SEXUAL IDENTITY CONFUSION

CLIENT PRESENTATION

  1. Confused/Uncertain (1)1
    1. The client showed a good deal of uncertainty about his/her basic sexual orientation.
    2. The client exhibited a high level of anxiety regarding the issue of his/her sexual orientation.
    3. The client has gradually begun to be more comfortable and less anxious about his/her sexual orientation.
  2. Sexual Fantasies/Desires Surrounding Same-Sex Partners (2)
    1. The client expressed distress about his/her fantasies and desires for a same-sex partner.
    2. The client tried hard to convince himself/herself that the desire for a same-sex partner did not upset him/her.
    3. The client reported a long history of fantasies and desires for same-sex partners that went back to late childhood.
    4. The client reported feelings of conflict and distress around sexual fantasies and desires with same-sex partners.
    5. The client has begun to process his/her desires and fantasies involving same-sex partners and is no longer feeling overwhelmed.
  3. Guilt/Shame (3)
    1. A strong sense of guilt and shame dominates the client's mood and manner.
    2. The client reported a pattern of guilt and shame surrounding the homosexual feelings, desires, and fantasies he/she was experiencing.
    3. The client described being unable to feel comfortable with others due to guilt and shame he/she constantly feels.
    4. The client's feelings of guilt and shame have decreased since he/she has started to accept his/her sexual orientation.
  4. Feelings of Worthlessness (3)
    1. The client's presentation reflected a low sense of self-esteem, and he/she avoided any eye contact and made consistent self-disparaging remarks.
    2. The client described himself/herself as being totally worthless.
    3. Due to his/her homosexual feelings, the client did not see any way for him/her to feel okay about self.
    4. As the client has acknowledged his/her homosexual orientation, he/she has started to entertain the possibility of feeling okay about self.
  5. Depressed/Withdrawn (4)
    1. The client presented in a depressed, withdrawn manner with low energy and a lack of interest in things.
    2. The client reported a pattern of depression that has led him/her to withdraw from others and from life's activities.
    3. The client described a history of being depressed that he/she can trace back to early teens and his/her questions about his/her homosexual orientation.
    4. Since stating his/her sexual orientation, the client appeared less depressed and has started to interact with others.
  6. Concealing Sexual Identity from Parents (5)
    1. The client admitted that he/she has always worked hard to keep his/her homosexual urges hidden from parents.
    2. The client reported avoiding any sexual questions parents have raised concerning him/her.
    3. The client has started to be more open with his/her parents regarding his/her struggle with sexual identity.
  7. Sexual Experimentation (6)
    1. The client reported recent homosexual experimentation that has raised questions about his/her sexual orientation.
    2. The client has involved himself/herself in impulsive, reckless sexual experimentation.
    3. The client's homosexual experimentation has strengthened his/her conviction that he/she is not heterosexual.
    4. The client indicated curtailing most of his/her sexual experimentation because he/she feels more certain of his/her sexual orientation.
  8. Parents' Concern over Client's Possible Homosexuality (7)
    1. The parents showed distress and concern about the possibility of their child being homosexual.
    2. The parents raised numerous questions about the issue of their child's possible homosexuality.
    3. The parents verbalized feelings of anger and rejection toward the client as the client talked of his/her homosexual orientation.
    4. The level of the parents' distress and concern has decreased since openly discussing the issue of the client's homosexuality.
  9. Disclosure of Homosexuality to Parents (8)
    1. The client reported that he/she recently disclosed his/her homosexuality to parents.
    2. The client indicated that his/her parents are struggling with his/her disclosure of homosexuality.
    3. The client was crushed by the parental rejection he/she received on disclosing his/her homosexuality.
    4. The client was surprised and shocked by the acceptance he/she received from parents after disclosing his/her homosexuality.
  10. Parents' Feelings of Failure (9)
    1. The client reported that his/her parents are feeling responsible and to blame for his/her homosexuality.
    2. The parents expressed feelings of failure in regard to their child's homosexuality.
    3. The parents denied any feeling of responsibility or failure due to the client's homosexuality.
    4. The parents have begun to work through their feelings of failure in regard to the client's homosexuality.

INTERVENTIONS IMPLEMENTED

  1. Build Trust (1)2
    1. Trust was actively built with the client through the use of unconditional positive regard and active listening.
    2. Warm acceptance and active listening techniques were utilized to build trust with the client.
    3. An initial level of trust was established with the client, and he/she is now being encouraged to express his/her feelings concerning own sexual identity.
