British Journal of Guidance & ounselling, Vol. 28. No. 1, 2000 © Gay affirmative therapy: a critical analysis of the literature NIGEL HARRISON ‘School of Health, Liverpool John Moores University, 79 Tithebarn Street, Liverpool L2 2ER, UK ABSTRACT A literature review indicated that the concept of gay affirmative therapy is fragmented and in need of further evaluation. A research approach was adopted, based on the notion that Anowledge is socially constructed. A qualitative approach and descriptive study, using a non-tra- dicional format, was used. This reporiad events as they occured, structured by a five stage ‘framework’ medel. The research sample consisted of 33 jownal articles and summaries of conference Papers, dated betwcen 1982 and 1995. Fifteen themes were identified as features of gay affirmative therapy. These were synthesised to form an integrated model. Evidence of counsellor working at micro and macro level within three intrconnscied domains emerged. A gay affirmative approach was idemifid in individual counscllors, within organisations, and within a social movement of pro= fessional group, Introduction ‘This paper outlines a study which focused on a critical analysis of literature on gay affirmative therapy. The term ‘gay affirmative therapy’ is adopted, since most of the literature reviewed used this wording. Variations exist, including ‘gay affirmative psychology’ and ‘affirmative dynamic psychotherapy’. The term ‘gay’ will be used to denote gay, lesbian and bisexual in an endeavour to write concisely, while respecting that these sexual identities differ. The report will be written in the first person. Webb (1992) states that this is acceptable if “appropriate to the mode of research reported and where an author is giving a personal judgment arrived at on the basis of reasonable cvidence’ (p. 747), T am asserting my right to claim ownership of personal views expressed, and knowledge generated from the study is viewed as mine, for which I am accountable, The research will be presented sequentially, adopting the chronological structure in which the research occurred. Distinct sections on the methodology and research findings are not included, but embedded within the method of data analysis used. ‘This is known as ‘frameworle (Ritchie & Spencer, 1994). Personal background ‘My interest in gay affirmative therapy emanates from my personal experience as a gay man, having a adopted a gay lifestyle in a society which continues to oppose ISSN 0306-9585 rin ISSN 14003534) NO/0057-17 © 2900 Careers Reseach al Adiary Case38 Nigel Harrison human diversity. I commenced counselling as a client, when ‘coming out’. Although this was a positive experience, I felt that the counsellor could have had a better understanding of gay lifestyles and familiarity with gay resources and networks, Over the past 15 years I have experienced verbal and physical abuse which I believe has enabled me to understand the needs of gay clients (Webb, 1992). Tacknowledge that some researchers prefer to keep silent about their sexual identity for fear of others questioning the objectivity of their work. However, I prefer to act on Coyle’s (1995) conjecture that ‘academic work on lesbian and gay sexualities is often undertaken by academics who are themselves lesbian or gay who wish to wrest control of psycho- logical discourse ... from those who prefer to promote a negative, condemnatory, pathological discourse’ (p. 2). While T was employed as a counsellor within a primary-care setting in ‘Manchester's ‘gay village’ and at the Manchester Lesbian and Gay Centre (MLGC), became aware of differences in the services provided by the two organisations and differences between the counsellors employed in these organisations. However, Twas unable to identify differences in the features of the services or in the characteristics of the counsellors. My experience as 2 gay man, nurse, lecturer and counsellor provided me with a vague notion of a model of counselling appropriate to working with gay clients. This required further exploration for integration of these nebulous ideas and strands. In particular, I was motivated to clarify aspects of good practice, Cooper (1989) stated that ‘reviews can attempt to integrate what others have done land said, to criticise scholarly works, to build bridges between related topic areas and/or identify the central issues in a field” (p. 13) In conducting the review, however, I acknowledge that it has been influenced by my personal and professional experience. This has shaped my perspective on life and my values and beliefs, including my attitude towards counselling gay clients, ‘Webb (1992) suggests that with interpretive approaches, researchers will inevitably invest and divulge much of themselves in their research. This research is therefore partly autobiographical. It is a descriptive study, which aimed to explore and clarify existing knowledge and to develop new themes, Literature review Historically, Weeks (1985) attributes the influences on sexuality over the last three centuries to religion, medicine, law and politics. These institutions have viewed homosexuality in the past as sinful, sick and