Competence and Confidence Working with LGBTIQA Clients

Meridian, a peer-led, community health organisation based in the ACT, provides one of the few dedicated mental health services catered to the LGBTIQA+ community in Australia. Practitioners at Meridian’s Wellbeing Services have extensive training to be able to support the needs of their clients, which can range from common mental health concerns to coping with experiences of social stigma and systemic discrimination. Clients are often seeking a safe and inclusive service where they can be confident that the staff and practitioners will be respectful of their identity. To connect with and support our clients, we rely on the same core skills all mental health clinicians learn, applied in a person-centred and trauma-informed way, and we want to encourage all practitioners to do the same.

Some clinicians refer clients to Meridian and other specialist services because they feel ill-equipped to support a client primarily because of the client’s LGBTIQA+ identity, not because of the content of the support that they require. The consequence of this is an unnecessary burden on clinicians who are willing to work with LGBTIQA+ clients and reduced access to mental health support for this. At the same time, clinicians who are hesitant to work with these clients cannot develop their competence as inclusive practitioners if they fail to take opportunities to gain experience.

When we talk about affirming mental health care, what we are identifying is the capacity for a practitioner to provide a safe and accepting space for clients to be themselves and feel understood. Counsellors do not need to be specialists in gender and sexuality in order to work competently with those issues when they arise. With some basic foundational knowledge, you should feel confident applying your existing skills in working with clients from the LGBTIQA+ community and providing affirming mental healthcare. Below, we highlight some key ideas and recommendations for practice to support your clients and your own growth and development as an inclusive practitioner, as well as some common misconceptions that can trip up even the most well-intentioned clinician.

Common mental health issues such as depression, anxiety, stress, and suicidality are also reported at disproportionately high rates in the LGBTIQA+ community. LGBTIQA+ young people (16-17 year-olds) are 40% more likely to suffer elevated levels of psychological distress than the rest of the population in Australia (Hill et al., 2021). These increased rates are associated with experiences of targeted discrimination, social exclusion and violence based on gender identity or sexual orientation (Wishart et al., 2020). Given this, a trauma-informed approach is an integral part of ethical practice when working with LGBTIQA+ clients. It is a requirement of our clinicians that they stay up to date with professional development in this area, and this is a good idea for all, regardless of your specialisation or area of practice. Anyone can disclose, uncover, or discover trauma at any stage of counselling.

Learning the appropriate terminology and ensuring that you are using inclusive language when working with LGBTIQA+ clients help them identify you as an ally and will increase clients’ sense of safety (McCormick et al., 2018). If you want to know more about different identities and sexualities, a good starting place would be with Meridian’s Flags Explained and Defined information sheet. If you’ve never heard the term “men who have sex with men” (or “msm”) before, for example, you might simply assume that a male client who makes a disclosure about engaging in same-sex sexual behaviours is gay. However, many men who report having sex with men don’t identify as gay or bisexual at all (Mauck et al., 2019).

Inclusive choices in language are also important in documentation, such as intake and consent forms. For example, it is common practice to ask clients to indicate their gender from set options. However, providing space for clients to describe their gender identity in their own words ensures that you do not inadvertently exclude clients who do not identify with the options provided. If someone uses a specific or unfamiliar term for their gender, or if they’re unsure of their gender identity, this is a simple way to allow them to communicate this to you. It’s a good idea to always know whether you are asking about sex or gender and use specific language. A primer on sex, sexuality and gender can also be found here. In general, it is valuable to consider how documentation can strike the right balance in gathering information that you need, in an inclusive manner, without coming across as unnecessarily invasive. If the intake process covers the data you must have, more information can always be elicited once rapport and trust are established.

Everyone’s experiences of gender are different and you’re never going to have a complete understanding of the experiences of others. It is a common belief that counselling someone who identifies with a gender that is not traditionally associated with the sex they were assigned at birth can only be carried out by a clinician who shares that identification or understanding. While some clients may directly request this, it is not mandatory - and there can be benefits to having a divergence of experience. Further, in our experience, some of the most powerful work in therapy comes from understanding different perspectives.

As Meridian is a peer-led organisation, there may be a perception that this aspect is crucial to the effectiveness of the service in meeting these populations’ needs. Peer support is at the heart of Meridian’s identity, forged in response to the AIDS epidemic in the 1980s, and for many of our clients, the fact that they are coming to a peer-led organisation provides them a sense of safety that encourages them to submit an online self-referral. However, once the conversation gets started, the clinician’s peer status in relation to the client or their presenting concern rarely comes up.

As with any minority, some counsellors may feel unsure if they are suitable to work with LGBTIQA+ clients, due to their own views or biases, however a lack of confidence can easily be rectified. If you are interested in learning more about providing gender-affirming mental health care, check out Meridian’s Guide. We all have biases, and as professionals we understand the importance of reflecting upon them, seeking supervision and when necessary, referring a client on. There is also no obligation to put a rainbow flag up in your office or select the ally badge for your online profile, especially if you are aware that your knowledge and experience working with these populations is limited.

As counsellors, we all work with clients who are different to us in one way or another, and to some, those differences can seem intimidating. Perhaps you are afraid that you’ll get someone’s pronouns wrong and misgender them. Meridian’s What are Pronouns? fact sheet may be a useful document to support your awareness and confidence with pronouns. You may also find that you have some unconscious bias to examine that is holding you back from working with LGBTIQA+ clients. While these concerns are fairly common amongst mental health clinicians, it’s important to recognise that regardless of the level of skill or expertise, we all make mistakes sometimes. The mark of a competent practitioner is the ability to admit to, learn from and correct mistakes that occur (Chang et al., 2018). By doing so, you maintain accountability to your clients and continue to build trust and safety.

Ellen has developed a trauma-informed, person-centred, and inclusive approach to counselling, which he continues to build upon through his degree. He has experience working within a multi theoretical framework known as Unified Psychotherapy, drawing theory and skills from a wide array of psychotherapeutic modalities to support the diverse needs of clients. Ellen believes in empowering clients to build psychological flexibility, make meaningful changes and form authentic connections with themselves and others. They always aim to foster strong therapeutic relationships built on foundations of trust, empathy, respect and understanding.

Prior to finding his calling in counselling, CJ was a high school and college teacher, career advisor and has worked in the construction industry. He has experience working with adults and adolescence, members of the LGBTIQA + communities, people with disabilities, and people who are neurodivergent or wish to explore possible diagnosis. CJ is neurodivergent himself and has experiences of the process of seeking mental health related diagnoses and an awareness of the LGBTQA+ space and non-monogamous lifestyles. Utilising an eclectic range of interventions in a trauma and shame sensitive way, CJ has a dynamic relational style, and tailors his practice, in line with the Unified Psychotherapy framework, to each of his clients needs. Supporting adults who relate to Pathological Demand Avoidance is a passion for him as is the intersection of neurodiversity and sexual and gender identity.

Competence and Confidence - Working with LGBTIQA+ clients