    4. The client is now being encouraged to express the fear, anxiety, and distress he/she is feeling about his/her sexual identity confusion.
    5. Despite trust and encouragement, the client struggled to express even a few feelings around his/her identity confusion.
  2. Gather Sexual History (2)
    1. A history of sexual desires, experiences, and fantasies was gathered.
    2. The client's current level of sexual functioning could not be fully assessed due to his/her resistance to revealing information on sexual experiences, desires, and fantasies.
  3. Explore Questions about Sexual Identity (3)
    1. The reasons the client began to question his/her sexuality were explored.
    2. The client identified the questions he/she has about his/her sexuality and the experiences that have triggered the questions.
    3. The client was reluctant to identify the questions that he/she has about his/her sexuality and was provided with acceptance and encouragement to help him/her explore these questions.
  4. Teach Commonality of Same-Sex Experiences (4)
    1. The client was taught the commonality of same-sex experiences in youth and informed that these do not necessarily indicate homosexuality.
    2. Questions and concerns regarding same-sex experiences were processed and answered.
    3. The client was reminded that same-sex experiences in youth do not necessarily indicate homosexuality but are a common part of sexual exploration.
  5. Conduct Psychological Testing (5)
    1. Psychological testing was administered to evaluate the client's emotional state and to rule out any severe mental illness.
    2. The psychological testing results indicate that the client experiences significant emotional distress due to his/her sexual identity confusion.
    3. The psychological testing reflected significant mental illness issues.
    4. The results of the psychological testing were interpreted to the client.
  6. Conduct Suicide Assessment (6)
    1. A suicide assessment was conducted with the client, who was open and honest about his/her feelings.
    2. Inpatient care was recommended and arranged for the client since a serious suicide risk was assessed.
    3. The client was uncooperative throughout the suicide assessment.
    4. The results and recommendations of the suicide assessment, which did not find serious risk to exist, were communicated to the client and the parents.
    5. Although the client denied any suicide plan or ideation, his/her level of anxiety and depression related to the sexual identity struggle suggests that ongoing monitoring of suicide potential is necessary.
  7. Sign No-Self-Harm Contract (7)
    1. A no-self-harm contract was developed, and the client was encouraged to sign it.
    2. The client was encouraged to verbalize a commitment to and to sign a no-self-harm contract.
    3. The no-self-harm contract was monitored for follow-through, and a more supervised level of care was determined to be necessary.
  8. Refer/Conduct Substance Abuse Evaluation (8)
    1. The client was referred for a substance abuse evaluation to assess the extent of his/her drug/alcohol usage and determine the need for treatment.
    2. The findings from the substance abuse evaluation revealed the presence of a substance abuse problem and the need for treatment.
    3. The findings from the substance abuse evaluation revealed the presence of a substance abuse problem that appears to be contributing to the client's behavior control problems.
    4. The evaluation findings did not reveal the presence of a substance abuse problem or the need for treatment in this area.
  9. Assess Level of Insight (9)
    1. The client's level of insight toward the presenting problems was assessed.
    2. The client was assessed in regard to the syntonic versus dystonic nature of his/her insight about the presenting problems.
    3. The client was noted to demonstrate good insight into the problematic nature of the behavior and symptoms.
    4. The client was noted to be in agreement with others' concerns and is motivated to work on change.
    5. The client was noted to be ambivalent regarding the problems described and is reluctant to address the issues as a concern.
    6. The client was noted to be resistant regarding acknowledgment of the problem areas, is not concerned about them, and has no motivation to make changes.
  10. Assess for Correlated Disorders (10)
    1. The client was assessed for evidence of research-based correlated disorders.
    2. The client was assessed in regard to his/her level of vulnerability to suicide.
    3. The client was identified as having a comorbid disorder, and treatment was adjusted to account for these concerns.
    4. The client has been assessed for any correlated disorders, but none were found.
  11. Assess for Culturally Based Confounding Issues (11)
    1. The client was assessed for age-related issues that could help to better understand his/her clinical presentation.
    2. The client was assessed for gender-related issues that could help to better understand his/her clinical presentation.
    3. The client was assessed for cultural syndromes, cultural idioms of distress, or culturally based perceived causes that could help to better understand his/her clinical presentation.
    4. Alternative factors have been identified as contributing to the client's currently defined “problem behavior,” and these were taken into account in regard to his/her treatment.
