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Using group therapy to navigate and resolve sexual orientation and religious conflicts.

This article considers the use of group therapy to explore sexual identity questions in light of religious beliefs and values. The authors describe the basis of their group therapy approaches for sexual, religious, and social conflicts that differ from approaches that provide group members only the option of sexual reorientation to an ex-gay identity or adoption of a lesbian, gay, or bisexual identity. The authors come from different backgrounds and discuss how their perspectives and biases can potentially affect group process and outcome. They present guidelines, structure, content, and strategies for their group therapy approaches,

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Sexual orientation conflicts are serious issues for individuals who are caught in the midst of trying to find some resolution to their distress. Research, clinical, and personal accounts (e.g., Haldeman, 2004; Jones & Yarhouse, 2007; Mark, 2008; Smith, Bartlett, & King, 2004) have described the depression, anxiety, confusion, and isolation that can be experienced by those who struggle with being attracted to someone of the same sex. Counselors may also feel conflicted about how to help these individuals, specifically when clients are torn between their sexual identity and other aspects of themselves, such as their religion, ethnicity, careers, and families.

The focus of this article is on the use of group therapy to navigate sexual identity conflicts associated with religious identity. In the discussions, religion is often thought of as a more formal community of like-minded persons who assent to codified doctrinal positions that address much of human experience, including human sexuality. Spirituality is often thought of as a personal search for meaning, purpose, and wholeness (Love, Bock, Jannarone, & Richardson, 2005). Equally, sexuality can provide meaning and wholeness as it orients individuals toward deeply felt needs for intimacy, love, and companionship (Firestone, Firestone, & Catlett, 2005). Religion is recognized as a diversity variable in the ethics code of the American Psychological Association (APA; 2002) and the American Counseling Association (2005), as are other expressions of diversity, including sexual orientation.

Many branches within Christianity, Judaism, and Islam prescribe and celebrate heterosexuality as normative while condemning same-sex sexual behavior and, in some cases, identification. When religious individuals come from these conservative or traditional backgrounds, they face unique challenges in sorting out their sexual and religious identities. Their experiences and the challenges they face have been documented in several studies (e.g., Coyle & Rafalin, 2000; Kama, 2005; Wolkomir, 2001; Yarhouse & Tan, 2004; Yip, 2005).

As we turn our attention to the use of group therapy to navigate sexual and religious identity concerns, we recognize that we are asking the following questions: What does it mean to take both religion and sexuality seriously as diversity variables, specifically when a client experiences confusion or distress about her or his same-sex attractions in light of religious beliefs and values? What constitutes an ethical approach to sexual orientation conflicts in the context of providing group therapy? This article was written to describe how we have addressed these questions by developing our unique group therapy approaches for this population.

We come from different backgrounds (Yarhouse identifies as heterosexual and is conventionally religious, and Beckstead identifies as gay and is formerly religious). We practice in a metropolitan area, Yarhouse on the East Coast and Beckstead in the West; each metropolitan area often experiences its own unique political and religious conflicts. Our group therapy approaches emerged as an alternative to the two often-polarized positions offered in the clinical literature of sexual reorientation therapy or lesbian, gay, bisexual (LGB)-affirmative or LGB-integrative therapy. The first agenda tries to create ways to "repair" and eliminate sexual attractions and behaviors to same-sex individuals so that the client can remain faithful to her or his religion and social aspects, whereas the second aims to promote the expression to self and others of being LGB and validate same-sex sexual and emotional relationships. We recognized how these exclusionary choices of becoming an "ex"-LGB or an "out" LGB may be too limiting and incongruent for some clients. Our approaches have as their focus a broader view of exploring with clients their beliefs and values about sexuality, religion, behavior, and identity, as well as beliefs and values about the other aspects of their lives, seeking to facilitate congruence between clients' beliefs and values and their lived experiences.

The structure of this article includes background information on sexual identity group therapy and a brief discussion of how mental health professionals have addressed sexual identity, as well as some of the polarized positions. We then share information on new proposals for addressing sexual identity concerns and how group therapy may be beneficial in navigating sexual identity concerns. This is followed by a presentation of both of our approaches to sexual identity group therapy, as well as a review of what we see as principles that reflect what our approaches have in common. Because the article is coauthored from our different perspectives, we hope to demonstrate how these perspectives can come together in a proposal for sexual identity group therapy that is respectful of both sexual identity and religious identity to increase understanding of how to help a wide range of conflicted same-sex attracted (SSA) clients (Brooke, 2005).

Historically, medical and mental health institutions have viewed same-sex attractions as indicative of a mental illness and proposed medical, cognitive, behavioral, psychodynamic, and religious methods to treat those who are attracted to individuals of the same sex (Drescher, 1998a; Haldeman, 1994). A long history exists of mental health professionals trying to find the "cause" and therefore the "cure" for sexual and gender minorities (Silverstein, 2003). Current approaches have attempted to find a way to reverse this trend and respect the multiple expressions of diversity, including sexual orientation, race, culture, ethnicity, and religion (e.g., Bartoli & Gillem, 2008; Bieschke, Perez, & DeBord, 2007; Brown, 2006; Perez, DeBord, & Bieschke, 2000; Ritter & Terndrup, 2002). However, a consensus still has not been made among mental health providers and within mental health institutions of how to help SSA clients who are in religious conflict (King, Smith, & Bartlett, 2004; Liszcz & Yarhouse, 2005).