illegal. During the 20th century, the notion of sin in ecclesiastical law was gradually changed to a scientific debate, in which homosexuality was seen as sick rather than bad. This prompted a search for a biological cause (Ruse, 1988) and physiological treatments (Marshall, 1987). Even in the last two decades, ‘cures® have included aversion therapy and psychoanalysis, @avies & Neal, 1996). Marmor (1965) admits that ‘therapeutic practices often seemed less designed to help the patient than to enforce the values of the therapist, on the patient’ (p. 41). * Lobbying by gay activists influenced the removal of homosexuality as a diagnos- able mental disorder by the American Psychiatric Association in 1973 (Dawson,Gay affirmative therapy 39 1994). The medical profession had constructed and then deconstructed homosexu- ality as an illness. Today gay relationships remain controversial in political debates. In recent years a number of gay MPs have been ‘outed? by gay political groups, and the lowering of the age of consent for gay men to 16 has been a contentious human rights issue which has been the focus of political debate. Weeks (1985) suggests that sexologists created the homosexual through cate- zorising sexuality. Previously, gay people expressed their sexuality and formed gay relationships but did not necessarily construct their whole life around their sexual orientation. DeCecco & Blia (1993) assert that, more recently, a gay identity and sub-culture has emerged due to a predominant liberal ideology and social constructionist paradigm. Gay communities have developed consisting of pubs, clubs, restaurants, clothes shops, hairdressers, taxi services and newspapers. This infrastructure provides 2 sense of belonging and security and encourages a gay lifestyle In the last three decades, gay communities have assembled gay people who have collectively opposed oppression. Messenger (1992) defines oppression as the ‘sys- tematic and institutionalised mistreatment of members of a group, either by another group or by society as 2 whole’ (p. 26). The Greater London Council (1985) provided one of the first definitions of heterosexism, asserting that it was a new term coined (like racism) to describe an attitude of mind that categorises and then unjustly dismisses as inferior a whole group of people; it assumes that no-one can, be naturally homosexual, so that a homosexual must be a failed heterosexual Although provisions for equal opportunities exist, they do not always include sexual orientation, an area which is not protected by legislation. Anti-oppressive practice with gay clients therefore relies on ‘good practice’, but is subject to varying standards. The British Association for Counselling (1993) states chat counsellors should take all reasonable steps to take account of the client's social context and that counsellors are responsible for working in ways which promote control over their ‘own beliefs and values. However, the Committee on Lesbian and Gay Concerns (1990) discovered evidence of biased practice, leading to inappropriate care, and ‘many psychoanalysts continue to view gay clients as pathological (Leitman, 1995). Moon (1994) states that ‘as counsellors we are part of a culture chat permits stigmatisation and prejudice towards gay people’ (p. 277). Counsellors may also be ‘caught up in the same normative values as lay people who are heterosexist (Gueney, 1996). Gay clients may benefit from having gay counsellors who seli-disclose their sexual identity and act as positive role models. However, heterosexual counsellors can be objective and develop their knowledge about gay lifestyles and resources (Moon, 1994). Gurney (1996) reminds counsellors that there are as many differ ences as similarities between the experiences of gay men and lesbians, and that there is a,danger of a counsellor at 1g all of a client’s problems vo their sexuality rather than to other origins. Nevertheless, gay clients do have unique issues related to their sexual orientation and lifestyle. If responses from others are affirming, individuals may be more likely to see themselves as having positi selfworth,40 Nigel Harrison Method Research aim and questions ‘The aim of the research was to analyse critically the literature on gay affirmative therapy. The key questions to be addressed, stated in priority order, were sequential and interlinked: @ Does gay affirmative therapy exist? Gi) Con gay affirmative therapy be defined? Gii) Are there distinguishing features implicit in gay affirmative therapy? Gv) What issues emerge which have wider implications for counselling clients ‘who are gay? Data cellection Data were collected from the technical literature, which Strauss & Corbin (1990) describe as comprising professional writing, research reports, and theoretical or philosophical papers. The literature examined was written in English, published between 1982 and 1995, and came from the UK, Europe and the USA. The justification for the geographical restriction is that a gay identity has been identified as a Westem concept. I targeted joumal articles which were accessible to me, through the databases that I could access in my roles