    5. Culturally based factors that could help to account for the client's currently defined “problem behavior” were investigated, but no significant factors were identified.
  12. Assess Severity of Impairment (12)
    1. The severity of the client's impairment was assessed to determine the appropriate level of care.
    2. The client was assessed in regard to his/her impairment in social, relational, vocational, and occupational endeavors.
    3. It was reflected to the client that his/her impairment appears to create mild to moderate effects on the client's functioning.
    4. It was reflected to the client that his/her impairment appears to create severe to very severe effects on the client's functioning.
    5. The client was continuously assessed for the severity of impairment, as well as the efficacy and appropriateness of treatment.
  13. Assess for Pathogenic Care (13)
    1. The home, school, and community of the client were assessed for pathogenic care and concerns.
    2. The client's various environments were assessed for the persistent disregard of the child's needs, repeated changes in caregivers, limited opportunities for stable attachment, harsh discipline, or other grossly inept care.
    3. Pathogenic care was identified and the treatment plan included strategies for managing or correcting these concerns and protecting the child.
    4. No pathogenic care was identified and this was reflected to the client and caregivers.
  14. Assign Rating of Sexual Attraction (14)
    1. The client was asked to rate on a scale of 1 to 10 his/her sexual attraction to both males and females.
    2. The ratings of the client were processed and assessed.
    3. It was noted that the client gave a high rating to his/her sexual attraction to same-sex peers and a low rating to opposite-sex peers.
    4. It was noted that the client gave a high rating to attraction to opposite-sex peers and a relatively low rating to same-sex peers.
    5. It was noted that the client gave sexual attraction ratings of approximate equal value to both same-sex and opposite-sex peers.
  15. Assign Writing of Future Autobiography (15)
    1. The client was asked to write two autobiographies, projected 20 years into the future, one of life as a homosexual and the other of life as a heterosexual.
    2. The client's two future autobiographies were read and processed.
    3. The question “Which life was more satisfying, and which had more regret?” was asked and processed.
    4. The client's projected future was noted to show a strong identification of self as a homosexual.
    5. The client's projected future was noted to show a clear identification of self as a heterosexual.
  16. Allow Self-Evaluation of Identity Evidence (16)
    1. A nonjudgmental atmosphere was created to allow the client to evaluate the evidence and to resolve his/her confusion regarding sexual identity.
    2. After a review of his/her sexual experiences, thoughts, and feelings, the client has identified himself/herself as homosexual.
    3. After a review of his/her sexual experiences, thoughts, and feelings, the client has identified himself/herself as heterosexual.
    4. Despite an accepting, nonjudgmental atmosphere, the client has not been able to identify his/her sexual orientation and was provided with additional support and encouragement in this area.
  17. List Deciding Factors (17)
    1. The client was asked to make a list of all the factors that influenced his/her decision on sexual identity.
    2. The completed list was processed, and key factors were confirmed.
    3. The client's list could be processed only in a limited way due to its being incomplete and vague.
    4. The client's list was noted to have a preponderance of factors that supported the homosexual identity.
    5. The client's list was noted to have a preponderance of factors that supported a heterosexual identity.
    6. The client has not completed a list of factors to help him/her decide on his/her sexual identity and was reassigned this task.
  18. Explore Feelings about Self as Homosexual (18)
    1. The client's feelings regarding seeing self as homosexual were explored.
    2. The client was assisted in identifying and expressing feelings about accepting self as a homosexual.
    3. Feelings that were identified by the client as ego syntonic were affirmed and reinforced.
    4. The client was noted to be relieved to finally accept himself/herself as homosexual.
    5. Active-listening skills were used as the client expressed strong feelings of anxiety and fear of the future regarding accepting self as a homosexual.
  19. Explore Negative Emotions about Hiding Sexual Identity (19)
    1. The client's negative emotions related to hiding and denying his/her sexuality were explored.
    2. Specific reasons for the client hiding or denying his/her sexuality were identified.
    3. Specific reasons for the client hiding or denying his/her sexual identity were probed and challenged.
    4. A warm, accepting, nonjudgmental approach was used to encourage the client to take risks and be more open about his/her sexual identity.
  20. Explore Religious Conflicts with Sexual Identity (20)
    1. The client's religious convictions were explored for ways they may cause conflict with his/her sexual identity.
    2. The shame and guilt surrounding religious convictions and sexual identity were assessed and processed.
    3. The client was assessed for the presence of religious conflicts with his/her sexual identity, but none were noted.
  21. Refer to Compassionate Clergy (21)
    1. The client was referred to a compassionate clergy member who will listen to his/her struggles on sexual identity.
    2. The client's experience with clergy was processed, and positive aspects of the experience were affirmed and reinforced.