Emerging Approaches to Resolving Sexual Identity Conflicts

Several researchers have investigated the intersections between religious identity development and sexual minority identity development (e.g., Beckstead & Morrow, 2004; Comstock, 2002; Garcia, Gray-Stanley, & Ramirez-Valles, 2008; Gross, 2008; Harris, Cook, & Kashubeck-West, 2008; Hernandez & Wilson, 2007; Knight & Hoffman, 2007; Mahaffy, 1996; Minwalla, Rosser, Simon, & Jamie, 2005; Ritter & O'Neill, 1989; Rodriguez, 2006; Schnoor, 2006; Schuck & Liddle, 2001; Shallenberger, 1998; Sherry, Adelman, Whilde, & Daniel, 2010; Yarhouse, 2001; Yip, 2005). These identity models describe a process of initial conformity and then dissonance, crisis, exploration, social support, reevaluation, identity reconstruction, and decision making that facilitates a variety of resolutions. This developmental process may fluctuate in degrees of exploration, openness, and acceptance depending on personal, cultural, familial, and professional situations and takes place in the context of stigma that constrains the individual to reject an LGB identity (Lease, Horne, & Noffsinger-Frazier, 2005; McCarn & Fassinger, 1996; Worthington, Navarro, Savoy, & Hampton, 2008). This process thus involves a contextual redefinition in the meanings and labels attached to being LGB and religious. Resolution may involve a continual process of managing boundaries and discrepancies of acceptance and rejection with self and others. For example, Balsam and Mohr (2007) found that identity confusion and sexual minority stress are reduced by having a sense of belonging to a group that forms a part of one's personal identity.

In these models, both sexual and religious identities are amenable to change, though religion may be looked at as more amenable because of its sociocultural designation. However, sexual identity is also a social construct and, from a narrative perspective, is also subject to explanation, examination, and modification. There may be many person-specific variables that account for which aspect of identity is more capable of modification. In summary, areas that can be considered as targets of intervention include changes in self-awareness; knowledge; attitudes; norms; self-efficacy; self-concept; coping; relationships; group affiliations; public, private, and self-identifications of one's sexual orientation identity; behaviors; motivations; values; and emotional adjustment regarding sexuality, religion, stigma, and discrimination (APA, 2009).

A range of suggestions has emerged from within LGB studies to describe how to facilitate the exploration and resolution of sexual religious conflicts. Some clinicians and researchers (e.g., Beckstead & Israel, 2007; Brzezinski, 2000; Drescher, Stein, & Byne, 2005; Glassgold, 2008; McMinn, 2005) have emphasized the need to provide a holding environment (Winnicott, 1986) within the therapy setting so that clients have the respect and freedom to look at all aspects of themselves, explore the meanings and contradictions of these inter- and intrapersonal experiences, and thus embrace and integrate these aspects into a coherent whole. Key to providing this environment is for the counselor to be aware of her or his biases, blind spots, and lack of knowledge and manage how this affects the client's process.

Haldeman (2004), for example, emphasized using a three-stage, person-centered approach to reconcile conflicts: assessment, intervention, and integration. Assessment involves evaluating and prioritizing with clients their sexual behaviors and fantasies, the implications of their sexuality and religious views, and the pressures acting on the clients. Intervention is based on the assessment, such as providing psychoeducation, and the evolving client's treatment goals, developed collaboratively between client and counselor. Integration involves a process of reviewing and evaluating client management of sexual identity.

As another example, Throckmorton and Yarhouse (2006) offered the sexual identity therapy framework. The main emphasis of this framework is to provide assessment and an advanced informed consent and then to facilitate congruence, so that people live and identify themselves in ways that are consistent with their beliefs and values. Changing sexual orientation is not the focus or goal; neither does the clinician determine in advance to integrate client attraction into an LGB identity synthesis. Rather, there is open exploration of beliefs, values, identity, and behavior so that a client is able to experience congruence and ultimately an identity that reflects that congruence. Other aspects of this approach involve exploring with the client the practical elements of a self-chosen synthesized identity, expanding the social networks to include social settings of the desired sexual identity, and assessing continually with the client her or his desire and direction and emotional status.

Specific case examples have been provided regarding how certain clients have resolved their sexual and cultural identity conflicts (e.g., Bing, 2004, Dworkin, 1997; Glassgold, 2008; Green, 1998; Greene, 1997; Halbertal & Koren, 2006; Isay, 1998; Israel, 2004; Lasser & Gottlieb, 2004; Schneider, Brown, & Glassgold, 2002). APA's (2009) recommendation for helping clients distressed with their sexual orientation and religion is to provide a multiculturally competent approach by integrating the scientific knowledge of the psychology of sexual orientation with the psychology of religion. This involves (a) providing affirmation and understanding for all aspects of the client; (b) providing a comprehensive assessment, including the client's personality and cultural variables, such as minority stress, that may affect distress and coping; (c) providing strategies for positive active coping; (d) enhancing social support; (e) facilitating identity exploration and development; and (f) having no prior assumption of which resolution or identity each client will ultimately live out. We turn our attention now to the benefits of group therapy and how a group format may utilize the aforementioned guidelines and variables as a resource in addressing sexual identity concerns.

Overall Benefits of Group Therapy

Group psychotherapy and support groups have been shown to create positive changes by helping members learn new ways to think of themselves and others as well as evaluate and adapt what feels congruent to their lives in relation to others (Bartkowski, 2000; Karp, 1992; Mason-Schrock, 1996; Taylor, 2000; Truax, 2001). Within the group setting, the distressed individual can feel less stigmatized and isolated and more capable of handling concerns as a result of group members' guidance and feedback about the shared problem (Humphreys, 2004). This mutual assistance can enhance members' self-esteem and shape their self-identity (Levine, Perkins, & Perkins, 2005).

Yalom (1995) specifically identified 11 "curative" variables that are associated with a positive group therapy client outcome. They are (in order he saw of their importance) instillation of hope, universality (i.e., not feeling so unique or alone), imparting information, altruism, corrective family reenactment, development of social skills, imitative behavior, interpersonal learning, group cohesiveness, catharsis, and existential factors (i.e., grappling with the knowledge that life is unfair and unjust). Readers are referred to DeBord and Perez (1999) for a discussion of how these variables apply to LGB group therapy.

