To disclose or not to disclose? The LGBT therapist’s question. Adam John Llewellyn Harris, BSc (Hons); MSc. Submitted in part fulfilment of the requirements of the University of Lincoln for the degree of Doctorate of Clinical Psychology 2015 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 1 of 202 Acknowledgments First and foremost, I would like to take this opportunity to thank my research supervisors David Dawson and Roshan das Nair. Their guidance, support, and constructive feedback in devising, implementing and writing up this research project has been valued and respected. It is also important to thank Dominic Davies for his support in developing the idea, the online survey and interview questions, providing useful points to consider and for allowing me to advertise the study through Pink Therapy. I would also like to thank Nima Moghaddam who, although not one of my research supervisors, was a great sounding board in the initial stages of the development of the research idea. Special thanks go to all the therapists who took the time to share their experiences of disclosure through the online survey and or the interviews. Without their participation and help this research would not have been possible. Finally, I need to acknowledge the support and encouragement from friends, family and fellow trainees during the process of completing this piece of work. Without all of you it would have been increasingly difficult to get through the dark times, when it seemed that thesis was never ending. Furthermore, to my partner, Luke, your unfaltering encouragement and support has kept me going, thank you. 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 2 of 202 Table of Contents Acknowledgments .............................................................................................. 2 Table of Contents ............................................................................................... 3 List of table and figures……………………………………………………………….8 Portfolio abstract ................................................................................................ 9 Statement of Contribution ................................................................................. 11 Systematic Literature Review ........................................................................... 12 Abstract………………………………………………………………………………..11 Introduction…………………………………………………………………………...12 Method………………………………………………………………………………...14 Results………………………………………………………………………………...19 Discussion……………………………………………………………………………35 Reference…………………………………………………………………………….40 Appendix A……………………………………………………………………43 Appendix B……………………………………………………………………45 Journal Paper ................................................................................................... 54 Abstract ............................................................................................................ 54 Introduction....................................................................................................... 55 Method ............................................................................................................. 59 Results ............................................................................................................. 63 Function of disclosure ............................................................................... 63 Function of non-disclosure ........................................................................ 65 How disclosure happens ........................................................................... 68 Discussion ........................................................................................................ 71 The function of disclosure ......................................................................... 71 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 3 of 202 The function of non-disclosure .................................................................. 72 How disclosure happens ........................................................................... 74 Limitations and future research ................................................................. 75 Clinical implications ................................................................................... 76 References: ...................................................................................................... 78 EXTENDED PAPER ......................................................................................... 84 EXTENDED INTRODUCTION ......................................................................... 84 Background research .................................................................................... 84 What works in therapy? ............................................................................. 84 Therapist self-disclosure ........................................................................... 84 Therapist self-disclosure of sexual orientation (TDSO) ............................. 85 Coming out and therapy ............................................................................ 88 Minority Stress Model (MSM) .................................................................... 89 Study Rationale ......................................................................................... 91 EXTENDED METHODOLOGY ......................................................................... 94 Research Design .......................................................................................... 94 Ontology and epistemology ....................................................................... 94 Researcher’s epistemological position ...................................................... 95 Rationale for a mixed methodology ........................................................... 96 Limitations of mixed methods .................................................................... 97 Methodology considerations ...................................................................... 98 Rationale for online survey ........................................................................ 98 Limitations of online survey ....................................................................... 99 Rationale for individual interviews ............................................................. 99 Limitations of individual interviews .......................................................... 101 Methodology used in the study ................................................................ 102 Procedure ................................................................................................... 102 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 4 of 202 Rationale for number of participant for interviews ................................... 102 Sampling and recruitment ....................................................................... 103 Online survey .......................................................................................... 107 Interview and transcription ...................................................................... 107 Ethical considerations and approval ........................................................ 107 Data Analysis .............................................................................................. 110 Quantitative approaches ......................................................................... 110 Qualitative approaches............................................................................ 111 Rationale for TA ...................................................................................... 113 A priori decisions ..................................................................................... 115 TA procedure .......................................................................................... 115 Establishing quality ................................................................................. 117 Researcher’s statement of perspective ................................................... 119 EXTENDED FINDINGS .................................................................................. 120 Quantitative findings ................................................................................... 120 Qualitative results ....................................................................................... 122 Function of disclosure ................................................................................. 122 Communicating ....................................................................................... 123 Disclosure as an intervention .................................................................. 