LGBTQ+ people from good exploratory therapy is a missed opportunity to experience a potentially vital and meaningful therapeutic encounter. 

Therapy Today, June 2024

Minority stress 

As a client I experienced harm from therapists ill-equipped to work with me. I was lucky to avoid overt conversion practices but the often inflexible theories and world view of some practitioners were damaging, creating ruptures that were unable to be repaired. Many of my clients have had similar experiences – some much worse. Too often exploratory therapy with LGBTQ+ clients goes straight to psychological defences without acknowledgment of the social context or the impact of minority stress.² Minority stress – or chronic minority trauma, as I prefer to think of it clinically – is the additional and unique stress that many minority people face. It comprises distal and proximal stress – distal stress refers to external stressors such as prejudice, violence or discrimination, while proximal stress refers to our internal defensive responses to the distal, such as concealment avoidance and self-hatred. Paradoxically these protective measures, once so necessary, can end up adding to our stress load, creating a vicious cycle.

As an example, the impact of Section 28, a series of laws in Britain from 1988 to 2003 that prohibited the ‘promotion of homosexuality’ by local authorities, along with homophobic bullying when I was at school, left me self-conscious and paranoid about the way I walk and talk, even into adulthood. I spent a lot of energy trying to hide aspects of myself that might draw unwanted attention. This kept me safer, to a degree, but at the cost of my spontaneity and ability to relax in public. 

Dark parts 

As minorities we can serve as a convenient location for the disowned dark and shadowy parts of normative society. Internalised homophobia is a proximal stress response where we identify with societal prejudice, often using it to police ourselves and others like us on behalf of the majority. As part of my hiding I kept myself distant from the gay community, telling myself it was necessary to maintain work boundaries. But really I was trying to avoid facing that part of me labelled by some as wrong, dirty and deviant. By way of a powerful projective identification, we can become what is expected of us in our responses to distal stress – for example, gay men as hypersexual or shallow, or black people as angry or violent. Society then uses these stereotypes to confirm its prejudice and pathology. Such context can be missed in work with minorities, especially by majority population therapists. 

Finding therapists who were affirmative as well as exploratory was a revelation to me, allowing that foundation of basic trust on which the necessary deeper work could build. As Ilan Meyer, the epidemiologist who first identified minority stress, says: ‘We must always strive to remove the stressor, not make the person more inured to it.’³ The world, however, can be tough and unfair, and not all stressors can be removed – we therefore need to attend to both social injustice and our psychological responses to it.

Linked to this is an overdiagnosis of borderline personality disorder in lesbians, gay men and transgender people compared to other groups.^4,5 Psychological splitting might speak to attempts to fit into a world that accepts a minority person only conditionally, and the resulting behaviours share some common ground with personality disorders. As practitioners we need to be open-minded as to what indicates psychopathology, and what relates to the cumulative trauma of a life of stigma and stress. 

Minority stress theory is helpful in bridging this gap. Where affirmative therapy acknowledges the distal stress impact of the external world, exploratory therapy attends to the proximal stress – those once necessary but now likely unhelpful internal defences. Finding the right person to help us to unpick both can be life-changing. 

Seeking balance

In my view, therapists working with minority clients should seek a balance between affirmation and exploration – which need not be mutually exclusive – in order to attend to both distal and proximal stressors. Indeed, a truly curious and exploratory therapy is affirmative, not because it verbally and effusively validates a client in what seems to have become a caricature of affirmation but because it takes LGBTQ+ clients as they are, not as seen through normative lenses and theories.⁶ Psychoanalyst Avgi Saketopoulou goes a step further, writing: ‘Our ethical call is toward metapsychologies and clinical spaces that treat gender and sexual diversity not by simply making room for them or “accepting them”, but by delighting in the pleasure of difference. A proliferation of difference is not a threat but a condition of possibility for enlarged collective living.’⁷ 

My wish is that we can unite the artificially created divide between exploration and affirmation, and successfully blend them in our work with LGBTQ+ clients. With an affirmative foundation, all good therapy should be challenging, explorative, deep and rewarding. Rather than a defensive doubling down, understanding and humility are vital if we are to move forward and unite the profession. Together we can ensure our LGBTQ+ clients are not put in harm’s way nor deprived of a meaningful therapy.