Investigations Into the Process of Sexual Identity Group Therapy

Several researchers have investigated how group settings can affect sexual and religious identity conflicts. Thumma (1991), for example, described how members of a gay male support group reconstructed their Evangelical religious identity to include a formerly incongruent gay identity. A central step in this integration was allowing members to reevaluate their self-denigrating beliefs by helping them identify the faulty reasoning behind these beliefs and then receive positive information to replace the former thoughts about self-identity. The group setting reinforced the possibility of being both gay and Christian by redefining participants' meaning structures and prescribing the direction of future action. The study by Wagner, Serafini, Rabkin, Remien, and Williams (1994) regarding those attending Dignity (a group that integrates a Catholic identity with an LGB identity) also suggests how such integration may help participants overcome earlier religious-based homonegativity. (Note. Dignity is not an officially recognized ministry of the Catholic Church.)

Ponticelli (1999), in her ethnographic study of women who identify as ex-lesbian, described how such women participated in groups that helped them reconstruct and maintain their unique sexual identity by taking on ex-gay cultural norms and language and finding a community that enabled and reinforced their primary beliefs, values, and concerns. As Ponticelli explained, "Crafting a sexual identity is a wholly interactional process" (p. 166). Erzen (2006) conducted an ethnographic study of how men negotiated their sexual and conservative religious identities within groups affiliated with Exodus International, an ex-gay organization. Erzen described Exodus as "an unlikely haven for those banned from conservative churches and alienated from family members and even from gay organizations or social networks" (p. 17). She noted how these individuals seemed desperate to locate themselves in a supportive cultural world.

Research has shown that LGB "coming-out" groups can be helpful in increasing some members' sexual identity development, ego development, and empowerment through a process of education, exploration, socialization, and reframing (e.g., Dietz & Dettlaff, 1997; Morrow, 1996; Morson & McInnis, 1983). For example, a preliminary study by Kuang (2007) suggests how lesbians from Japan and Taiwan increased their mental health through participation in a support group that allowed participants to share their life story and experiences, come in contact with positive role models, and decrease insecurity through social support.

As a clinician, Coleman (1981/1982, 1990) described the advantages of his group therapy for men and women who were exploring decisions about their sexual identity and heterosexual marital status. Coleman (1990) saw the need for a group format that was an alternative to a sexual reorientation therapy group or a coming-out group in which only one option is considered and worked toward. Coleman (1981/1982, 1990) emphasized how heterogeneity within such groups (i.e., male and female members who have tried or experimented with different ways of solving their conflicts) helped members discover new and individualized solutions. This process dispelled the belief that only one "right way" exists to solve such conflicts. Coleman (1981/1982, 1990) emphasized that the group facilitator's role is to maintain this heterogeneity and validate all options.

Taking into account these investigations and suggestions, we next describe our group therapy approaches, followed by a synthesis of both approaches. We hope to model how heterosexual, conservative religious perspectives and gay, nonreligious perspectives can dialogue to increase understanding, respect, and common ground. This is similar to our proposed group therapy approaches that promote diverse individuals joining together to change the way they relate to the conflicts within them and their communities.

Beckstead's Approach to Sexual Identity Group Therapy

Beckstead has been facilitating sexual identity therapy groups since 1999: two groups within a university counseling center setting that lasted two semesters and three groups within a private practice setting that lasted from 1 year to currently 7 years. The groups have had mixed-gender coleaders and have been open to men, women, and transgender individuals who experience a significant level of distress around their sexual orientation and religious and social identities.

Groups require a pregroup assessment to understand the basis of potential members' conflicts, needs, and goals and to screen out those clients whose conflicts have no basis in a same-sex sexual orientation (e.g., obsessive-compulsive fears of being gay). Typically, group membership has involved only White European Americans but has at times included those from other racial backgrounds. Similarly, members typically are from a Latter-day Saint background, although other faiths have been represented. Other demographics include various levels of commitment to, ambivalence toward, or dislike of homosexuality, religion, spirituality, celibacy, and LGB or heterosexual identities and relationships. Not all members have been torn between their religious and sexual selves, however. For example, several were clear about their sexual/religious lives but joined the therapy group to resolve painful conflicts with their religious family members.

Unique Business Aspects and Group Guidelines

The group is advertised as a therapy group for members to resolve spiritual, sexual, and social conflicts and a place to talk with others, enhance self-esteem, develop relationships, consolidate a positive identity, and find comfort within their lives. The group is also advertised as a place to explore a wide range of options to identify solutions that fit for the individual. Recruitment of group members involves creating and maintaining ties with both religious and LGB groups and with organizations such as university settings and inpatient psychiatric units.

Members are asked to commit to attend the group for at least 6 weeks to manage initial anxiety and preconceived conclusions and create safety for members' self-disclosures. Basically, all members express significant anxiety about beginning group therapy (e.g., fears related to opening up to others after talking to only a few about their same-sex attractions).

The guideline to allow or disallow members to have contact with each other outside of the group was a difficult one to create. Allowing outside contact was considered possibly inhibiting and complicating the group process. However, because the clinician perceived that ex-gay ministries and religious organizations tend to have a strong stance of cutting off social, romantic, and sexual relationships between LGB or SSA people, and because of the isolation of group members, the norm of allowing outside-of-group contact was created. However, members are informed in the group guidelines that the therapy group is not a place to make social friends or find romantic partners, and if they use it in this way, they may not have the desired benefits they want out of their experience. Group therapy is described as a chance for members to learn more about themselves and the ways in which they relate to others so that they can develop more effective ways of making social friends or finding romance. If they have contact with another member outside of group, it is expected that they share that contact with the group at the next meeting and process any leftover feelings or situations. (Note. Allowing outside-of-group contact did pose a problem when two group members developed a romantic and sexual relationship outside of the group without any of the other group members' or cofacilitators' knowledge. Similarly, one group had difficulty because a specific member was stopping other members [i.e., those who were younger and more passive] after group sessions and eliciting sex or dates. Because of members' passivity, fear of conflict, and compliance, these actions were not brought up to the group facilitator until several months after their occurrence. In both situations, these members had left the group before the issue could be brought up and confronted.)