as a lecturer and student, ‘Webb (1992) points out that data are often selected appropriately, rather than being, collected absolutely systematically: this involved me making a judgment about the relevance of the articles identified. ‘The key words adopted for searching the literature were ‘gay/lesbian/homosex- ual’, ‘affirmative’ and ‘therapy/counselling/psychology’. ‘The databases accessed included: psych-lits medline; ctics counselling webs psychology web; social citation index; social science citation index; and the arts & humanities citation index. Sixty-nine articles were uncovered, 19 of which were from the Journal of Homosexu- ality CTable 1). Sixteen articles appeared in 1982; all but one of the other articles had been published since 1989, Twelve of the articles published in 1982 appeared within a ‘Practitioner's Handbook of Affirmative Models’ within a special edition of the Jowmal of Homosexualipys five articles discovered in 1995 were presented at a ‘Diversity Conference’ which focused on gay affirmative therapy (ALGBP, 1995). An increased interest in gay affirmative therapy has been demonstrated in the published literature since 1989. I believe that 9 change in the sociopolitical climate hhas fostered this, together with the influence of academics and gay activists. Cooper (1989) states that ‘a topic is probably not suitable for review unless it has appeared in the literature and has created appreciable interest within a discipline’ (p. 19). T reduced the number of articles within the research sample so that it was of a manageable size and specific to my aim and questions. In the end, 33 articles were included because they fully or partially alluded to gay affirmative therapy. A further 36 articles were excluded on the grounds that they focused on using an affirmative approach in areas other than counselling gay clients, i.e. medicine, education, health, religion, politics, general counselling and ‘other’| | Gay affirmative therapy 41 TTASLE 1. Sources ofjoumnal articleson gay afiemative therapy Jounal of Homoseruaioy Diversity Conference Counseling Poychatogst Carser Development Quarter ‘Shi Coleg Stuies tn Social Wor ‘American Pozhalogie Journal of Sex Resarch Nowe: Thirty-one other journals each inciuded one publication, Data analysis ‘The five stages of ‘framework’ (Ritchie & Spencer, 1994) were used for data analysis: @ familiarisacions Gi) identifying a thematic framework; Gii) indexing; Gv) charting; and (¥) mapping and interpretation, ‘Framework’ was originally used in the social sciences for analysing group inter- views, longitudinal studies, case-studies and group projects. The five interconnect ing stages incorporate the tasks of defining, categorising, theorising, explaining, exploring and mapping. This methodology was selected because the process is flexible, dynamic and open to change. It is systematic and comprehensive, allows analysis between cases, and is accessible to other researchers for review. The data analysis is not an activity concentrated at the end of the research, but is a central part of its continuous process (Bryman & Burgess, 1904). The researcher is expected to move backward and forward between the different sequences in the research process. Thus the traditional research stages of methodology, data analysis and results and discussion are not adhered to in that sequence; instead, each is returned to throughout the five stages. An important consideration was my own selfawareness. I needed to recognise my own personal bias originating from my interest in anti-oppressive practice, Strauss & Corbin (1990) refer to the questioning of personal assumptions as theoretical sensitivity. I believe that this process enhanced the study's validity and reliability. Guba & Lincoln (1989) advocate using ‘decision trails’ or clearly ex- plained descriptions by the researcher, which allow another researcher to study and arrive at comparable conclusions. Lincoln & Guba (1985) refer to these as ‘audit ‘rails', where the researcher enables others to ‘walk through their work’. ‘The process involved me detailing how data were collected and justifying what was undertaken and achieved within the study. Accordingly, all data were cross-referenced and coded to allow the origins and development of themes to be followed through, and| | | ROURE {, The three domains of gay affirmative approcch Gncorparating gay affirmative therapy) made as explicit as possible (Sandelowski, 1986). However, the interpretation of the data is mine, and other researchers may have made different interpretations. I will now summarise the five stages of the data analysis. Famitiarisation According to Ritchie & Spencer (1994), the first stage involves “taking stock and gaining a feel for the material as a whole’ (p. 178). Where the material is extensive, a selection must be made from it. McLeod (1994) points out that ‘inspection of the research literature reveals cycles of interest and attention to certain topics and ‘questions’ (p. 12). On initial reading of the literature identified, three distinct but interconnecting domains emerged (Fig. 1) “The first domain focuses on working with individual