A Model of Affirmative Intersectional Rehabilitation Counseling With Sexual Minorities

Researcher as instrument

Research team members (n = 7) identified as cisgender women (n = 4), cisgender men (n = 3), heterosexual (n = 4), gay (n = 2), and queer (n = 1). Concerning racial/ethnic identification, research team members identified as White/European American (n = 4), biracial (n = 2), and African American (n = 1). All research team members were born U.S. citizens, and raised in the southeast United States (n = 6) and the northeast United States (n = 1). Regarding educational backgrounds, research team members were either completing graduate degrees (n = 6) or possessed a master’s in rehabilitation counseling and doctorate in counseling psychology (n = 1).

Research team members reflectively documented, discussed, and bracketed any personal biases, dispositions, and assumptions throughout data collection and analyses (Lincoln & Guba, 2000). The following themes were identified and discussed throughout the extent of the study, as research team members exposed and processed their (a) feelings toward sexual stigma, ableism, and other forms of discrimination toward diverse sexual minority persons; (b) beliefs on how religious, family, and cultural systems reinforced certain forms of oppression in U.S. society; (c) etic and emic viewpoints in relation to sexual minority populations, CID, and being a counseling professional; (d) ethnic, cultural, sexual, and gender identities; (e) personality and cultural factors that could influence their interviewing and analyzing abilities; (f) beliefs on what constituted effective affirmative rehabilitation counseling practice with sexual minority persons; (g) diverse rehabilitation counseling practices; and (h) identification as sexual and gender minority persons and allies. In addition, there were several conversations to facilitate the diffusion of power dynamics between the principal investigator (the primary author) and the research team members.

Interview protocol

A semi-structured interview protocol was created for this study (refer to the appendix for the protocol). The content of the interview protocol was constructed by members of the research team and reviewed by two certified rehabilitation counselors (not interviewed for this study) who possessed more than 15 years of experience in multicultural and diversity issues. Personal demographic information, such as age, identified gender, sexual orientation, and CID status, was collected from each participant. In addition, data regarding current and previous work experiences, education and training, years as a rehabilitation counselor, and possession of any certifications and licenses were gathered. The same semi-structured interview protocol was used with each interviewed participant; however, follow-up probes differed depending on the responses participants gave. Follow-up probes allowed for a collection of in-depth and rich data regarding the phenomenon under inquiry, and allowed us to capture nuances among the differing experiences of our participants.

Data analysis

Data collection and analysis took place simultaneously and lasted approximately 12 months. Utilizing a constant comparative method, the research team compared themes and concepts across incidents, cases, and participants (Gordon-Finlayson, 2010). GT specifically employs the use of a three-level thematic coding process: open coding, axial coding, and selective coding (Strauss & Corbin, 1998). The initial coding process, open coding, focused on specific concepts and themes that emerged line-by-line from the first two transcribed interviews. All members of the research team coded the two interviews independently and then came together to discuss the codes. During our meeting, research team member agreement was necessary to apply the code to the data. After this, we generated the initial coding manual that reflected the relationships among the codes.

Given that the coding process requires that the researchers constantly compare concepts and themes across the interviews, the research team then proceeded to engage in axial coding. During this phase, the research team began identifying salient categories (Fassinger, 2005; Gordon-Finlayson, 2010). Research team members continued to individually code each interview and then gathered in a group to discuss their findings. Again, research team member agreement was necessary to apply the codes. The coding manual was slightly amended after each research meeting to reflect any changes in the identification of concepts. Members of the research team then engaged in selective coding, which required the construction of a core category and finalizing the coding manual (Holton, 2007). Members of the research team then proceeded to recode all 12 interviews with the finalized coding manual, core category, and respective subcategories.