  22. Teach Safer Sex (22)
    1. Guidelines for safer sex were taught to the client.
    2. The client's questions related to the details of safer sex practices were answered.
    3. The client was asked to make a commitment to consistently follow safer sex guidelines.
    4. The client's adherence to a safer sex commitment was monitored, and he/she was confronted when not following that commitment.
  23. Identify Myths and Replace with Positive Beliefs (23)
    1. The client was assigned to identify 10 myths about homosexuals and, on a scale of 1 to 5, rate how firmly he/she believes in each.
    2. The identified myths and their ratings were processed; then the client was assisted in replacing each with more realistic positive beliefs.
    3. The client was reminded of the positive beliefs about homosexuality to reinforce his/her sexual identity.
    4. Myths and negative statements about homosexuality by the client were confronted.
  24. Explore Homophobic Peer Experiences (24)
    1. The client's peer relationships were explored.
    2. Assistance was provided to the client in describing homophobic experiences in peer relationships.
    3. Ways to respond to homophobic and rejection experiences in peer relationships were identified.
    4. The client's peer relationships were explored for homophobic experiences, but none were identified.
  25. Identify Gay/Lesbian Peers (25)
    1. The client was encouraged to identify other lesbian and gay adolescents from school and support groups as possible companions in social activities.
    2. The client's fears regarding initiating social contact were addressed and resolved.
    3. The client was asked to commit to making one attempt each week to initiate a social activity with a gay or lesbian peer(s).
    4. The client has not followed through on initiating social contacts with gay/lesbian peers and was redirected to do so.
  26. Support Group Referral (26)
    1. The client was assisted in identifying the benefits of attending a support group for lesbian and gay adolescents.
    2. The client was referred to a lesbian/gay adolescent support group.
    3. The client's experience in attending the support group was processed, and positive aspects were affirmed and reinforced.
    4. The client's resistance to attending a support group was explored and resolved.
    5. The client was provided with positive feedback as he/she made a commitment to attend a support group for gay and lesbian adolescents.
    6. The client has not attended a support group for gay and lesbian adolescents and was redirected to do so.
  27. List Advantages/Disadvantages of Disclosing Sexual Identity (27)
    1. The client was asked to make a list of advantages and disadvantages of disclosing sexual orientation to family and significant others.
    2. The client was assisted in processing his/her list of advantages and disadvantages of disclosing sexual orientation to the family and significant others.
    3. The client's inability to list advantages of disclosing sexual identity was explored and addressed.
  28. Develop Plan of Sexual Identity Disclosure (28)
    1. The client was asked to develop a detailed plan for disclosing his/her sexual orientation.
    2. The client was assigned the exercise “Disclosing Homosexual Orientation” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
    3. The client's plan for disclosing his/her sexual identity was probed, and possible questions and reactions from others were identified and addressed.
    4. The client's inability to develop a plan for disclosing his/her sexual identity was explored.
    5. The client was assessed to be ready to go forward with the plan for disclosing his/her sexual identity.
  29. Role-Play Sexual Orientation Disclosure (29)
    1. Role-play was utilized to prepare the client for disclosing sexual orientation to significant others.
    2. Issues that were identified from role-plays were addressed and resolved.
    3. Feelings that emerged from role-plays were recognized, expressed, and processed.
  30. Support and Guide Sexual Identity Disclosure Plan (30)
    1. The plan developed by the client for disclosure of sexual identity was reviewed, and he/she was encouraged to enact the plan.
    2. The client was given support, encouragement, and guidance as he/she implemented his/her sexual orientation disclosure plan.
    3. The client's hesitancy and fear to go forward with his/her plan were explored and addressed.
  31. Process Reactions to Sexual Orientation Disclosure (31)
    1. The client was probed about the reactions of significant others to his/her disclosure.
    2. Significant others' reactions were role-played to provide opportunities to process their reactions.
    3. Encouragement and positive feedback were given to the client for disclosing his/her sexual orientation.
    4. Active-listening skills were used as the client reported that family members were shocked, angry, disappointed, and worried when he/she announced his/her sexual orientation.
    5. Support and encouragement were provided as the client reported that family members were accepting and supportive when he/she disclosed his/her sexual orientation.