Theoretical Framework

Beckstead's interpersonal group therapy approach was developed in part from his qualitative research (Beckstead & Morrow, 2004) of 50 individuals from the Church of Jesus Christ of Latter-day Saints who underwent sexual reorientation therapy and their descriptions of what helped resolve their conflicts and what they described as harmful. Research participants represented a wide range of resolutions, from identifying and living as heterosexual to identifying and living as LGB. Research participants chose to call the approach modeled after their experiences as exploratory therapy that looks at all options and focuses on "Finding oneself: Don't repair me; empower me to become what I am" (Beckstead, 2001, p. 360). The four major foci described as helping participants and that served as the basis of Beckstead's approach are (a) gaining a different perspective; (b) developing self-acceptance; (c) constructing a personalized, positive self-identity; and (d) finding courage and making difficult interpersonal choices. The following sections illustrate how these elements play out in Beckstead's group therapy sessions. No individual or group therapy outcome or process data have been collected on the variables within Beckstead's studies. Results presented in this article are from memory and are from a review of Beckstead's group notes regarding members' interactions and discussions.

Gaining a different perspective. A norm addressed in the group guidelines and reflected throughout group sessions is the right of group members to question authority, even the group facilitator and each other. The goal is to give members permission to explore what they have learned about themselves and other LGB/SSA religious individuals and how they might be getting too much of a one-sided view. To facilitate this self-assertiveness and exploration, Beckstead, as a group facilitator, does not maintain a specific group structure but allows topics to emerge from the present members' immediate questions and concerns. Yet, Beckstead attempts to maintain an awareness of what his research and the current literature describe as helpful content areas to process (e.g., identity; minority identity development; self-acceptance; self-esteem; assertiveness; familial reactions; impact of stereotypes and false information; maladaptive and adaptive coping; the need to belong; and the impact from heterosexist, homonegative, sexist, racist, or antireligious environments). As members initiate these content areas, Beckstead's approach strives to deepen members' exploration and processing by making reflective and observational inquiries of their views, emotional reactions, and behavioral reactions. For example, if one member expresses not knowing who she is because the "lesbian" label does not seem to fit her, group facilitation may involve asking this member about her understanding of what it means to be lesbian, how other group members view this identity, and what experiences inform the group members' understanding and emotional reactions.

Because of the intentional heterogeneity of group members, sessions involve discussions from diverse perspectives on multiple topics that members initiate, ranging from sexuality, sexual orientation, LGB relationships and dating, celibacy, monogamy, nonmonogamy, masturbation, pornography, sexual orientation etiology, homophobia, heterophobia, God, religion, spirituality, family dynamics, discrimination, gender identity, shame, anger, depression, coming out, intimacy, marriage, to parenting. Members are also encouraged to review literature from a wide range of perspectives on such topics and bring them to the group for discussion.

Dissenting voices are the norm, especially because members tend to feel like "the minority within the minority" and are keenly aware of being different from others. To challenge conformity, whenever a groupthink mentality (Janis, 1972) is created wherein the facilitator or members focus on only one viewpoint or openly criticize only one aspect of the conflict, then the facilitator should shift the focus to include how others may view such issues. The group facilitator's intention is not to take a stand and dictate what behavior or lifestyle is acceptable. The norm is to emphasize possibilities and provide permission to learn about and evaluate such possibilities. Despite diverse discussions and viewpoints, group members seem to develop a sense of cohesiveness and safety as they express that they are not so different from one another and fundamentally want the same thing (e.g., respect, validation, intimacy, and autonomy).

This process seems to allow not only for increased learning but also for negative affect to be expressed about those with whom group members trusted to instruct them. Group members express anger about being treated unfairly by those who reject them or tell them what they should do and acknowledge that such individuals do not know them fully.

Developing self-acceptance. Variables described by Beckstead's research participants as essential to helping them acknowledge who they are include (a) meeting others like oneself and finding a place to belong, (b) rejecting negative self-labels and outside validation, (c) finding inner strength, (d) finding one's value, (e) accepting one's same-sex attractions and framing them in a positive light, (f) adopting and living by one's ethics, (g) becoming comfortable with one's gender role and identity, (h) finding family and peer acceptance, and (i) addressing the negative consequences of their conflict. Group process involves discussions of each of these domains, with group members allowing for each aspect of their lives to be openly addressed, given feedback on, and supported.

Most poignantly, group members discuss feeling "homeless" and unable to find a place to fit in and be valued and accepted. Thus, group members are provided with information about local, national, and international resources (e.g., organizations, books, events) of which they might not have been aware that emphasize all or a portion of their identities.

Compassion and empathy are expressed constantly in session for each member's difficult dilemma. Overall, members tend to develop a collective identity of respecting one another, which seems to transfer to respecting themselves. That is, as members relate positively to one another through concern, dialogue, and curiosity, they begin to express more of a willingness and desire to validate their own diverse choices, feelings, values, and relationships.

Constructing a personalized, positive self-identity. As noted by Beckstead and Morrow (2004), sexual minorities tend to consciously or unconsciously hold negative self-concepts (e.g., inferior, sissy/tomboy, abomination, unacceptable) as a result of struggling with their conflicts and growing up in homophobic and heterosexist environments. Such self-constructs are uncovered and addressed in group discussions by identifying when and how members reenact these self-constructs within group. For example, when members are not expressive in group, they may be asked how or if being overlooked is familiar to them in their other relationships. These individuals then typically express resentment and loss for not feeling valued and allowing others to take charge of their lives. This is followed by a reevaluation of which self-constructs play into their relational styles and which self-constructs fit who they really are and want to be.

