Religious Identity and Sexual Identity in Therapy

Sienna, age 27, comes to the office and — after a little small talk — shares that she is looking for help with a conflict she's felt for years: "I have felt attracted to other girls since I was maybe 12 or 13. I wasn't sure what it meant, and I didn't dare tell anyone. My family raised me in the church. My dad was an elder; he still is. My mom is also what I guess you'd call a 'strong Christian.' I mean, I am a Christian too; my faith matters to me. Growing up, I knew better than to bring up my attraction to girls. It was a confusing time for me, and in some ways, it still is. Middle school was hard. High school was hard. I guess we can talk about that later. College was better. In college, it felt like if people knew, they wouldn't judge me. But I wasn't sure how to fit my sexuality with my faith or vice versa. After I graduated, I started my career, and that's been fine, I guess. No real drama there. But I feel like I'm having a hard time finding a local church. I don't know what to make of the gay community. I don't see myself at a pride parade. I don't know what to do with my same-sex sexuality. I don't know what to do with my faith. I guess I'd like to talk with you about it."

SIENNA EXPERIENCES a conflict between her religious identity and her sexual identity. She is looking for a place, a therapeutic relationship, where she can navigate that conflict. It goes without saying that some people do not experience such a conflict between religious and sexual minority identity, or they find ways within their existing support system to navigate that conflict without the aid of therapy. But for Sienna and many others, it can be helpful to have a place to discuss both religious and sexual identity and to work out a coherent sense of identity to move forward in life.

It is worth noting that 89% of adults in the United States say they believe in God, and three fourths (77%) of adults identify with a religion (Pew Research Forum, 2015b). Reports of a recent dip in American religiosity cite the rise of the "nones," or those who hold no religious affiliation, a stance especially prominent among millennials (Pew Research Forum, 2015b). Despite this apparently growing minority view, religion continues to be an important part of many people's experience in the United States.

When we look at the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community, we see a drop in religious affiliation, although most (59%) still adhere to a religion. Similarly, while 71% of the general public identifies as Christian, about half (48%) of LGBTQ+ persons identify as Christian (Pew Research Forum, 2015a).

Andrew Marin (2016) of The Marin Foundation, a not-for-profit that has worked to bridge religious faith traditions, especially Christianity, and the LGBTQ+ community, reported on a study of over 2,000 LGB Christians who were asked about their Christian faith and current religious practices. Most of them (86%) indicated they were raised in a faith community, and just over half (54%) left their faith community after age 18. A little over a third (36%) of LGBT people surveyed reported that they continued their faith practices after age 18, and most of these (about two thirds) continued practicing in theologically progressive faith communities, while about a third continued to practice in theologically conservative faith communities. Also, 80% of LGBT people surveyed indicated they regularly pray (regardless of religious identification or affiliation).

Religion will have varying degrees of impact on a person navigating same-sex sexuality or sexual identity. A shared faith tradition does not mean agreement when it comes to LGBTQ+ experiences. One Christian, for instance, may embrace his same-sex sexuality, view it as blessed from God, and pursue a faith community that shares this perspective. Another Christian may view same-sex sexuality as an experience that God did not intend for her and choose to forego same-sex relationships as a result.

What is particularly important is how clinicians navigate these potential differences with their clients. What does it mean to explore both religious identity and sexual identity in therapy?

Religious Identity and Sexual Identity In Therapy

The approach to care presented in this book is referred to as Sexual Identity Therapy (SIT). It follows the Sexual Identity Therapy Framework (SITF; Throckmorton & Yarhouse, 2006) and has been discussed in various forms for individual (Yarhouse, 2008) and group therapy (Yarhouse & Beckstead, 2011). SIT and the SITF were both cited in the 2009 American Psychological Association (APA) task force report on Appropriate Therapeutic Responses to Sexual Orientation as examples of identity-focused alternatives to sexual orientation change efforts (SOCE). Before we look more at SIT, let's look at the 2009 task force report.

The task force report was primarily focused on whether SOCE should be considered a viable therapeutic option when a person reports unwanted same-sex attraction. The task force provided a fairly extensive review of the extant research and concluded that "enduring change to an individual's sexual orientation [is] unlikely" (APA, 2009, p. 4). Interestingly, however, the task force also noted that the support clients received in such therapies had some perceived benefits. For example, when clients attempted to change their orientation, they perceived benefits in approaches that "emphasize acceptance, support, and recognition of important values and concerns" (APA, 2009, p. 4).