clients, The Hiterature highlights the importance of enabling clients to adopt a positive view of themselves, self-acceptance (Hay, 1984), and improvement of low self-esteem through develop- ing assertiveness skills (Sanderson, 1993). The origins of this approach are unclear, with various authors being cited (Brooks, 1991; Brown, 1993; Sinfield, 1994). Davies & Neal (1996) cite Malyon (1982), who suggests that gay affiemative therapy is not an independent system of psychotherapy, but rather represents a special range of psychological knowledge which challenges the traditional view that being gay is pathological. Gay affirmative therapy can thus be integrated into a variety of different peychotherapeutic approaches. ‘This definition provides a useful set of values as @ guide for a counsellor to adopt, but requires expansion on what psychotherapeutic techniques are used. Davies & Neal (1996) emphasise the educational role of the counsellor and the need to respect a client’s unique position as a gay person; while others focus on the personal/professional development of the counsellor (Clark, 1987, cited in Davies &Gay affirmative therapy 43 Neal, 1996). The Association for Lesbian, Gay and Bisexual: Psychologies (1995) provide guidelines to prospective clients who are seeking a gay affirmative counsel- Jor. They suggest that the client asks a counsellor to clatify: the counsellor’s code of ethics; their counselling approach; their level of experience of working with gay clients; the training they have undertaken related to gay lifestyles; and the level of personal development they have undertaken on their own sexuality. Fig. 1 also identifies, as second domain, a gay affirmative approach within organisations. Dryden (1994) aptly asks in what ways counsellors need to change counselling services to make these more applicable to minority groups, Eldridge & Bamett (1991) appear to respond by providing guidelines on how to assess whether an organisation is gay affirmative, based on criteria for assessing a student coun- selling service within a university. The criteria include: demonstrating positive written acknowledgement of gay people, e.g. on assessment documentation; use of anti-oppressive language; verbal recognition of gay concerns/availability to see a gay counsellor; visible resources aimed specifically at gay clients, e.g. health education literature; an advocacy service; networking with gay organisations; and an equal- ‘opportunities policy which is monitored and enforced, ‘The third domain outlines a political role and a social movement for affirmative action on policies and laws to protect gay civil rights (Stafford, 1988), Dawson (1994) outlines how prolonged lobbying by gay rights activists and committed pressure groups has helped to change attitudes since the 1960s. Fig. 1 suggests that, an affirmative counsellor can work at a micro level with clients: this could be seen as reactionary, supporting individual clients in distress. Alternatively, at a macro level, a counsellor has a proactive role in addressing the origins of many problems affecting gay people in organisations and socicty, e.g. in work and recreation. A counsellor may empower @ client to be more assertive, and/or may act as the client’s advocate, suggesting, for example, that equal-opportunities policies within the counsellors and client's place of employment should include attention to sexual orientation, Identifying a thematic framework Ritchie & Spencer (1994) describe this second stage of data analysis as a framework for sifting and sorting: ‘identifying key issues, concepts and themes according to which the data can be examined and referenced’ (p. 179). Woods (1996) appears to summarise this when recommending being perceptive in relation to repetitions of words or incidents. I accordingly combined some of the main features previously highlighted in the ‘familiarisation’ stage. This included the guidelines provided by the ALGBP (1995), Eldridge & Barnett (1991) and Davies & Neal (1996). Ritchie & Spencer (1994) believe that ‘the first version of an index is often largely descrip- tive and heavily rooted in a priori issues. Tt is then applied to a few transcripts when categories will be refined and become responsive to emergent and analytical themes” (p. 180). According to Ritchie & Spencer, an index can be developed as a list of questions presented sequentially, providing ‘a mechanism for labelling data in manageable bits for subsequent retrieval and exploration’ (p. 180). This is similar to44 Nigel Harrison ‘Tamia 2. An index iterising ey feansces of gay atirmative therapy 1. Does the author(s foeus on improving 2 clien' self-esteem? 2, Does the author(s) suggest strategies for challenging ‘oppressionfheterosexisuhomophobia? 3. What teaching methods and or resourcesfoblitherapy does the author(s) recommend? A. Does the authors) identify the use ofthe core conditions? 5. Docs the authors) endorse a noa-pathological view of homosexuals? 16. Does the aushor(s) encourage counsellors to disclose their somal identity and act as visible role model? 7. Does the author(s) identify specific types of social newwarks and support for cleats? 