Along with this process of deciding who they are and who they are not, group members are encouraged to identify norms and communities they consider incongruent (see Drescher, 1998b), specifically regarding LGB, heterosexual, religious, and ex-gay communities and norms. Furthermore, discussions involve members identifying and prioritizing the aspects of their lives and discussing what they feel is essential to them and what they believe they can emphasize less. This is an evolving process as members learn more about themselves and their options.

Group members come up with their own unique ways to identify themselves, such as being a gay heterosexual man (because he feels affiliation and attractions toward gay men but chooses to remain married), being a spiritual lesbian, or having same-sex attractions and being religious. In addition to trying out certain self-labels, members are encouraged to expand how they view themselves by incorporating other areas into their self-identity, such as career, hobbies, cultural identities, and family and community roles. As described in Beckstead's research (Beckstead & Morrow, 2004), some individuals who experience such conflicts sway between all-or-nothing lifestyles and waver between ex-gay, "out" gay, or celibate identities that focus on restricted cultural norms rather than self-informed choices. Some group members undergo this similar pattern and receive support, permission, and feedback as they explore extremes.

Finding courage and making difficult interpersonal choices. Group members tend to need to problem solve and receive support as they face three core decisions: (a) being more honest and authentic and coming out; (b) deciding to leave, stay in, or redefine their current relationships; and (c) deciding to remain in, leave, or redefine their association with their religion and LGB communities. Through increased self-awareness and connection to their needs and values, group members tend to report being more informed and capable of being self-directed and making such difficult decisions. For example, several members comment on how group therapy helps them practice being more transparent and thus helps them feel more secure in being open with others about their feelings and needs. In addition, group members use the therapy group to ask for help before and after making major decisions, such as leaving or rejoining their religion.

Group process can also allow members to experiment with being assertive with their anger, as they express their need to separate physically or emotionally from inaccurate and abusive views and relationships. Coming to terms with the reality that their anger, compliance, and suffering will not always change people's viewpoints or personalities is an important process explored within the group. Grieving losses and accepting that they cannot have everything they want are sobering but intensely meaningful moments within sessions, especially as group members decide about associations that will not accept their choices and needs.

To summarize Beckstead's approach, group members are given a message of empowerment that is based on expanding perspectives and evaluating existing messages that have previously had an impact on group members. Empowerment also involves accepting all aspects of themselves, learning new ways to respond to distress and societal stigma, and constructing a self-informed positive identity. This process allows group members to make difficult interpersonal choices while in a supportive group therapy setting.

Yarhouse's Approach to Sexual Identity Group Therapy

Yarhouse has conducted preliminary research on his groups with a focus on primarily the qualitative experience of individual participants (e.g., Yarhouse & Brooke, 2005; Yarhouse & Nowacki-Butzen, 2007). As of this writing, Yarhouse has offered several sexual identity therapy groups: Some had a general focus on sexual identity development and synthesis, one focused on narrative understandings of sexual identity, and another focused on God image or one's emotional experience of God. The major themes that have come up in groups thus far include (a) isolation from social supports, (b) religious strain (with respect to one's community of faith and one's God image), (c) parent-child relationships, and (d) shame (a negative response to who one is rather than what one does, i.e., guilt; Yarhouse & Brooke, 2005).

Unique Business Aspects and Group Guidelines

In terms of running a group, Yarhouse tends to advertise through local clinical practices, churches, and a university campus. The purpose of the group in one flyer reads as follows:
   The purpose of this group is to be a safe and supportive group for
   men and women who experience same-sex attraction. It is designed to
   be a safe place to sort out the complexities of how to live in a
   way that is consistent with your beliefs and values about sexual
   attraction.


Recruiting may be difficult because individuals who could benefit from this group may remain closeted and isolated from such information, and potential clients may fear that "If I go to group, it's admitting I have these attractions." Group members have all identified as conservative Christian and were from diverse cultural backgrounds. Whereas more than half have been Caucasian, others have been African American or Latino, and there have been two international students (from Central America and Africa). Some group members have been married, some single. There have been mixed-gender groups and all-male groups.

Providing a clear informed consent about the purpose and format of group has proved important. For example, in the initial group, there was a misunderstanding by one participant that the group would focus on sexual orientation change. The facilitators realized how important it was to clearly communicate this in written informed consent to the therapy group, as well as in the phone-screening interview and again at the outset of the group. In another group, one member was under the impression that the group was like an ex-gay ministry he had participated in previously. He expected greater emphasis on prayer and healing and at times seemed dissatisfied with the process-focused, psychotherapy group format.

The groups conducted by Yarhouse have historically had mixed-gender coleaders and have been open to both male and female group participants. Although one group was open-ended and ongoing, subsequent groups have been closed and time-limited (typically 10-12 sessions). The groups have been a mixture of both process and content so that there is a psychoeducational component and review of homework (as applicable) and then process of experiences between sessions and with the new content being introduced. For example, one group followed material adapted from a resource on sexual identity (Yarhouse & Burkett, 2003). This material focused on the meaning of same-sex attraction to each group member, how one's personal narrative about sexuality has been written thus far, and how that narrative might be written as members now identify and explore various ways of making meaning out of their experiences of sexual attractions.

Yarhouse encourages each group to identify specific guidelines for that group. These have included limiting contact outside of group and speaking for oneself rather than advice giving.