Trustworthiness and credibility

Trustworthiness of the data was ensured via iterative questioning throughout the interview process, collecting rich descriptions from participants, frequent debriefing sessions before and after interviews, as well as reflective and analytic notes (i.e., memos) by research team members (Shenton, 2004). Trustworthiness was further established by triangulating across researchers—that is, utilizing several different members during the analysis process (Lincoln & Guba, 2000). In addition, negative case analysis was used by intentionally finding contradictions in the major findings for purposes of code and model refinement (Morse, 2007). As major themes were constructed from the data, research team members would review the narratives of all participants to see how their experiences fit or vary within the developing themes (Morrow & Smith, 2000). For instance, several participants reported disclosing their sexual orientation and CID status to clients as part of building an affirmative working alliance. During interviews and analysis, members of the research team intentionally looked for instances that participants did not self-disclose, and this allowed for the code to be refined as intentional self-disclosure. Credibility was established through the use of in-depth member checks, such as providing participants with copies of the transcribed interviews and asking for any corrective feedback. Study participants were also asked for feedback on the codes and categories. Participants reported that the final results were consistent with their experiences. They offered no other feedback with regard to the results, and thus, no other changes were made.

Subcategory 1a: Values and virtues

Among our participants, we asserted that values and virtues were the possession of righteous and benevolent beliefs that facilitated the desire to provide affirmative rehabilitation counseling to sexual minority persons. As Paula stated with regard to her values, “I believe in people. I value the human spirit, as a whole. People are important. Professionally, I think it’s guided by my virtues and ethics.” In relation to values and virtues, participants discussed possessing a sense of compassion, genuineness, acceptance, empathy, openness, being nonjudgmental, and happiness to describe themselves as rehabilitation counselors. Lisa stated, “I really believe I’m a genuine person. I’m not in the place of judgment, because we must always accept people in the context of what they’re coming from.” Colin reported, “It’s about being gentle and compassionate—that is something that I value. I’m happy to work with individuals the best I can to help them achieve their personal goals.”

Subcategory 1b: Self-awareness

Participants consistently des-cribed themselves as taking the time to be reflective, cognitively flexible, and self-understanding. We deemed that these personal awareness traits assisted with ethical service delivery when working with sexual minorities living with CID. Nicole, who maintained a private rehabilitation counseling practice, reported,

I possess awareness, as rehabilitation counselors are trained to have. I try to keep a very strong awareness when I’m working with someone who is addressing his or her LGBT identity. I also try to be very aware of my limitations. My job is to improve the quality of their life and to be mindful of the fact that we are working on a particular treatment goal, and I must constantly check to see if I can help that person meet those treatment goals.

As demonstrated by the participant above, having a sense of self-awareness helped facilitate their rehabilitation counseling work with sexual minorities living with CID. This participant, like many other participants, experienced his or her interventions to be more goal directed as a result of being more aware of his or her own beliefs, limitations, biases, and even interests. As demonstrated by Danielle, “Internally, there are aspects about me that leave me hungry for information about people. I feel that my professional relationships with clients have really been strengthened because of my own awareness of my need to know more.” Some participants even connected their sense of self-awareness with their own professional development, competency, and growth as a rehabilitation counselor. As Shary stated, “It’s important for me to be conscious of my biases, and trying to counteract those biases with my counseling education, exposure, and experience.”

Subcategory 2a: Empathy and emotion validation

Participants expressed the importance of engaging in the stories of their clients with empathy and emotional validation. Participants encouraged their clients to explore their feelings, would consistently reflect emotions during counseling to emphasize understanding, and did so for the purposes of strengthening the counseling bond. Paula, who worked as a counselor in an urban prison, poignantly stated,

I’m always focused on the client. I’m sensitive to where they are, and I meet the client where they are at. I validate the person and the world that they live in. It’s about validating my client’s feelings and concerns, and really making that known to them as much as possible. I reflect back to make sure I am understanding what they were saying. I emphasize their feelings. I want to connect with them and their world.

Julia indicated, “Once you develop rapport, a client will reveal more. Getting to understand their world means they talk about familial issues, they talk more about economic issues, and they open up.” Adopting an empathic worldview further allowed counselors the opportunity to establish rapport and genuinely appreciating their clients’ emotions, with the intention of strengthening the alliance to allow the client to disclose more personal information.