At the same time, gay affirmative therapy, which is in many ways the default posture clinicians take toward sexual minorities, may not be a good fit for all clients. In particular, clients who hold conventional religious beliefs and values may not feel the posture of gay affirmative therapy to be a supportive one for their own needs, depending on how such therapy is practiced. Gay affirmative therapy is not so much a protocol as a way of seeing a person's sexuality. In practice, gay affirmative therapy can at times assume a preferred identity outcome (e.g., gay) and same-sex sexual behavior as a taken-for-granted expression of that identity, in keeping with its assumptions about sexual identity and expression, even though these assumptions are not necessarily shared by every client.

The task force suggests that today's gay affirmative therapy, what they refer to as simply "affirmative therapy," is best practiced in a more open-ended manner, without a fixed outcome:

Although affirmative approaches have historically been conceptualized around helping sexual minorities accept and adopt a gay or lesbian identity ... , the recent research on sexual orientation identity diversity illustrates that sexual behavior, sexual attraction, and sexual orientation identity are labeled and expressed in many different ways, some of which are fluid. ... We define an affirmative approach as supportive of clients' identity development without a priori treatment goals for how clients identify or express their sexual orientations. (APA, 2009, p. 14)

To avoid confusion, I think of this more nuanced approach as "client-affirmative" so as to not conflate it with gay affirmative therapy, which may sometimes be balanced and client-affirmative but is not always practiced in quite this way by all practitioners. SIT is client-affirmative, as will be described in greater detail below. It functions as an alternative both to SOCE and to gay affirmative therapy as it is sometimes practiced.

The task force, even as it expressed concerns about SOCE, raised important considerations about what therapists stood to learn from the SOCE phenomenon. Among these considerations is the suggestion that mental health professions show respect for clients whose traditional religious values may conflict with the values of gay affirmative therapy as it has often been practiced. In other words, while the task force had concerns about SOCE, they also perceived a need for mental health services to create a safe space within which clients could explore beliefs and values that appeared to put their sexual and religious identities in conflict. In my view, such beliefs and values have at times precluded a person from being a good fit for gay affirmative therapy as it has traditionally been practiced.

The task force report concluded that when a client like Sienna presents with a conflict between her religious and sexual identities, clinicians are encouraged to utilize client-centered and identity-focused interventions rather than SOCE:

Conflicts among disparate elements of identity play a major role in the conflicts and mental health concerns of those seeking SOCE. Identity exploration is an active process of exploring and assessing one's identity and establishing a commitment to an integrated identity that addresses the identity conflicts without an a priori treatment goal for how clients identify or live out their sexual orientation. The process may include a developmental process that includes periods of crisis, mourning, reevaluation, identity deconstruction, and growth. (APA, 2009, p. 64)

In addition to being client-centered and identity-focused, the task force report outlined several other qualities they believe should be part of an affirmational approach to care. Such care would also reflect multicultural competence and foster both social support and coping skills.

In light of the conflicts experienced by conventionally religious clients who experience same-sex attraction, and in light of the concerns raised about SOCE, there appears to be a need for more "third way" models of care. The task force described some of the elements of an approach to care that could reflect these benefits without attempting to make gay people straight and cited a number of examples of "integrative and affirmative [or client-affirmative] perspectives" that include the SITF (Throckmorton & Yarhouse, 2006) and SIT (Yarhouse, 2008), among many other approaches (see Beckstead & Israel, 2007; Beckstead & Morrow, 2004; Glassgold, 2008; Haldeman, 2004). What the task force appeared to appreciate were approaches that explored identity rather than attempting to manipulate orientation. They emphasized the value of clinical services that demonstrated respect for religious identity while avoiding some of the pitfalls they saw in SOCE. Taken together, these various approaches suggest that "psychotherapy that respects faith can also explore the psychological implications and impact of such beliefs" (APA, 2009, p. 20).

The task force noted that although there are no empirically supported treatments (EST) for this population, in part because EST are "interventions for individuals with specific disorders" that "have been demonstrated to be effective through rigorously controlled trials" (APA, 2009, p. 14), affirmative care is evidence-based insofar as it integrates the best research we have as a field with clinical wisdom and expertise, in light of a number of client diversity considerations.

SIT is a therapeutic approach that is consistent with the SITF (Throckmorton & Yarhouse, 2006). The SITF provides a kind of scaffolding for people who wish to help clients navigate sexual identity in therapy.