Yarhouse's Theoretical Framework

The approach Yarhouse has taken to group therapy follows a theoretical model and empirical research on sexual identity development (Yarhouse, 2001; Yarhouse, Stratton, Dean, & Brooke, 2009) and empirical research on the experiences of Christians who identify as gay and those who disidentify with a gay identity (Yarhouse & Tan, 2004; Yarhouse, Tan, & Pawlowski, 2005). In terms of core elements, Yarhouse's approach has drawn from cognitive behavior, person-centered, and narrative theoretical orientations and has focused on attributional search for sexual identity, navigating religious identity conflicts, and facilitating personal congruence.

Attributional search for sexual identity. Concerning attributional search (Wong & Weiner, 1981), Yarhouse's approach looks at what it means to join group members on an attributional search for sexual identity. This process uses a cognitive behavior approach and was discussed in previous research (e.g., Yarhouse & Tan, 2004); it is based on using descriptive language to talk about a person's experience of same-sex attraction. For example, it has been helpful to make a three-tier distinction between same-sex attraction, a homosexual orientation, and an LGB identity. This usually entails a discussion of research in which a higher percentage of people report experiencing same-sex attractions than identifying with a homosexual or bisexual orientation (e.g., Laumann, Gagnon, Michael, & Michaels, 1994). Presumably, if a person experiences a sufficient amount of same-sex attraction that is persistent and durable, that person might report a homosexual orientation. An LGB identity is a more recently documented experience--a sociocultural label one can use to convey to oneself and to others about one's sexual orientation. An LGB identity can be experienced by some religious persons as prescriptive of exploring same-sex relationships. Discussions of same-sex attraction and orientation are often experienced as more descriptive of people's experiences, allowing them room to decide for themselves about future identity and behavior (Yarhouse, 2005, 2008).

The attributional search, then, has to do with making meaning out of one's experiences of same-sex attraction. This can include causal inferences (such as "What caused me to experience same-sex attraction?") as well as more existential and religious considerations (such as "What purpose or relevance do I find in my attractions today?"). In group therapy, this means that group members are sorting out how to think about themselves in light of their attractions. They may think of themselves as gay, bi, bicurious, curious, or questioning, or they may not feel comfortable adopting an identity label. In any case, they may benefit from a safe place to sort out their attributions and make meaning out of their experiences. In the meantime, talking about attraction is the most descriptive way a person can discuss his or her experiences. Thus, descriptive language includes discussing attractions rather than an LGB identity, at least at the outset. For example, one male Latino group member completed a work sheet and shared the following: "I am talking about 'same-sex feelings' more than a gay identity--I don't think my feelings have to determine my identity." In contrast, a Caucasian male group member confirmed in his own mind his gay identity toward the end of one 10-week group. He was able to share this with the group. Group members are free to use any language that best captures their experience. However, they are given the three-tier distinction in case they have never seen the distinction made previously.

Navigating religious identity. A second key element involves exploring one's religious identity in light of experiences of same-sex attraction. This often includes reflecting on attributions one has about one's attractions, as mentioned earlier. However, this discussion of attributions is often extended to a discussion of both their cognitive and their emotional experience of God, as well as sorting out negative emotions toward God or one's community of faith.

A cognitive understanding of God is referred to as God concept, or people's thoughts about who God is and what God thinks about them or their circumstances (Moriarty, 2006). It is often derived from early experiences in one's family of origin and from religious doctrine.

God concept is often distinguished from God image, or a person's emotional experience of God (Moriarty, 2006). A person may believe that God is gracious and loving but may feel guilt and shame when the person reflects on how she or he actually feels about God. For example, when one group member was asked to describe his God image or personal/emotional experience of God, he shared the following:
   I feel like God exists, but I'm a little devoid of emotion about
   him. I feel like he puts up with me. He definitely claims me.
   Watches me. Knows all about what I do. But he doesn't evoke a lot
   of emotion.


To facilitate emotional expression in the group, we tend to use ubiquity statements. These give group members permission to share negative emotions. An example of a ubiquity statement is, "Many people who are sorting out these issues talk about negative feelings they may have toward God, feelings such as confusion or frustration. How about you?"

Personal congruence. The third key focus in sexual identity group therapy is facilitating personal congruence. In Yarhouse's approach, congruence is thought of as bringing behavior and identity into alignment with beliefs and values (or vice versa). This draws on both person-centered and narrative understandings.

To facilitate personal congruence in group, we find that it is helpful to discuss the very concept. This allows group members to have a flame of reference and to acknowledge that some people experience a conflict between their religious identity and sexual identity. Group members also share their experiences and their beliefs and can reflect on them, often helping others understand where beliefs come from, how they came to play a role in decision making, and whether they will continue to hold specific beliefs. This can lead to a kind of exploration and eventual sense of ownership of beliefs. For example, one group member, a woman originally from Africa, completed an exercise based on narrative theory that involved reflecting on scripts from which people read that influence their identity. She shared the following:
   Sometime ago I was handed a script to read and follow for my life.
   Of course, believing everything that is written, I followed it to
   the tee. The writers include my parents, old friends, television,
   news, the Internet, teachers, preachers, leaders, and the National
   Inquirer. One dark cold season of my life, I was woken up by the
   reality of the power of choice. I chose to rewrite the script.... I
   am rewriting the script with the experiences I've had and of those
   who have gone before me. Each meaningful experience has become less
   useful in my new role. The lesson becomes a tool to make changes.


To summarize Yarhouse's approach, group therapy emphasizes a more descriptive account of group members' experiences of sexual attraction and the attributions associated with those attractions. These attributions and the meaning-making activity are seen as central to members sorting out religious identity questions and attaining personal congruence, so that they are able to live and identify themselves in keeping with their beliefs and values.