8. Does the author(s) recognise the spirituliphilosophical eds ofelients? 8. Does the author(s) propose that counsellors require specific knowledge/skils about gay developmen fesylesproblems? 10. Does the author(s) advocate that count theie personal awarenest? *11, Does the authors) suggest the use ofa particular counselling approach? "12. Does the author(s) propose guidelines fora counselling contrect? "13, Docs the auchor(s) suggest that counsellos asset cients to revolve conticts? 14 Does che author(s) indicate how counsellom can act as 3 client's advocate? *15,_Docs the author(s) support counsellors being politically active? ‘These five index items were added tothe lit during the indes stage. undertaking an interview with a client and asking them alist of questions, but in this cease the questions are directed at the journal articles. The questions used are listed in Table 2 Some researchers would view this stage of ‘framework’ as the commencement of data collection. Since there were 33 articles within the rescarch sample, I decided to select a smaller number for pilot indexing. I arranged the articles into five categories as outlined by Gonsiorek (1982). Nine articles were chosen for the pilot study—one from each of the sub-categories shown in Table 3. All nine articles were then reviewed to identify the key features of gay affirmative therapy. Ten recurrent themes were identified. Evidence of all of the themes incorporated into the 10 questions in Table 2 were found within the nine articles. I acknowledge that there may be isolated features not included which are important in another context—for example, only Browning et al, (1991) advocated using a feminist approach with lesbians, Indexing In stage three, Ritchie & Spencer (1994) propose that the thematic framework isGay affirmative therapy 45 ‘Tass 3. Categorisation of articles ‘Counselling mode Individual ‘Couple Grow Family Sexual identity Gay men Lesbians Bisexsst men/women Counseiting orientation Prychodynainic Different professional groups Careers counsellon, [Glients with special needs ‘Mental health Source: Gonsiore (1982). ‘systematically applied to the data in its textual form’, ‘This involved reading all 33 articles and categorising them according to the framework (p. 176). All articles were numbered in alphabetical order according to their author. Relevant information was then highlighted in the article and transcribed, under the headings of the ten questions. Page numbers from where they were obtained were identified. Direct quotes were written in italics; plain text was used where I summarised the original author's work, Indexing involves making numerous judgments as to the meaning and significance of data. The process is subjective and open to different interpretations (Ritchie & Spencer, 1994), An enormous amount of data was generated. ‘Through this process, five additional themes emerged that had not originally been identified within the index, but were recurrently evident in several articles (Table 2). These themes were added to the index, to make 15 questions in total, All articles had to bbe reviewed and re-indexed to check if the new themes had been present Charting Charting is a process in which a picture is developed of the whole data by lifting ‘material from the original text and arranging it according to the thematic framework ‘Chunks of text are regrouped according to their index reference, devised with headings and sub-headings, which may be drawn from the thematic framework Ritchie & Spencer, 1994). Some researchers would view this stage as involving the analysis of data. Charts of data were organised and presented in lists, paitings, diagrams, tables and cycles, for each of the 15 indexed themes, summarised in Table 4. It is beyond the scope of this paper to include each of these charts, ‘The third theme focused on the methods and resources used for teaching gay clients, known as bibliotherapy. Resources are becoming more widely available which specifically target the issues affecting gay people, e.g. safer-sex materials. Leaflets, pamphlets, brochures, magazines, journal articles, educational books, gay46 Nigel Harrison “Tante 4, List of charts which emerged from the data ‘Strategies for improving seltesteem. Strategies for challenging oppression. “Topics for teaching, including possible methods and resources ted, ‘Demonstration of the core conditions being used, ‘Anite and interventions for adopting a non-pathological approach. Benefits of self-disclosure and role modelling by gay counsellors. ‘Types and purpore of sociesupport networks Avenues and benefits for exploring spiritual/philosophical needs. ‘Famifiarigy with problems presented by gay clients and knowledge and ekils requir by affirmative counselors ‘Methods available o couacellors for developing thee celf-awarcness, CCountelling orientations and their key features, Reatons for and characerctice ofa counelling contract, A conflict resolution cycle. ‘Opportunities for counselors to act as client advocate ‘Aims, achievements and politieal groups for counsellors. fiction, posters, audiocassettes, videos and music focus on particular themes, e.g. the ‘coming-out process. Such resources were described as being used in counselling sessions or created a topic for discussion, where the use of resources had been set as homework Gay resource centres provide some information and high-street book stores now stock gay literature. The benefits of teaching and the use of bibliotherapy, and indeed any of the other themes in Table 4, could be the focus for future research. Mapping and imerpretation ‘This last stage of ‘framework’ forms the equivalent to the ‘results and discussion’ phase of research. It includes finding associations, providing explanations or devel- ‘oping strategies for the future (Ritchie & Spencer, 1994). Each of the original research questions were addressed here. Does gay affirmative therapy exist? Guy affirmative therapy does exist. The majority of the 33 articles were ‘technically based” and theoretically focused, adding to the development of the concept. Some literature provided real and/or fictitious case- study examples, demonstrating features of clinical practice. The experience of the authors of the articles was shared in their writing, providing the reader with the benefit of their knowledge, skills and insight. Gay affirmative therapy has a concep- tual basis, but little empirical work was found to underpin the approach: this is a major criticism. The literature was fragmented, focusing‘on vague notions, and not linking the macro and micro levels, or integrating the knowledge, skills and values of the counsellor. Friedman (1991) criticises the type of literature examined because it focuses on clients who are on the healthier side of the health/iliness spectrum and not those with severe and enduring mental illness. The needs of transvestites andGay affirmative therapy 47 ‘transsexuals were not addressed, leading to questions about whether gay affirmative therapy is used with this client group, Can gay affirmative therapy be defined? The definition of gay affirmative therapy provided by Malyon (1982) appeured to be referred to and well supported in the literature reviewed. This definition focuses on the therapist challenging patholog- al view of homosexuality, developing knowledge appropriace to working with gay clients, and integrating this into their own counselling approach. The outcome of my study was the synthesis of a descriptive tool developed from the literature analysed, represented diagrammatically by an integrated model of a gay affirmative approach incorporating therapy (Fig. 2). ‘The elements of Malyon’s definition are encom- passed and developed further, to include the therapist challenging oppression in self and others, being familiar with and able to respond to issues presented by gay clients, and devetoping competence in using a range of therapeutic interventions, ‘together with an awareness and acceptance of personal limitations in working with this client group. The model evolved through the continuous development of the first four stages of ‘framework’. It offers a guide for good practice, mapping the range and nature of the characteristics of gay affirmative therapy. The model is labelled as a gay affirmative approach incorporating gay affirmative therapy, since a ‘gay affirmative approach is used in gay affirmative therapy, but not all people using 8 gay affirmative approach are providing therapy. Are there distinguishing features implicit in gay affirmative therapy? Ritchie & Spencer (1994) suggest reviewing the charts and research notes, comparing and contrasting perceptions, accounts or experience, and searching for patterns within the data to seck explanations. This is achieved through ‘unpacking’ the integrative model. In Fig, 2, working from the inside of the model outwards, the core value of adopting a non-pathological view of homosexuality is emphasised, originating in index number 5 in Table 2. The counsellor’s personal values determine whether they are able to adopt this approach. In the articles within the study, a number of counselling approaches were reported to have been reviewed in relation to their beliefs about gay clients. O’Connor & Ryun (1994) revised traditional psychoana- lytic theory to allow lesbian therapists and clients to work together, avoiding assumptions about the nature and origins of identity. Kottman et al. (1995) con- tended that Adlerian counsellors are able to address stigma and to work towards creating self-acceptance in gay adolescents, founded in a commitment to promoting ‘equal relationships between clients and other. Mylott (1994) discussed the use of rational emotive behaviour therapy with gay clients. The second dimension of the model describes how the therapist draws upon a non-pathological view to challenge hheterosexism, homophobia and internalised homophobia in self and others. Continuing to work from the inside of the model outwards, the third dimension describes those who can adopt a gay affirmative approach, titled the ‘users of the model’. This includes counsellors, clients themselves, friends or parents of gay clients, counselling or health care organisations, institutions like the British Associ- ation for Counselling or medical professional