The SITF organizes mental health services into four distinct areas: assessment, advanced informed consent, psychotherapy, and congruence. Assessment includes general mental health concerns as well as a client's religious background or upbringing, current religious beliefs and values, and sexual identity. Advanced informed consent addresses general consent information (such as the limits of confidentiality) but also broaches the controversies surrounding sexual identity and religion in some detail so that clients have adequate information to decide whether this is the right approach for them. Psychotherapy should reflect a client-affirmative approach and can be based on any number of theoretical orientations; the key is that such therapy leads a person toward congruence, which means that the peson's behavior and sexual identity is in keeping with the person's beliefs and values.

Any number of therapy models could be consistent with the SITF. SIT is one of those models. Let's look at a brief overview of the key components of SIT.

Sexual Identity Therapy

SIT (Yarhouse, 2008; Yarhouse & Beckstead, 2011) is one approach to providing therapy in keeping with both the SITF and recommendations from the 2009 APA task force. It is considered an alternative to both SOCE and gay affirmative therapy. SIT is for individuals who experience a conflict between their religious and sexual identities. It follows a theoretical model of, and empirical research on, sexual identity development (Yarhouse, 2001; Yarhouse, Stratton, Dean, & Brooke, 2009), as well as empirical research on the experiences of Christians who identify as gay and those who disidentify with a gay identity or the mainstream LGBTQ+ community (Yarhouse & Tan, 2004; Yarhouse, Tan, & Pawlowski, 2005). SIT is client-affirmative and, in addition to a focus on sexual identity exploration, it reflects a nuanced understanding of both the mainstream LGBTQ+ community and the range of beliefs and values found in religious communities. In terms of core elements, SIT originated with an emphasis on cognitive elements, most notably attributions clients make about their same-sex sexuality in light of their religious faith. Today, SIT, as I practice it, also draws upon narrative elements. In a recent article I described SIT as drawing from "cognitive-behavioral, person-centered, and narrative theoretical orientations and [focusing] on attributional search for sexual identity, navigating religious identity conflicts, and facilitating personal congruence" (Yarhouse & Beckstead, 2011, p. 108).

There are a few steps to SIT. The therapy begins with assessment and advanced informed consent. It is important for the therapist to distinguish SIT both from SOCE — which a client may have participated in previously or be hoping for — and from gay affirmative therapy. There is then often a time of psychoeducation. These are typically the first two to three sessions. After these are completed, much of therapy entails an "attributional search" for sexual identity that involves navigating the principal conflicts the person experiences between that person's religious and sexual identities. Attributional search refers to how clients make meaning and come to construct purpose out of their same-sex sexuality. The final step is that of personal congruence.

Assessment

Assessment and advanced informed consent often occur in tandem. A clinician is collecting initial information at intake and providing information about services. The clinician collects further information through a more thorough assessment, determining if SIT would be a good fit for a client. I will discuss assessment and advanced informed consent in that order, but to treat them as strictly linear would be oversimplifying the process. Also, as we will see, informed consent is obtained at the start of therapy but is returned to throughout the course of therapy.

We will see in subsequent chapters that assessment of both sexual identity and religious identity is important in SIT. It is also important to assess the history of conflict between these two aspects of identity and personhood. Clinicians also collect information on experiences with key milestone events in identity development, such as first awareness of same-sex attractions. If a therapist uses a more narrative approach to SIT, assessment will consider more explicitly how experiences have been informed by "stories" people have heard about same-sex sexuality and what those stories mean to them today.

Advanced Informed Consent

In tandem with a proper assessment, it is important to obtain advanced informed consent for SIT. Advanced informed consent includes going over standard information covered in informed consent as well as detailing common questions people have about sexual orientation and identity, the nature of SIT, and so on. The reason for advanced informed consent is that the topic of sexual identity and the potential conflicts that exist between religious and sexual identities are such that it seems prudent to provide more detailed information to the client so that the client can truly make an informed decision about possible services.

Psychoeducation

There are two common components of psychoeducation. The first is a three-tier distinction between attractions, sexual orientation, and identity (Yarhouse, 2005). In other words, some people experience same-sex attraction. Many but not all of these individuals experience so much same-sex attraction — and they experience it in a consistent, enduring way — that they would say they are oriented toward the same sex. Still others would adopt a gay identity, either privately or publicly. A gay identity may to some clients simply reflect an account of their sexual orientation, which is the common vernacular today, or a gay identity could reflect a close affiliation with the mainstream LGBTQ+ community and communicate certain beliefs and values.