  32. Solicit Parents' Cooperation with Family Sessions (32)
    1. Conjoint sessions were arranged with the parents to process the client's disclosure of his/her homosexual orientation.
    2. The parents were encouraged to attend and participate in family therapy sessions.
    3. The parents' resistance to attending family sessions about their child's sexual orientation was addressed.
    4. The parents pledged to cooperate with family sessions focused on the client openly discussing his/her sexual orientation.
  33. Process Parents' Reactions to Client's Identity Disclosure (33)
    1. The parents' reactions to the client's disclosure of homosexual identity were explored.
    2. The parents were assigned the exercise “Parents' Thoughts and Feelings About Son/Daughter's Sexual Orientation” in the Adolescent Psychotherapy Homework Planner (Jongsma, Peterson, and McInnis).
    3. Emotional support and understanding were provided to the parents in regard to their reaction to the client's disclosure.
    4. The parents were encouraged to express their thoughts and feelings about the disclosure.
    5. The client's parents were noted to be very resistive to supporting the client's sexual identity.
    6. The client's parents were noted to be supportive of the client's homosexual identity, but they expressed fears regarding future adjustment.
  34. Educate Parents about Homosexuality (34)
    1. The parents were educated about homosexuality, its possible causes, reversibility, lifestyle choices, and so forth.
    2. The parents' questions regarding aspects of homosexuality were elicited and answered.
    3. The parents were specifically reminded that homosexuality is not caused by faulty parenting or mental illness.
    4. The benefits to the parents and the client of accepting the client's sexual orientation were explored and identified.
  35. Assign Parents Books on Homosexuality (35)
    1. The parents were directed to books and other resources on homosexuality and the homosexual individual.
    2. The parents were encouraged to read portions of Is It a Choice? (Marcus).
    3. The parents were encouraged to read portions of Beyond Acceptance: Parents of Lesbians and Gays Talk about Their Experiences (Griffin, Wirth, and Wirth).
    4. The parents were encouraged to read portions of Coming Out, Coming Home: Helping Families Adjust to a Gay or Lesbian Child (LaSala).
    5. The parents were encouraged to read portions of Always My Child: A Parent's Guide to Understanding Your Gay, Lesbian, Bisexual, Transgendered or Questioning Son or Daughter (Jennings).
    6. Questions from the parents' readings were answered.
    7. The parents have refused to follow through on reading information regarding homosexuality and were reminded to do this reading.
  36. Refer to Parent Support Group (36)
    1. Options for the parents to attend a support group for parents and friends of lesbians and gays (PFLAG) were explored and barriers identified.
    2. The possible benefits of attending a support group were identified and processed.
    3. The parents were referred to and encouraged to attend a support group for parents and friends of lesbians and gays.
    4. Barriers to attending a support group were resolved, and the parents were encouraged to attend.
    5. The parents' support group experience was processed, and positive benefits were identified and reinforced.
    6. The parents have not attended a support group for the parents and friends of lesbians and gays and were redirected to do so.
  37. Process Parents' Religious Beliefs about Homosexuality (37)
    1. The parents were asked to list their religious beliefs regarding homosexuality.
    2. The parents' religious beliefs were processed, and beliefs that were problematic to acceptance of homosexuality were identified.
    3. Empathy was conveyed to the parents in regard to coming to some peace with their religious beliefs and the client's homosexuality.
    4. It was noted that the parents' religious beliefs were firmly opposed to acceptance of homosexual relationships and behavior.
    5. Although the parents have held religious beliefs that are contrary to homosexual practice, they are open to reexamining these beliefs.
  38. Refer Parents to Clergy (38)
    1. The parents were referred to a gay/lesbian-positive member of the clergy to assist them in coming to terms with their beliefs regarding the Bible's condemnation of the client's homosexuality.
    2. Gay and lesbian-positive books were suggested for the client and parents to read and discuss.
    3. The parents have not followed up with the referral to a clergy member, and their resistance to this contact was reviewed.
  39. Assign Parents Books on Religion and Homosexuality (39)
    1. The parents were asked to read Chapter 4 in Beyond Acceptance (Griffen, Wirth, and Wirth) and to process key ideas with the client.
    2. The parents were asked to read the chapter entitled “The Bible and Homosexuality: The Last Prejudice” from The Good Book (Gomes) and to process key concepts and reactions with the client.
    3. Assigned readings were processed with the parents, and opportunities to increase their level of acceptance were explored and encouraged.
    4. The parents have not done the assigned reading and were redirected to do so.