associations, a culture, a section of the48 Nigel Harrison JRiGURE 2, A guide for good practice: an integrative model of gay afiemative approach (incorporating ea¥ affirmative therapy). community, or society as a whole. Work can be at a micro or macro level. The political activism of the gay liberation movement is one illustration of an affirmative approach at a macro level (Coyle, 1995). Details of how each individual or ‘organisation may use the mode! is beyond the remit of this paper. However, it is imporcant to clarify that only therapists are able to provide therapy, but that other ‘users’ of the model such as fiends and work colleagues may provide a ‘gay affirmative approach’. The literature analysed, confusingly, did not always make this distinction. ‘While some articles clearly outlined the festures of ‘gay affirmative therapy’ ‘(Malyon, 1982; Shannon & Woods, 1991; Coyle, 1995), others like Baron (1991) merely alluded to ‘affirmative therapy’. McWhirter & Mattison (1982) reported on, psychotherapy with gay male couples without using the term ‘gay affirmative therapy’. Murphy (1989) stressed the importance of a counsellor working with lesbian couples being ‘lesbian affirmative’, and Ball (1994) outlined his use of an ‘affirmative group model’. Uribe (1994) described providing a support group and an ‘affirmative approach’ with gay adolescents in a school outreach service. A few articles also examined characteristics of ‘gay affirmative career counselling’ (Choj~ nacki & Gelberg, 1994; Croteau & Hedstrom, 1993). These differences in terminol- ‘ogy used can be partly explained in that some of the articles referred to working affirmatively when counselling gay clients, while other authors described using an ‘affirmative approach’ in their work with gay people. This created confusion as to whether it was therapy or an approach that was being described. Some of the articles were written prior to the term ‘gay affirmative therapy’ becoming widely known.Gay affirmative therapy 49 Interestingly, I had previously excluded articles from the research sample on the grounds thar they referred to a range of professionals describing their approach to ‘working with gay clients rather than focusing on therapy. ‘The fourth dimension of the model clarifies the type of issues presented by gay clients within the literature analysed, ‘This included: the effects of oppression; difficulties experienced in coming out; problems with interpersonal skills and inti mate relationships (Shannon & Woods, 1991); mental health problems; difficult career choices; and other problems characteristic of heterosexual clients ldridge & Bameit, 1991). Gay clients may present with addictive disorders, isolation, anxiety, depression and low self-esteem (Sanderson, 1993). ‘The fifth dimension highlights the range of therapeutic interventions that appeared, aiming to address the issues identified in the fourth dimension. Details of approptiate types of contracts and an ethical code were identified. Counsellors and clients may frequent the gay scene, be involved in gay voluntary services, attend the seme recrcational venues and have interrelated friendships or lovers, Clients were also described as having unrealistic expectations of counsellors. Accordingly, an explicit contract needs to be negotiated, adhering to a professional ethical code and ‘to guidelines provided by the employing organisation. Limiting speech to a ‘hello’ or a head nod between counsellor and client, if meeting out in public, seems to be a strategy sometimes used to maintain a professional boundary. Confidentiality needs to be respected, and personal and professional boundaries maintained. Some coun- sellors may choose to maintain a distance from the gay community for this reason. Establishing an explicit contract between a gay client and a therapist is one of the key features which distinguish gay affirmative therapy from a gay affirmative ap- proach. Another would be a therapist having regular supervision, although this is not highlighted in the articles, A range of methods used for improving self-esteem and developing assertiveness in clients was identified. ‘The importance of self-disclosure and role modelling by counsellors was stressed, and the relevance of teaching and use of bibliotherapy was extensively cited in the literature. ‘The use of the core conditions and recognition of spiritual/philosophical needs was also identified. A conflict-resolution model was developed, and ways in which therapists could be more politically active and act as client advocate were listed. ‘The outer dimension of the model encompasses all the other dimensions, ‘suggesting that in order for counsellors to use the model, they need to increase their personal knowledge and to develop their self-awareness. A counsellor needs to be familiar with gay lifestyles, resources and networks, and conscious of their own imitations and areas for future development. Gelberg & Chojnacki (1995) indicate that heterosexual counsellors can develop such knowledge and skills, although an ‘out’ gay counsellor actively involved in the gay scene and gay liberation movement may have an advantage from