Tuesday, June 2, 2015

Group Intervention for the Treatment of Internalized Homophobia in LGB Adolescents






Group Intervention for the Treatment of Internalized Homophobia in LGB Adolescents
Jared Smith
University of Dayton










Abstract
            Lesbian, gay, and bisexual (LGB) clients are often faced with negative wellness outcomes due from complications of living in a heterosexist world and dealing with the stress and pressure associated with minority status.  While the external world is full of threats and must certainly be navigated, there is another component which must also be addressed.  Internalized homophobia is an internal dissonance of self- expectation.  The process of growing up in a heterosexist world often results in negative stereotypes about LGB status being turned inward.  The following group proposal will attempt to reduce and mitigate internalized homophobia and increase self-love and personal mastery through the use of cognitive behavioral, acceptance and commitment, psychoeducational, and gay-affirmative techniques.










Introduction
            Sexual minority clients have a higher risk of serious mental illnesses, negative health outcomes, and emotional distress than majority client members.  Research suggests that many of these negative outcomes are partially due to homophobia which exists and is institutionalized in the heteronormative society around us. McGeorge and Carlson (2011) summarize the effects of heterosexism on LGB individuals:
 “The literature also clearly documents the negative influences of heterosexism on the relationship experiences and mental health of LGB persons. Examples of these negative influences include increased rates of depression and anxiety (Bernhard & Applegate, 1999; Bos, van Balen, van den Boom, & Sandfort, 2004; Lewis, Derlega, Grin, & Krowinski, 2003; Mays & Cochran, 2001); suicide (Bernhard & Applegate, 1999; Faulkner & Cranston, 1998; Garafalo, Wolf, Kessel, Palfrey, & DuRant, 1998; Gibson, 1989; Mays & Cochran, 2001); and alcohol and drug misuse (Cheng, 2003; Faulkner & Cranston, 1998; Garafalo et al., 1998; Jordan, 2000; Kruks, 1991).”
 What becomes complicated is that this disadvantageous system which effects our clients is not only externally influenced.  Alas, the result of growing up in a homophobic society is the internalization of homophobia.  In order for self- actualization of sexual identity to come to fruition, this internal struggle must be dealt with and the wounds of internalized homophobia must be healed.  This proposal includes a review of literature poised at creating a safe group environment wherein internalized homophobia can be measured, and reduced.  The proposal suggests a technically eclectic approach with foundations in cognitive-behavioral therapy supplemented with psychoeducation, strength based techniques, gay-affirmative techniques, and acceptance and commitment techniques.
It is important in therapy that we always consider the influence of culture on clients.  When dealing with LGB individuals, this can be complex.  Homophobia may be a very real part of your client’s external environment as it is institutionalized and built into the society around them.  But what about the homophobia that comes from within?  Research suggests that growing up in a homophobic world leads to internalized homophobic values and self-concepts.  An LGB client will have to battle not only with the world around them, but the world inside of them. 
Literature Review
            It is our job as practitioners to use empirically grounded and culturally applicable treatment plans when treating our clients.  Certainly, the LGB population is no exception.  There have been many different schools of thought on the issue of helping LGB individuals toward acceptance of self, and reduction of comorbid conditions that tend to correlate with LGB status.  The approach that will be utilized in this group proposal will be that of a technical eclectic approach.  A framework of cognitive behavioral theory will be used as the platform upon which additional techniques will be supplemented.  From there, a strong psychoeducational piece will be utilized as a supplement to treatment.  The treatment component in addition to the CBT frame will include techniques from Gay-Affirmative and Acceptance and Commitment models.  Although the core of content will be focused from a CBT perspective, group members will find that group dynamic and process design also borrow person-centered tenants of unconditional positive regard, congruence, and empathic understanding in order to facilitate an environment of growth which will feel safe to clients. 
Cognitive-Behavioral Therapy
The basic framework on which the internalized homophobia reduction techniques will be built will be that of a cognitive behavioral perspective.  This is a very deliberate decision and is based on research which suggests that cognitive behavioral approaches work well with adolescents (Craig Austin & Alessi, 2012; Compton et al., 2004).  It will also be useful in achieving our goal of reducing internalized homophobia and increasing acceptance because of the models’ focus on recognizing maladaptive thought patterns, reality testing, and cognitive restructuring of accompanying beliefs. CBT focus was also chosen due to its “homework” components which will encourage group members to take the personal growth and insight gained in the group setting and apply it to their lives outside of therapy.  The fact that these cognitive-behavioral principles will be utilized under a group setting will also have the added benefit of providing a support system should these attempts to integrate therapeutic outcomes with their lives not go as planned, and a system of peer accountability to encourage members to continue their work outside of therapy.
Psychoeducation