Discussion of Our Combined Understanding

Similarities in Conducting Group Therapy

Bringing our two approaches together, we see some similarities in how we conduct sexual identity group therapy. Probably the area of greatest overlap is the concerted effort to have the client form an identity that he or she can "own." Beckstead refers to this as a personalized constructed positive identity, whereas Yarhouse refers to this as an attributional search for identity. In both cases, there seems to be a realization that group therapy can facilitate a resolution with respect to one's sexual and religious identities. Various theorists have referred to this as congruence, resolution, synthesis, or achievement.

There is also a kind of "reality check" associated with both approaches to group therapy. The reality is that the group members experience same-sex attraction. We do not know or focus on the causes of attraction toward the same sex, and we share that the major mental health organizations do not consider attraction to the same sex to be a mental illness. However, the fact remains that group members have in common an attraction toward the same sex and some stated conflict in sorting out their sexual identity in light of personal or religious beliefs and values.

This reality check leads to another common element: difficult choices. Both of our approaches recognize that group therapy can be an important platform for making difficult life choices. These choices might include identifying safe people outside of group with whom one can share one's experiences, leaving a religious community that has been formative in one's worldview, leaving an LGB community that has been accepting of one's sexual identity, finding connections between and within communities, and so on. Group therapy in both approaches also recognizes the value in addressing shame and encouraging self-acceptance.

Strategies for Resolving Sexual Identity Conflicts

We mentioned earlier that sexual identity group therapy is an alternative to the two polarized positions of reorientation and LGB-affirmative (coming-out) group therapy options. We see sexual identity group therapy as providing a much-needed in-between model for addressing sexual and religious identity conflicts, and perhaps the following principles and strategies for resolving sexual identity conflicts could inform existing models of service delivery. Here are what we see as important strategies or principles:

1. Reflect on attributions and motivations. Assist group members in identifying and assessing their attributions and motivations as they pertain to resolving their conflicts. What do same-sex attractions mean to group members? What other meanings exist? What attributions and meanings do they associate with "being LGB" or self-labeling as such? What motivations (mixed as they may be) contribute to group members wanting attractions to the opposite sex rather than the same sex (or for celibacy rather than same-sex behavioral expression or relationships)? What motivations (mixed as they also may be) contribute to group members wanting to remain faithful to their religion?

2. Examine the effects of negative messages and experiences. Explore the effects of negative beliefs from the broader culture and group members' families and their religious and LGB communities on their sense of themselves. Assess what it means to grow up with different experiences and milestone events and any history or fears of marginalization or validation from others. This assessment can lend itself to building self-esteem and assertiveness by identifying negative self-labels that may have been internalized and adopting positive self-labels (Martell, Safren, & Prince, 2004) to create an inner strength to make difficult decisions. Many clients express much relief at being able to work through negative feelings associated with experiencing their attractions. This can be balanced against possible negative messages against religion or religiously chosen behaviors or convictions such as celibacy or chastity and a formed identity that for some might conflict with an LGB identity.

3. Facilitate self-acceptance. Central to resolving sexual identity conflicts is helping clients come to terms with their attractions rather than try to cut themselves off from them. The emphasis is on facilitating discussions between group members of how they could change the way in which they relate to and consider their attractions so that it promotes well-being and mental health. This leaves open the option of whether to integrate same-sex attractions into an LGB identity or to disidentify with an LGB identity.

4. Support adaptive coping. Group discussions can involve understanding how members have dealt with their stress and attractions and how to replace maladaptive coping with more effective ways. It can be helpful to distinguish between problems arising from dealing with same-sex attractions and problems experienced regardless of sexual orientation (e.g., sexual compulsiveness, objectification of others, lack of assertiveness, and intimacy problems). For group members who want to limit their sexual behaviors, treatment may focus on developing self-monitoring skills that do not reinforce repression. It may be important to help members, regardless of their self-identification, develop internal and external resources to withstand losses, fears, interpersonal conflict, and discrimination.

5. Explore religious identity and conflicts. Group members will more than likely appreciate focused discussions on how spirituality and religion play a (positive and/or negative) role in their lives (Pargament, 2002). It can be helpful to explore how members experience God and how they perceive God experiences them and how this intersects with their sexual identity development. Some of this can be described through projective drawings of God and themselves, as well as drawings of their sexuality. It can be helpful to explore a variety of options so members can be both spiritual and SSA (and modified to address other religions that are not monotheistic or do not affirm belief in God).

6. Provide accurate information. This can be challenging in terms of who determines what constitutes accuracy. However, some may forget that homosexuality does not represent a personality or lifestyle; it represents a sexual orientation (Morin, 1977). Thus, group leaders must communicate to group members the range of ways a person can live with his or her same-sex attractions, while communicating how the major mental health organizations do not view homosexuality as a mental illness. Also, same-sex relationships can be stable and satisfying experiences that are personally meaningful. The causes of sexual orientation are unknown, and new information is being discovered continually regarding how much is due to nature and nurture.

7. Be familiar with community resources. Extending options for group members to meet others like themselves and find support may be helpful to increase resources, self-acceptance, and a variety of places to belong. Thus, group facilitators will need to assess the ability of group members and their families to openly discuss issues of culture and sexuality and the group members' access to local, national, and international resources that support aspects of their diverse identities. Exploring fears and negative beliefs of going beyond their familiar settings, even the group therapy setting, may help facilitate more secure risk taking and increase opportunities for well-being.

8. Support members in adopting self-chosen sexual identity and behavioral expression. This can be facilitated by providing the space for group members to identify, sort out, and prioritize the values, needs, and dimensions of their lives. It may involve aiding group members as they consider redefining their life dreams, value, uniqueness, and purpose. Creating an individualized time line of the past, present, and future may help members examine and discuss among themselves what has been important to them and what they foresee as short- and long-term needs, problems, and options (Dworkin, 1997).