personal experience. However, some gay counsellors may need to challenge their own internal homophobia (Malyon, 1982; Sanderson, 1995). ‘There are links between all dimensions of the model. It is described as integeative, since counsellors from a broad range of orientations are identified as50 Nigel Harrison adopting an affirmative approach, including cognitive behavioural, psychoanalytic and person-centred. There is an ongoing need to challenge the philosophy of all counselling orientations. Gumey (1995) contends that the neutrality or positive stance of some orientations can hide problems and avoid the special needs of gay clients. What issues emerge which have wider implications for counseling clients who are gay? Baron (1991) clarifies that ‘gay/lesbian affirmative psychology is in its early stages of evolution’ (p. 243). I view my rescarch as a summary of literature which provides Tinks in a chain of progress. An amorphous collection of ideas has been brought together in an integrative model under an umbrella term, Emerging issues are presented as recommendations for the future (Table 6). Future research could ‘measure the impact of using gay affirmative therapy with clients, focusing on the benefits and outcomes of cach of the dimensions such as bibliotherapy, assertiveness training, therapist self-disclosure and role modelling. ‘Tanuz 6. Recommendations on how to address the isues that emengel and implications for counseling, clients who are gay ‘Counsellor to adopt a gay afrmative approach A diectory of gay affirmative therapists and gay affirmative organisations to be developed Counselors to he proactive and work at a micro and macro level ‘Counsellor t9 challenge oppression in self and others ‘Counselling courses to include training on gay affirmative therapy Gay affirmative therapists to develop networks between satutory, Yehintsry and private counselling organizations [Research to be undertaken to distinguith between a gay affirmative approach and gy affirmative therapy ‘Empirical recearch to be conducted to clvily the charateritics of gay affirmative therapy and evaluate ‘the outcomes of specific interventions Gay affirmative therapists in the UK to publish theoretical writing and case sudies Counselinspsychotherapy awarding and accrediting bodies to recognise guy affirmative therapy as & specialist branch and develop guidelines for practice and an ethical code for counsellors Conclusion ‘The literature used in the study was theoretically focused and only a snapshot of existing knowledge has been sampled. The issues raised may not be generalisable. ‘The data analysed are predominately from the USA, where a distinctive culture and values exist amongst therapists and in the gay community. I accept that some personal bias also exists. The data were not quantified, ic. the themes that emerged were credited with equal importance regardless of their frequency of occurrence in the data. The inclusion of articles in the research sample included those which ‘fully or partially’ alluded to gay affirmative therapy. ‘This could be part of the reason why there was difficulty distinguishing between gay affirmative therapy and 2 gay affirmative approach. Being more selective and excluding more of the literature fromGay affirmative therapy 531 the study might have created Jess confusion. However, it would also have resulted in a much smaller sample being available for analysis, ‘An integrated model of a gay affirmative approach has been developed, the principles of which can be utilised by therapists in gay affirmative therapy. This is summarised as therapy which has as its core belief a non-pachological view of gay people that is operationalised through the therapist challenging oppression in self and others. This involves empowering clients and acting as their advocate. Within this model, the therapist is familiar with the type of issues presented by gay clients and responds affirmatively, developing competence in using a range of therapeutic interventions. A gay affirmative therapist endeavours to develop self-awareness and acceptance of personal limitations in working with a gay client group. A knowledge of gay lifestyles and resources is required, along with the integration of these features into one’s own counselling orientation, ‘The mode! developed is underpinned by a set of values, with logical sequences and integrated dimensions for working at a micro and a macro level. This challenges those counselling approaches which leap from a set of values to interventions. ‘Three domains of a gay affirmative approach were identified, including how therapists work individually with clients, the approach adopted by organisations, and the approach within a social movement, professional group or society. Each requires further exploration and refinement. A useful Iiterature is emerging on therapeutic perspectives in working with lesbian, gay and bisexual clients. Davies & Neal (1996) ‘outline the use of different theoretical approaches, including gay affirmative supe sion as a practical guide for therapists, counsellors and others in related professions. 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