Subcategory 2b: Establishing confidentiality

Participants emphasized the importance of establishing confidentiality during the rehabilitation counseling process, especially because they were working with individuals who experienced marginalization as a result of both their sexual minority and CID identities. Bonnie indicated, “Some of my clients have had really bad experiences because of disclosing information about their personal relationships.” Participants relayed that their clients reported being discriminated against by physicians, potential employers, family members, schoolteachers, supplemental security income/supplemental security disability income workers, and VR personnel. When speaking of confidentiality at a state VR agency, Colin mentioned,

We certainly talk about confidentiality. It comes into play because in a lot of instances my clients don’t necessarily want to disclose that they identify as lesbian, gay, or bisexual to employers, to friends, or to family. Sometimes, they haven’t even disclosed their sexual orientation to those people.

As such, focusing on confidentiality became an important aspect to the counseling practices of our participants, especially given the multiple systems that their clients would navigate. Spending time during the first or second counseling session to establish confidentiality especially allowed for the co-creation of safety. As noted by Lisa, who worked at a medical hospital,

We talk about confidentiality because one of the biggest goals that I have is creating a safe space. When there’s safety, we are open to explore. It goes across the board, but especially my gay, lesbian, and bisexual clients, especially in the South, especially to those who are coming from other parts of the country. That makes me even more so aware of wanting to engage in a very transparent and very safe way to engage with that interpersonally.

Subcategory 2c: Shifting professional role types

Given the diversity of work settings and presenting concerns of their clients, participants discussed shifting the way they viewed their counseling roles when interacting with their sexual minority clients living with CID. Participants personified the need to be educators, advocates, mediators, facilitators, case manager, coaches, and supporters. Fiona stated, “I am a facilitator. As a facilitator, I can honestly say that my clients felt heard, understood, didn’t feel judged,” while Danielle mentioned, “My role is to be a cheerleader, of sorts. I use strength-based counseling for my clients, and I find that that works to help them identify their strengths and then build on that to greater functioning.” When asked about professional roles, Nicole clearly reported several different roles, “Sometimes I am a sounding board. Sometimes I am a supporter, I am a listener, I am a guider, and at times a teacher. Other times, I am a confronter.” As another example, Shary mentioned,

A big part of my role is advocacy for the patients. There can be times where they’re not being heard, and so I can act as the mediator, especially because there are so many different personnel working—playing the advocate role specific to the rehabilitation setting.

Shifting their professional roles provided our participants an innovative means of forming strong working alliances and bonds. As a result, participants believed that their clients were heard, understood, and possessed the hope to achieve their personal goals.

Subcategory 2d: Intentional self-disclosure

Some participants discussed utilizing an appropriate level of self-disclosure to construct a trusting bond between themselves and their sexual minority clients living with CID. In some instances, participants chose to intentionally disclose some personal aspect related to their sexual orientation and CID status, or they disclosed aspects related to personal loved ones (e.g., family, friends) who identified as sexual minorities or persons living with CID conditions. Gaston stated, “I’m pretty open with my sexuality. I think that by me being open, it helps break down barriers or helps take away some stigma that can be attached with being gay.” Given the experiences related to her own disability, Julia discussed how she used self-disclosure with one of her clients,

I was working with one individual who has a physical disability. This individual’s caretakers know that my client identifies as a member of the LGB community, but they don’t accept it. This creates difficulty because my client relies on these caretakers for transportation. So, while they will bring my client to school, they will not under any circumstance take my client on to a date, or to meet with other LGB identified people. I don’t drive myself. So, I would talk with my client about how I navigated issues of getting to and from school and I also talked about the different resources that I used.

It is important to note that there were participants who reported not disclosing their sexual orientation or a CID to clients, but the choice of not disclosing was also done intentionally. Either way, the intentionality surrounding self-disclosure was done to enhance the working alliance between the client and the counselor and was deemed beneficial by our participants.

Subcategory 3a: Collaborative empowerment

Having acknowledged the degree of prejudice and discrimination that their clients encountered during their daily lives as a result of their multiple marginalized identities, participants discussed investing time to collaborate on the development of dignity, strength, and power in the lives of their clients. When describing her counseling approach, Julia stated, “We try to look at this as a collaborative relationship. It is very important to provide my clients the skills to generate respect in the world, and be able to live their lives in a way that’s honest and safe.” Bonnie, who worked at a state VR agency, reported,

I have a very empowering counseling style. Some individuals will come to their VR counselor and expect labor market information to be printed out for them and being told what to do and where to go. I collaborate with my clients to have them take the first step in the career process, like having them do an informational interview, or self-directed search, or going home to do their own labor market research, then coming back to me to talk about their research. I have an empowering approach, and I am pretty open about boundaries and my expectations for a consumer.