Lessons Learned From Our Dialogues

"Crossing the divide" between supposedly opposing viewpoints by extending questions and honest feedback between us proved beneficial on many levels. Central to these dialogues involved offering respect for each other and being more curious rather than combative with each other's views. This step toward healing the divide between our views seemed congruent with our desire to help clients change the way in which they relate to the divides within themselves and their communities.

One fundamental question that we addressed in our dialogues (although not entirely answered) was defining how to facilitate group therapy that is affirmative toward all aspects of the client. Are LGB-affirmative therapy and religion-affirming therapy mutually exclusive? Does being affirmative mean supporting conservative religious beliefs and attitudes that group members hold, although they may be negative toward same-sex attractions, behaviors, and relationships? How can a counselor support a client's self-determination while challenging social and internalized oppression? Is challenging the correct intervention? Does being LGB-affirmative mean promoting only an "out" and positive LGB identity? How can LGB counselors create room for conservatively religious, SSA individuals who wish to decrease the intensity or experiences of same-sex attraction or marry heterosexually? How can conservative religious counselors create room to celebrate a client's same-sex erotic expression although it is defined as a sin from their specific religious standpoint?

To explore these questions, we discussed our vantage points and blind spots. As a group facilitator, Yarhouse, for example, recognized that he tends to see more clearly the positives of a religious identity, whereas Beckstead tends to see more clearly the positives of an LGB identity. However, these biases could affect clients' processes. For example, identity clashes may occur with an LGB counselor who is in a "gay pride" sexual minority stage and encounters a client who is struggling within a dissonance stage. The counselor may be a reminder of what the client is trying to stay away from, and the counselor may assume that the best outcome for the client is the one the counselor obtained. Yarhouse related further how conservative religious individuals may be put on the defensive when they hear gay-affirmative language because it may presume an ideological commitment that does not allow for any conservative religious expression. In contrast, Yarhouse explained how a member in one group commented on how the leader might not understand the struggles of group members because the leader did not experience same-sex attraction. The leader responded to this in a nondefensive, affirming manner, because the comment was believed to be true and because a nondefensive response helped set the tone of safety for views to be expressed in the group (Holahan & Gibson, 1994).

On one hand, we both agreed that a balanced stance involves respecting clients' personal and religious beliefs and principles while exploring and evaluating with clients the extent to which their beliefs and principles reflect a formed judgment rather than a prejudice caused by misinformation or stereotypes. In doing so, group members can consider and reevaluate their internal motivations (e.g., "I can't be gay because it is shameful") and external motivations (e.g., "I don't want to be gay because I will lose my marriage, contact with children, employment, and standing in my religious and ethnic community").

On the other hand, we both discussed that taking a counterposition against inaccurate beliefs does not necessarily mean imposing a position on the client, and therapy should be about making the space for such a dialogue and conversation to occur. The client has the freedom to believe what she or he wants, but the counselor must not collude with false information or oppressive beliefs. Yet, both "conservative" and "liberal" (for lack of better terms) perspectives are grounded in ideological commitments that lie beyond empirical data and touch on metaphysical and ethical commitments that science cannot address directly. Therefore, it is not about trying to take away from clients their beliefs but to explore, understand, "air out," and provide alternative perspectives to invite complexity, ambiguity, paradoxes, and possible expansion of viewpoints. Counselors must strive to hold in tension what it means to be competent and affirming in all aspects of the client so as to counteract inherent societal pressures and not prevent foreclosure on one identity or promote one resolution over others.

We acknowledged the need for us and other mental health professionals to continue dialoguing about how this type of exploration and positioning with clients can take place in a way that checks our biases. This was emphasized by one earnest audience member who spoke to us after we presented at the APA 2007 annual convention regarding our group therapy approaches. She stressed the need for us (and others) to conduct outcome and process research because treatment for sexual orientation conflicts is a "hot topic" and has a strong potential to be harmful or at least ineffective because those in the helping profession think that they are being culturally sensitive and affirming but in fact are not (Gushue & Constantine, 2007). Overall, we realize the need for more dialogues, awareness, and bridge building between divides to check blind spots and enhance further understanding.

Conclusion

The APA (2009) Task Force on Appropriate Therapeutic Responses to Sexual Orientation "encourages advocacy groups, elected officials, mental health professionals, policy makers, religious professionals and organizations, and other organizations to seek areas of collaboration that may promote the wellbeing of sexual minorities" (p. 122). This article represents our attempts to model this collaboration and bridge understanding from diverse viewpoints to provide a practical utility for mental health professionals who currently provide--or would like to develop--a therapy group for clients distressed with their sexual orientation.

Above all, clients who are in conflict with their sexual, religious, and social identities need a setting in which all disparate parts of themselves are allowed to emerge, be fully appreciated, and be explored. Rarely are such individuals allowed to be all of themselves without fear of rejection. Group therapy has the potential to provide such clients with opportunities to normalize their attractions and conflicts, experience a sense of belongingness and acceptance, develop authentic relationships, desensitize anxiety and shame of self-disclosure, facilitate respect for differences while seeing the commonalities in each other, and allow for exploration of a broad range of resolutions. Given the often polarized debates in the area of sexual identity and orientation, it is important that out of respect for all types of diversity, we begin to explore various avenues that allow people to validate all aspects of themselves and make informed decisions for themselves about how to live out their spiritual, sexual, and social identities.

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Mark A. Yarhouse, School of Psychology and Counseling, Regent University; A. Lee Beckstead, private practice, Salt Lake City, Utah. Correspondence concerning this article should be addressed to Mark A. Yarhouse, School of Psychology and Counseling, Regent University, 1000 Regent University Drive, Virginia Beach, VA 23464 (e-mail: markyar@regent.edu).
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Author:Yarhouse, Mark A.; Beckstead, A. Lee
Publication:Counseling and Values
Article Type:Report
Geographic Code:1USA
Date:Oct 1, 2011
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