            In part because this group is geared towards adolescents, there will be a strong psychoeducational portion that will be utilized to help disperse accurate information about LGB individuals to the group participants.  This part of the group will be geared toward informing group members about relevant information regarding sexual education, STI and HIV/AIDS reduction through safer sex practices, rights and protections belonging to LGB individuals, and community resources available to group members.  This psychoeducation provides several purposes: helping to dispel myths and stereotypes associated with the LGB population; reducing internalized homophobic beliefs; reducing risk and symptomology of LGB related health issues; and creating future support networks for the group members as they continue on in a heterosexist society.
Gay-Affirmative Therapy
                        A Gay-Affirmative perspective will be part of the lens through which the counseling group will operate. This approach will be used in supplement to our existing CBT framework due to its focus on LGB issues and its adaptability to being used simultaneously with other models.
“Gay affirmative practice is not an independent practice approach; it is used to enhance a practitioner’s existing treatment model and can be incorporated into individual, couple, family, and group work (Davies 1996). However, gay affirmative practice differs from traditional treatment approaches. It views homosexuality as a normal variant of sexual identity development, which, in turn, ‘‘affirms a lesbian, gay, or bisexual identity as an equally positive human experience and expression to heterosexual identity’’ (Craig, Austin, & Alessi, 2012).  This positive approach to dealing with LGB clients will allow for a safe and nurturing environment to be formed.  The affirmative component will allow for growth and help reduce internalized homophobia and increase acceptance through client-counselor modeling, and validation of the clients experience as an LGB individual in the world.  The article Gay Affirmative Cognitive Behavioral Therapy for Sexual Minority Youth: A Clinical Adaptation discusses use of the existing ten component model of Gay- Affirmative therapy.  The interventions and techniques drawn from these ten tenants will be utilized throughout the group due to their focus on affirming client experience and identity, building good rapport with the client, and using cognitive restructuring in a lens which is used to question the helpfulness of thoughts rather than their validity. As these components focus on restructuring, homework, and collaboration the pieces fit nicely over our CBT framework.  The ten tenants found in the article are listed are listed as follows:
1-Affirm the identities of SMY during the assessment process.
2-Foster collaboration by clearly explaining the process.
3-Identify the SMY’s personal strengths and support networks.
4-Distinguish between problems that are environmental and those that stem from dysfunctional thoughts
5-For environmentally-based problems, help clients make changes that decrease stress, increase personal strengths and supports, and to build their skills for interacting with the social environment.
6-Validate clients’ self-reported experiences of discrimination.
7-Emphasize collaboration over confrontation, with attention to client–therapist differences.
8-With cognitive restructuring, question the helpfulness (rather than the validity) of the thought or belief.
9-Use client-identified strengths and supports to help SMY develop a List of helpful thoughts.
10- Ensure that homework assignments emphasize congruence with LGBQ culture as well as the client’s stage in the coming out process.
Note: In the above mentioned excerpt the term SMY is used to refer to Sexual Minority Youth.
Acceptance and Commitment Therapy
            I chose to also supplement this group with techniques from Acceptance and Commitment therapy (ACT).  ACT is a good for dealing with coming to acceptance of one’s sexuality because it delivers symptom reduction via accepting what cannot be changed and creating a new relationship with thoughts, feelings and physical sensations.  The goal of ACT is to renegotiate the power the client gives their negative thoughts rather than attempting to eliminate them.  The ACT model is also heavily reliant on both mindfulness techniques and metaphor, encouraging both present moment awareness and deeper emotional awareness through creative thinking and assessing and separating fact from judgment (Bowden T. & Bowden S. 2012).  The model itself will be a good fit for group intervention because the model works on six different and interconnected areas of creating wellness.  These areas may be worked on in any order and the ACT model believes that progress in one area leads to progress in the other areas.  It is adaptable, which is helpful in the group setting. The six tenants are referred to in the model as the “hexaflex” and have been described as follows:
a.       Defusion: What sort of unhelpful thinking is keeping us stuck, this could be rigid rules, self-limiting beliefs, harsh judgments, reason giving etc.?
b.      Acceptance: What experiences (thoughts feelings, sensations) is this person avoiding and how? What are the costs of avoidance?
c.       Present Moment: How much time is spent dwelling on/ re-living the past, worrying about the future, getting lost in thought?
d.      Self-as-context: how clients see themselves. “Are you your struggle or are you more than that? Are you stuck and only able to see the problem from one perspective?”
e.        Committed Action: whether the current actions are helping the client get where they want to be
f.       How connected/ Dis-connected are the client from what matters to them.
 (Bowden T. & Bowden S., 2012).
           