124 Function of non-disclosure .......................................................................... 127 Damaging the alliance continued ............................................................ 128 Risk continued ......................................................................................... 128 The client’s focus .................................................................................... 129 How Disclosure Happens............................................................................ 130 During therapy ......................................................................................... 130 EXTENDED DISCUSSION............................................................................. 136 The function of disclosure ....................................................................... 137 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 5 of 202 The function of non-disclosure ................................................................ 140 How disclosure happens ......................................................................... 143 A model of therapist minority stress ........................................................ 145 Clinical implications ................................................................................. 146 Strengths and limitations ......................................................................... 148 Recommendations for future research .................................................... 149 Critical reflection ...................................................................................... 150 REFERENCES ............................................................................................... 156 APPENDICES ................................................................................................ 171 Appendix A: Study Advert ........................................................................... 171 Appendix B: Ethical Approval Email ............................................................ 172 Appendix C: Consent Page (Online Survey) ............................................... 173 Appendix D: Interview Schedule ................................................................. 174 Appendix E: Thematic Maps: Overarching themes and main themes ....... 176 Thematic Map: Overarching themes – sub-themes ................................ 177 Appendix F: Procedure Flow Chart ............................................................. 178 Appendix G: Online Survey Questions ....................................................... 179 Appendix H: Participant Information Sheet – Online survey ....................... 182 Participant Information sheet: Interview .................................................. 183 Appendix I: Debriefing Information Sheet: Online Survey ........................... 185 Debriefing information: Interview ............................................................. 186 Appendix J: Transcription Confidentiality Agreement ................................. 187 Appendix K: Quantitative Analysis .............................................................. 188 Appendix L: ................................................................................................. 192 Example Theme 1: Checking Codes under their Theme Headings ......... 192 Example Theme 2: Checking Codes under their Theme Headings ......... 193 Example Theme 3: Checking Codes under their Theme Headings ......... 194 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 6 of 202 Appendix M: Example Transcript with Codes ............................................. 195 Appendix N: Coding template ..................................................................... 196 POSTER......................................................................................................... 197 Summary of Service-Related Research and associated Impact (SSRI) ......... 198 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 7 of 202 List of tables and figures Systematic Literature Review Figure 1: Quorum diagram…………………………………………………………17 Table 1: Study characteristic………………………………………………………..21 Table 2: Critical appraisal tool……………………….……………………………..23 Table 3: Facilitators and barriers to therapist disclosure…….………………….29 Table 4: Perceived impacts of TDSO on therapeutic alliance………………….31 Table 5: Therapists’ choice in disclosures……………………………………….33 Table 6: Context of TDSO…………………………………………………………35 Journal Paper Table 7: Participant characteristics (interviews)…………………………………59 Table 8: Thematic table: conceptualisation of disclosure………………………62 Extended Paper Table 9: Participant information (online survey)……………………………….105 Table 10: Number of clients disclosed to……………………………………….119 Table 11: Clinical context of disclosure…………………………………………120 Table 12: Awareness of guidelines……………………………………………...120 Table 13: Thematic table: conceptualisation of disclosure……………………122 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 8 of 202 Portfolio abstract Background: Research indicates that it is the non-therapeutic factors such as warmth, empathy, understanding and therapeutic alliance that are most effective at creating change. The use of the therapists’ own identities has been highlighted as a means of enhancing such non-specific factors. The literature suggests that 90% of therapists disclose something about themselves to clients; however therapist disclosure is a contentious issue. Furthermore, literature suggests that for therapists working with stigmatised or minority groups (e.g. sexual minorities) disclosure can be beneficial. Guidelines suggest that therapist disclosure of sexual orientation (TDSO) should be used judiciously, while others suggest that TDSO could be classed as the therapist displaying sexualised behaviours towards the client. Aim: This study aimed to understand the purpose of lesbian, gay, bisexual and trans (LGBT) therapists’ disclosing sexual orientation to clients, while exploring their perceptions and experiences of disclosure. Method: This study employed a mixed methods design. Purposeful sampling was used to recruit 53 participants from an international sample of LGBT therapists, through professional body listservs and an LGBT therapist directory, to complete an online survey. From this survey 17 participants were purposively sampled to take part in a semi-structured interview. Quantitative and qualitative analysis methods were utilised. Results: The findings highlighted that 81.1% of the online survey sample reported that they had disclosed their sexuality to a client, with the majority stating that they mainly disclosed to non-heterosexual clients and 73.6% of participants stating that they were not aware of any guidelines related to using TDSO. Chi-square test of independence found that there was no significant association between therapists’ awareness of guidelines and TDSO. A Mann- Whitney U analysis revealed that there was no significant difference between participants post qualification experience (years) and making a disclosure. Three main themes were derived from the qualitative analysis: 1) Function of 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 9 of 202 disclosure; 2) Function of non-disclosure; 3) How disclosure happens, each of these themes have between two and five subthemes. Conclusions and recommendations: TDSO was shown to occur mainly with non-heterosexual clients. Disclosure was highlighted to facilitate the enhancement of the therapeutic alliance and create a safe, non-judgemental space for sexual minority clients. However, therapists expressed that concealing their sexuality was common when working with heterosexual clients because of fear of judgement and personal safety. Psychological effects were also noted due to therapists’ concealment. Disclosure was found to happen in various contexts, with direct verbal disclosures being one of many ways that sexuality was disclosed. It is suggested that supervisors and training courses need to acknowledge the psychological impacts of therapists concealing their sexual identity by showing an understanding of how concealment can lead to increased stress for professionals who are trying to maintain focus on the clients. Sexuality is seen as a key characteristic of being human and concealing it is like trying to conceal your gender or ethnicity. Future guidelines need to reflect the experience of non-heterosexuals working within a heteronormative society and understand the importance of therapists’ rationales for making disclosures. 1415, RPV, UoN: 4194596, UoL: 12353909, Research Portfolio & Viva Page 10 of 202