The rehabilitation counseling process was viewed by most of our participants as a means of developing tools that could be used by their clients to advocate for honest expression of their multiple marginalized identities. In addition, our participants collaboratively empowered their clients to help them achieve a sense of mastery over their personal goals.

Subcategory 3b: Nurturing autonomy

As a result of the unfair treatment from possessing multiple marginalized identities, participants discussed the importance of respecting and fostering the free will and independence of their clients during the counseling process. Fiona indicated,

One of the things I do is try to allow the individual to be as autonomous as possible. So if the person calls with a concern or question, I’m not recommending or telling them they need to do something. I discuss things with them and I give them as much information as possible so my client can make informed decisions themselves. I think that really helps.

In some instances, participants talked about the limited autonomy experienced by their clients as a result of their CID, and as such, participants were further committed to nurturing the development of their clients’ sense of independence. In relating a particular incident with a sexual minority client living with HIV-related vision impairments, Nicole, who also worked in a private practice reported,

My client had a family member that blocked me from direct contact, and was overly possessive and guarding in ways that did not promote my client’s autonomy. I believe my client was grateful to have an advocate in this family member and signed full release for me to communicate through this family member. However, I always tried to make the effort to get past the family member and into direct engagement with my client, hoping always to increase my client’s independence even when it wasn’t easiest to do so.

As evident by the quotes above, autonomy was operationalized as the ability to make one’s own decision, being informed, and free from external forces that could distract or overpower one’s own implementation of independence. Participants were committed to respecting this principle for the genuine betterment of their clients.

Subcategory 4a: Appraising intersectional contextual barriers

With regard to their sexual minority clients living with CIDs, participants discussed needing to assess and identify obstacles that limited functioning or any progression toward personal goals. Working with youth and families in the foster care system, Danielle stated,

I sit back and explore all aspects of a person’s life—both their sexual orientation identity and their disability. I want my clients to tell me what they think is important to them and what they feel I should know. I do this because it matters. I specifically focus on what are the unique barriers and support systems that they have in place that could affect their access to things in regards to their disability or sexual identity. I explore who in their life is safe and unsafe with regards to their disability and sexuality.

As evident by the quote above, participants specifically explored the perception and responses that their clients had of their respective environments. In particular, participants discussed attending to experiences of discrimination, isolation, loneliness, and homelessness as barriers relevant with this population. By far, stigma was the most prevalent contextual barrier that our participants focused on in their practice. When discussing incidents regarding a gay client living with HIV and mental illness at an outpatient psychosocial medical center, Virginia discussed,

There is considerable stigma, a stigma related to both the disability and gay identity. Stigma is the number one barrier I’m assessing. The stigma doesn’t always have to do specifically with the LGBT identity, but a lot of it has more to do with ignorance as far as disabilities are concerned. You know, how disabilities are spread or not spread, what is contagious versus not contagious, and lack of knowledge of mental health issues.

Participants also discussed the need to appraise intrapersonal-related barriers, such as sexual minority stressors (e.g., internalized homophobia, concealing sexual orientation, anxiety) and internalized ableism. When discussing her approach of identifying barriers perceived by her sexual minority clients living with CID at a college student disability office, Hermione reported,

I have seen clients have the perception that things are more likely to go wrong in their lives. Also, the level of worry and judgment are pretty high in the instances that I’m thinking. Those are the barriers. [Interviewer: Do you have a sense of why that may be?] Because of the way our society is when it comes to sexual minorities. Even though men are kissing each other on television, I don’t think society, as a whole, is ready for that. The way we are socialized impacts us and we internalize message of heterosexism. [Interviewer: Then, how do you address barriers in your counseling?] In session, I do. That’s the first thing I think about, “what are the barriers?” Because in my agency, barriers are what we’re trying to get out of the way so that my clients can progress with their goals and get on with their lives—whether it be barriers from their disability or sexual orientation. That’s the first thing I always remember, “What is that environmental barrier that keeps that person from moving forward?”