Purpose and Objectives
            The purpose of this group is to help young adults of sexual minority status come into loving acceptance and understanding of their sexual identity.  The progress made in creating loving acceptance of self will also lead to reduction of symptomology considered to be comorbid with sexual minority status (anxiety, depression, suicidality, etc.).  The group will provide an affirmative environment and education with a focus placed on creating change by reducing internalized homophobia. The objectives are as follows:
·         Clients will leave the group with lower levels of internalized homophobia than when they entered the group
·         Clients will be educated on issues pertaining to sexual minority status
·         Clients will learn tools to help them create a relationship of loving acceptance with themselves
·         Clients will develop sense of community and work on interpersonal communication
·         Clients will form a less judgmental relationship with their thoughts and learn how to combat cognitive distortions and negative thought patterns
·         Self-esteem and self-efficacy of clients will improve
·         Clients will learn to presentize their awareness to come to a deeper understanding of themselves, the environment around them, and the interaction of the two domains
Structure and Setting
            The structure of the group will consist of 8-12 adolescent youth whom identify as lesbian, gay or bisexual.  The group will take place in an open room setting such as an empty classroom or small conference room as seen in many office buildings, schools, and churches.  The group will meet twice every week for a total period of two hours per session. A 10 minute break will be provided after the first 40 minutes of each session.  Longevity of the group will be based on CBT model which suggests intervention length of 7-12 weeks.  As such, the program will be built as a twelve-week program.  The group will be closed to new members to prevent the group from having to repeatedly re-establish trust with newcomers. Members will be chosen based on self-reported symptomology of difficulty of coming to acceptance of sexual minority status. The room will be in a closed door setting to encourage disclosure and feelings of safety in the group.  The group will be conducted in the format of a rounded chair circle.  As new clients join the group the rules and norms of the group will be explained as a group.
Process
            The content of the group will be set in advance as topics of conversation to encourage education and awareness.  Group activities will also be a part of the group work on a regular basis.  To encourage trust within the group, each session will start with introductions and a “highs and lows” check in.  The group schedule will be posted in advance to allow group members to prepare for the topic, and do any activities that would have been required of them to complete in the previous session.  Content will psychoeducational in design; however, process regarding daily lesson will be more free-formed and open to group will.
            Process will be based upon renegotiating relationships with client’s negative thoughts and internalized homophobia. Topics of content will be used as catalysts to process conversations.  As present moment awareness is important to the outcome improvement of clients, process will be present moment focused and mindful activities will be intermittently used where applicable. 
            The leadership of the group will model acceptance and affirmative attitude when treating group members.  The group dynamics will be based on creating a safe environment where empathy and trust is felt, and education and healing can take place as the agreed upon goals of the group.  Leadership will keep the group’s focus initially on the topic of the night through the use of activities and hand-outs.  Upon finishing the content portion, the group leader will open the forum and allow for process of the topic to occur.  Leadership will keep group up to date on the processes and purpose of interventions being used to allow the group to feel and act as co-facilitators in their own group/self-work.
Concern and Limitations
            Like any therapeutic endeavor, it is impossible to say with certainty what outcomes (if any) will be achieved.  The set-up of the group is prone to some limitations which could potentially cause regression to the group members or possible harm to the therapeutic alliance.  Concerns include the following:
