The Couch in Rainbow Colors: ‘L.G.B.T.-Affirming’ Therapy

Dr. Sadownick’s work as a gay-rights activist long precedes the founding of the Antioch program. Last month, after the massacre inside the Pulse nightclub in Orlando, Fla., he noted that though huge strides have been made toward in the field of civil rights, “it doesn’t mean that the decades — the centuries — of hiding and shame don’t manifest psychologically,” he said. “In some ways we’re only at the beginning of the liberation movement. All of the hate crimes against gay people come from homophobia.”

Antioch’s program is a fully galvanized undertaking, one whose political zealousness may surprise some who work in the psychotherapeutic profession. As Dr. Sadownick put it, this is the “therapist as activist” model. “This is a radical mission, a revolutionary mission.”

Ian Jensen, an Antioch student currently finishing the L.G.B.T.-affirmative requirements, said, “What often happens to a gay or trans client is that they go see a therapist, and the therapist doesn’t know anything about gay issues at all.”

Mr. Jensen had a first career as an actor but decided to switch directions after working with an L.G.B.T.-affirming therapist.


Doug Sadownick, right, a founder and the former director of the “L.G.B.T.-affirming” clinical psychology program at Antioch University. Here, he conducts a class on family systems.

Kendrick Brinson for The New York Times

“Having a gay-affirmative therapist really changed my life in a lot of ways,” he said. “I had always thought, ‘I’m just like my straight friends, only I’m attracted to men.’ But what I found out is that there’s a deeper level of experiencing what it means to be a gay person than just my sexual identity. So discovering that — and realizing there’s so much more to be discovered — I thought, I really want to do that for other people as well. I want to be an agent of change.”

Yet to others in the profession, psychotherapists who do not specialize in any single kind of patient, the very claims on which Antioch’s program is based are fraught.

“The problem with essentialism is that it creates a very big category of difference between L.G.B.T. people and everyone else,” said Michael Garfinkle, a psychoanalyst in New York. “Is this phenomenon unique to L.G.B.T.? Is it true of Jews? Is it true of Muslims? Is it true of British people versus Alaskan people?”

“It’s oddly an incredibly cynical position,” he said, “in that it deprives therapists and patients of the possibility that we as people can do better, without such heavy-handed intervention.”

Jamieson Webster, a psychoanalyst in New York who, like Dr. Garfinkle, does not consider herself a specialist, has a different concern. “Freud was incredibly worried about any idea of one political outcome that you’re trying to seek with patients,” Dr. Webster said. “And I think that’s a caution that’s still really worthwhile. If you have a specific goal in mind with a patient, then you’re going to miss any other that they’re there to discover.”

Antioch’s specialization is, in some sense, a reaction to the long, troubled history of how the mental health profession has approached the treatment of gay and transgender patients in this country and elsewhere. The problem wasn’t inherent to psychoanalysis itself. Freud famously argued that human sexuality is fluid, existing on a continuum.

When the mother of a gay child wrote to Freud in distress about her son, he replied, in an often-cited letter: “Homosexuality is assuredly no advantage, but it is nothing to be ashamed of, no vice, no degradation; it cannot be classified as an illness.”

Yet, in the generations of analysts who followed Freud, theories built up trying to explain homosexuality in terms of pathology, as a result of trauma or defective parenting.

It was in only 1973 that the American Psychiatric Association removed homosexuality from its ever-shifting Diagnostic and Statistical Manual of Mental Disorders. Removing that diagnosis was a milestone moment, and it was followed by an outpouring of theorizing about how old ideas may be applied in newly illuminating ways to the psychology of being gay.

Yet despite the flowering of such new ideas all through the 1970s and ’80s, it would take another quarter-century for the American Psychological Association to issue guidelines for the ethical treatment of lesbian, gay and bisexual clients, eschewing therapeutic attempts to “cure” patients of being gay. Those techniques — what is called conversion or reparative therapy — are still practiced throughout the country.

Equivalent guidelines for the ethical treatment of transgender patients appeared more than a decade later, yet many feel that far too little has been clarified on this subject. The very fact that the letters L, B, G and T are routinely lumped together is seen by many as problematic and imprecise.

Cadyn Cathers, a transgender instructor at Antioch (and a graduate of the specialization himself) who is in the process of becoming a fully licensed psychologist, sees transgender patients almost exclusively in his case work.

For Mr. Cathers, one of the most obvious issues specific to working with such patients is the medical component: Often, what brings transgender patients into psychotherapy is to discuss gender reassignment surgery, for which many insurance companies require a letter of recommendation from a mental health professional.

The therapeutic relationship, Mr. Cathers said, is then complicated by the dynamic of “gatekeeping,” which is to say, “that the therapist keeps the patient in therapy for as long as they want, until some arbitrary thing happens, before they’ll write a letter approving hormones or surgery.”

Mr. Cathers contrasts this with the “informed consent model,” which he himself follows. “Even if you aren’t a gatekeeping therapist,” he said, “patients come in thinking that you are, because that narrative is the most common narrative that’s heard in the community.”

The scenario this produces, Mr. Cathers said, is that patients often feel compelled to prove that they really are the gender they say they identify as, believing that only if they are persuasive enough will they secure the therapist’s letter enabling them to get what they want. Mr. Cathers often begins by telling his patients, “You don’t have to prove anything to me.”

Yet while Mr. Cathers, Dr. Sadownick and others believe that it is urgent for L.G.B.T. patients to be treated by therapists who have been specifically trained to help them — or risk the psychic hurt of not being truly seen — they also believe that the potential benefits of such therapy are in no way reserved for just these clients.

The sensibility imparted by L.G.B.T.-affirming therapy is of huge worth to straight clients, too, they say, because it is built around the urgent need to wake up to the social assumptions that shape all of our lives, whether or not we want them to.

“A heterosexual woman is saturated in all of these norms about how she should be with a male, how she should pass her time clock, how she should get married,” Dr. Sadownick said. “There’s very little maneuver room. And that is where the L.G.B.T.-affirming therapy can also be helpful.”

Matthew Silverstein, a psychotherapist in West Hollywood, Calif., who was also involved in the creation of the Antioch program, described from his own practice how freeing the L.G.B.T.-affirming sensibility can be, for straight patients as well as gay. On the question of fidelity, for example: “It’s not that I don’t believe in communication and trust,” Dr. Silverstein said, “but I have many different models of what it means to be in a relationship, and I can thank the gay community for opening my eyes to that.”

So when, for instance, a patient comes in distressed over a husband’s affair, real or suspected, he said, “I can help her identify what are the expectations she holds that are leaving her so anguished.”

After all, he noted, “the whole idea of the crisis of infidelity is based on the expectation that it ought to be otherwise. And that somehow if a relationship changes in its dynamic and somebody has sex with somebody else, that somehow it’s ruinous to the intimacy and potential for growth and love. That’s an enormous assumption. And it’s just another example of a hetero-normative assumption, one that causes enormous suffering.”

“So you would like to see more flexibility around that assumption?” I asked Dr. Silverstein.

“More inquiry,” he replied.

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