Participants made it apparent that a holistic focus was necessary when appraising intersectional contextual barriers, particularly interpersonal, intrapersonal, and environmental domains.

Subcategory 4b: Mobilizing adaptive resources

Participants discussed the importance of helping their clients assemble, organize, and utilize various psychological resources to optimize behavioral, emotional, and vocational functioning. Among our participants, activating coping resources to address stressors related to stigma was most apparent. Fiona discussed how she approached coping in her private rehabilitation counseling practice,

I currently have a 40-year-old lesbian who is coming in regarding loneliness, relationship issues, and she has a severe psychiatric history. She is coping well. She is educated and has many year of experience. During our counseling, she is also much more aware of how stigma impacts her and we can talk about ways that she could use her coping to deal with the stigma. The 15-year-old teenager that I’m working with on the other hand, who is questioning his sexuality and seeing me for a learning disorder, talks about stigma and disability in a very different way. In my experience, I think my adolescent LGB patients struggle with stigma differently, and really need additional support in life. And if I could think of a population that needs more support I would go with teenagers because they don’t fully understand stigma and oppression. They don’t understand those things because they’re not developmentally there. But also because in my opinion, especially where I geographically live, it is just really hard. Some high schools are open and there is less stigma and oppression, but some schools are not. This is very hard on my part when working with those patients to address what they are comfortable with and talking to them about how they are going to cope with certain situations in school.

As with other participants, this particular quote exemplified the manner in which our participants altered and developmentally contextualized the manner in which they mobilized coping resources. Participants in the study also highlighted helping their clients implement adequate social supports for interpersonal coping and the use of creative outlets. Shary mentioned,

We used art and creativity. Also humor was a big thing that each client had. Humor has played a big role, which sometimes can be a hindrance, but as for getting through the bumps and bruises, the creative outlet has been very helpful. I had clients who were into radio, acting, poetry, creating children’s plays. Those were the things that helped my clients thrive. Support is another important component. The people that were meaningful to my clients were supportive of them coming out and managing their health conditions. Those were the protective factors. Having a support system is crucial. Those who had that seemed to do better than those who were actively disowned.

Other participants also discussed the importance of bolstering logical reasoning and problem solving skills, guiding clients through the decision-making process, and positively reinforcing and encouraging adaptive behaviors. As demonstrated by Gaston,

When it comes to my counseling work, I am all about helping my clients hear themselves, helping them generate a solution, problem solving that solution, weighing the pros and cons. I think I’m really good at that and it takes lots of patience.

Subcategory 4c: Social justice actions

Participants strongly identified as sexual minority allies and reported moments in which they personally took action to buffer against stigma-related offenses. Participants discussed the importance of maintaining professional relationships with other ally affirming professionals and being knowledgeable of community referrals and resources that provided services to both sexual minorities and persons living with CID conditions. In some instances, participants discussed being directly involved in social-justice-related advocacy efforts for their clients. As demonstrated by Danielle, who was working with a family who had a sexual-minority-identified adolescent,

I have stepped in to speak to the school personnel, such as the principal and Special Ed teacher because I was not sure they were aware of issue going on with my client. And I do think that because I was a professional that they were more likely to listen to me more than they would listen to the parents. If it is what is needed for my client, then I will do it.

As demonstrated by the participant above, she took direct action and systemically intervened to advocate for her client. Fiona took action by the use of curious inquiry as a means of challenging policies and procedures that appeared stigmatizing against sexual minorities and persons living with CID:

I have collaborated and worked in conjunction with other counselors and staff members that were either not comfortable with LGBT individuals or they just did not have the right professional skill set to approach things on a treatment level with an individual who was LGBT. In this one particular setting where I encountered this, we had group team meetings. When LGBT issues came up—or if that come up in individual supervision or peer supervision—I feel that part of my duty being a professional is to bring that up, but I would do it in a particular way. I would ask the person questions, “Are you having difficulty in that area?” “Have you ever seen it this way?” I acted like Colombo in the way I questioned.