·         The groups’ use of leadership as both a facilitator and a psychoeducator could potentially create a perceived power differential in which the group/leader relationship is perceived as a student/ teacher relationship.  This barrier will be reduced by warmth, genuineness and appropriate, applicable self-disclosure on the part of the leadership.
·         Although confidentiality and anonymity are goals of the group, any group member threatening harm to self or others will require immediate appropriate action on the part of leadership.  Due to age of clients this may involve disclosure to parents/guardians.  This barrier will be reduced by making clients aware of this policy throughout the process, and encouraging clients to speak to parents/guardians with the leadership present in instances where disclosure to guardians/parents is necessary; this latter process will occur outside of the group process
·         Confidentiality is also harder to maintain in a group setting.  To try and reduce this potential barrier, emphasis will be repeatedly placed upon the importance of inter-group confidentiality.  Any breaches of confidentiality in the group will be dealt with as appropriate and the group will be part of the process of dealing with breaches.
·         Using a highly integrative model comes with restrictions as well.  The combination of CBT and ACT while mostly complimentary do have some offsetting differences.  Most notably is the dissonance between the models views on thoughts.  CBT focuses on stopping and changing negative thoughts and refers to them as being maladaptive. On the other hand ACT focuses on defusing from all thoughts, negative or positive and rather than placing labels like maladaptive or negative on thoughts, the model simply looks for value of thoughts. (I.e. is this thought helpful to me in this moment).  The groups’ integrative approach will try to utilize the best of both of these models by explaining to clients the difference in models and encouraging clients to change unhelpful thoughts when they can have non-judgmental acceptance of thoughts which cannot be changed.  The ACT concept of questioning the value of thoughts rather than the legitimacy will be used in all instances.
Evaluations
            Evaluations will be accomplished via combination of several measures which will measure internalized homophobia, shame and stage of sexual minority identity development. Measures were chosen based on the research presented in the article Stage of Sexual Minority Identity Formation: The Impact of Shame, Internalized Homophobia, Ambivalence Over Emotional Expression, and Personal Mastery (Greene & Britton 2012). These measures will be administered as pre and post tests to create baseline of group members and track personal development and growth.  The Internalized Homophobia Scale (IHC) (Martin & Dean 1987) will be used to measure pre and post levels of internalized homophobia.   Clients will also be administered a 10 question post group experience questionnaire which will be utilized to measure clients’ perceived efficacy of the group experience.  Shame will be measured using the Experience of Shame Scale (Andrews, Qian & Valentine, 2002).  The final empirical measure will be the Stage Allocation Measure (Cass, 1984) which will be used to classify the stage of LGB identity development of group members and to track their movement through stages. These stages via the Cass model are as follows:
“Stages of identity are defined as Stage 1 (Identity Confusion), Stage 2 (Identity Comparison), Stage 3 (Identity Tolerance), Stage 4 (Identity Acceptance), Stage 5 (Identity Pride), and Stage 6 (Identity Synthesis)”. (Cass, 1984)
Conclusions
            Due to the complexities which surround the minority experience it will always be challenging to work with clients of minority status.  LGB individuals in particular have a bevy of comorbid mental and physical wellness issues correlated with the pressures caused by living in a heterosexist society. Group intervention with an affirmative focus, and an ACT and CBT framework will allow clients to become educated about their minority status, find helpful tools to navigate their challenges, reduce internalized homophobia while increasing self-love, and grow in a supportive community environment.




Reference
1)      Bowden, T., & Bowden, S. (2012). Acceptance and Commitment Therapy (ACT): An Overview for Practitioners. Australian Journal Of Guidance & Counselling, 22(2), 279-285. doi:10.1017/jgc.2012.32

2)      Burns, D. (1999). The feeling good handbook (Rev. ed.). New York, N.Y., U.S.A.: Plume. *Taken from Sample Paper

3)      Craig, S. L., Austin, A., & Alessi, E. (2013). Gay affirmative cognitive behavioral therapy for sexual minority youth: A clinical adaptation. Clinical Social Work Journal, 41(3), 258-266. doi:10.1007/s10615-012-0427-9


4)      Greene, D. C., & Britton, P. J. (2012). Stage of sexual minority identity formation: The impact of shame, internalized homophobia, ambivalence over emotional expression, and personal mastery. Journal Of Gay & Lesbian Mental Health, 16(3), 188-214. doi:10.1080/19359705.2012.67112

5)      Herrick, A. L., Stall, R., Chmiel, J. S., Guadamuz, T. E., Penniman, T., Shoptaw, S., & ... Plankey, M. W. (2013). It gets better: Resolution of internalized homophobia over time and associations with positive health outcomes among MSM. AIDS And Behavior, 17(4), 1423-1430. doi:10.1007/s10461-012-0392-x

6)      Jordan, K. M., & Deluty, R. H. (1995). Clinical interventions by psychologists with lesbians and gay men. Journal Of Clinical Psychology, 51(3), 448-456. doi:10.1002/1097-4679(199505)51:3<448::AID-JCLP2270510321>3.0.CO;2-8


7)      Langdridge, D. (2007). Gay affirmative therapy: A theoretical framework and defence. Journal Of Gay & Lesbian Psychotherapy, 11(1-2), 27-43. doi:10.1300/J236v11n01_03

8)      Lock, J. (1998). Treatment of homophobia in a gay male adolescent. American Journal Of Psychotherapy, 52(2), 202-214.


9)      McGeorge, C., & Carlson, T. S. (2011). Deconstructing heterosexism: Becoming an LGB affirmative heterosexual couple and family therapist. Journal Of Marital And Family Therapy, 37(1), 14-26. doi:10.1111/j.1752-0606.2009.00149.x

10)  Meyer, I. H. (1995). Minority stress and mental health in gay men. Journal Of Health And Social Behavior, 36(1), 38-56. doi:10.2307/2137286


11)  Pearson, Q. M. (2003). Breaking the silence in the counselor education classroom: A training seminar on counseling sexual minority clients. Journal Of Counseling & Development, 81(3), 292-300. doi:10.1002/j.1556-6678.2003.tb00256.x
















Appendix A: Session Outlines
Session 1
Topic: Introductions, rules and outline of treatment plan.
Goals: Group members will get to know each other and the facilitator. Group members will leave with an understanding of what the purpose of the group is, and what expectations will be throughout treatment.
Materials/Handout: A copy of expectations and contact information outlined in the consent form (see appendix C).
Process:
  • Group leadership will introduce themselves, and open the floor for group members to do the same.
  • Members will introduce themselves and share a high and low for the day.
  • New members will be welcomed into the group by the leadership and group members.
  • New members will be asked to share about themselves and what they hope to accomplish through group membership.
  • Group expectations will be reviewed.
  • 10 minute break will occur following first 40 minutes.
  • Group leadership will describe the processes and goals of the group.

Session 2
Topic: A Psychoeducational look at internalized homophobia.
Goals: Introduce group to the concept of internalized homophobia.
Materials/Handouts: notebook, writing utensil,
Process:
  • Group leadership will introduce themselves, and open the floor for group members to do the same.
  • Members will introduce themselves and share a high and low for the day.
  • 10 minute break will occur following first 40 minutes.
  • Group leadership will introduce the topic of internalized homophobia and its influence on the mental and physical wellbeing of sexual minority individuals.
  • Group members will be given open time to discuss topic as facilitated by group leader.
  • Group members will be asked to journal about a time they noticed an instance of internalized homophobia in their lives.
  • Session will close with an introduction to mindfulness via a closing body scan to relax group members and help them learn to create nonjudgmental awareness of thoughts and sensations.




Session 3
Topic: An introduction to cognitive errors.
Goals: Members will learn about common cognitive errors and maladaptive cognitive patterns.
Materials/Handouts: cognitive errors handout notebook and writing utensils
Process:
  • Group leadership will introduce themselves, and open the floor for group members to do the same.
  • Members will introduce themselves and share a high and low for the day.
  • Group members will be asked to share thoughts or excerpts from last weeks’ journal assignment.
  • A mindful body scan will be used to model and foster nonjudgmental awareness/acceptance of thoughts and sensation.
  • 10 minute break will occur following first 40 minutes.
  • Group leadership will introduce the topic of cognitive errors and its relation to internalized homophobia.
  • Group members will be given open time to discuss topic as facilitated by group leader. Examples of interventions to deal with cognitive errors (i.e. reframing) will be discussed.
  • Group members will be asked to journal about maladaptive thought patterns and cognitive errors that they feel might be present in their interactions with themselves and others. The handouts will act as a guide.

  • Session will close with a body scan to relax group members and model/ foster nonjudgmental awareness of thoughts and sensations.

Session 4
Topic: An introduction to attitudes of affirmation.
Goals: Group members will learn gain an introduction into the benefits of viewing themselves and other group members through a gay-affirmative lens.
Materials/Handouts: notebook, writing utensils
Process:
  • Group leadership will introduce themselves, and open the floor for group members to do the same.
  • Members will introduce themselves and share a high and low for the day.
  • Group members will be asked to share thoughts or excerpts from last weeks’ journal assignment.
  • A mindful body scan will be used to model and foster nonjudgmental awareness/acceptance of thoughts and sensation.
  • 10 minute break will occur following first 40 minutes.
  • Group leadership will introduce the topic of affirmation and its importance in relation to internalized homophobia and LGB identity.
  • Group members will be given open time to discuss topic as facilitated by group leader.
  • Group members will co-facilitate a gay-affirmative mantra for the group.
  • Group members will engage in active affirmation by telling each other something affirmative about themselves and another group member.
  • Group members will be asked to create a daily personal affirmation in their journal. Homework will to be to say their created affirmation out loud to themselves daily throughout the week, use of mirror will be encouraged.

  • Session will close with a body scan to relax group members and model/ foster nonjudgmental awareness of thoughts and sensations.

Session 5
Topic: Acceptance and commitment.
Goals: Group members will be introduced to ACT concepts of accepting thoughts, feelings and sensations which we cannot control and evaluating their helpfulness.
Materials/Handouts: notebook, writing utensil
Process:
  • Group leadership will introduce themselves, and open the floor for group members to do the same.
  • Members will introduce themselves and share a high and low for the day.
  • Group will recite the gay-affirmative mantra they created last week.
  • Group members will be asked to share thoughts or excerpts from last weeks’ journal assignment.
  • A mindful body scan will be used to model and foster nonjudgmental awareness/acceptance of thoughts and sensation.
  • 10 minute break will occur following first 40 minutes.
  • Group leadership will introduce the topic of acceptance and its importance in relation to internalized homophobia and LGB identity.
  • Group will listen as facilitator recites the ACT “monsters on a boat” metaphor
  • Group members will be given asked to identify the monsters that are present on their boats, how they have dealt with them in the past, and how they may deal with them differently in the future.
  • Session will close with a body scan to relax group members and model/ foster nonjudgmental awareness of thoughts and sensations.

Session 6
Topic: LGB Issues Day (Prejudice, Stereotypes and Discrimination).
Goals: Members will learn the difference between prejudice, stereotyping, and discrimination, gain an understanding of how it effects their communities, and given a chance to discuss instances in which they have been effected directly or indirectly by these.
Materials/Handouts: notebooks, writing utensils
Process:
  • Group leadership will introduce themselves, and open the floor for group members to do the same.
  • Members will introduce themselves and share a high and low for the day.
  • Group will recite the gay-affirmative mantra they created by the group.
  • Group members will be asked to share thoughts or excerpts from last weeks’ journal assignment.
  • A mindful body scan will be used to model and foster nonjudgmental awareness/acceptance of thoughts and sensation.
  • 10 minute break will occur following first 40 minutes.
  • Group leadership will introduce the topics of prejudice, stereotyping and discrimination and its importance in relation to internalized homophobia and LGB identity.
  • Group will process direct and indirect personal experiences with prejudice, stereotyping and discrimination. 
  • Group will watch “It Gets Better” video. Discussion of overcoming heterosexism as a community will be introduced and briefly touched on (Will be discussed in depth in future session).
  • Session will close with a body scan to relax group members and model/ foster nonjudgmental awareness of thoughts and sensations.




Appendix B: Questionnaire
Client Post-Treatment Survey
Please rate your agreement on the following items according to the key below:
  1. Strongly disagree
  2. Disagree
  3. Neutral
  4. Agree
  5. Strongly agree

1.      I have increased understanding of sexual orientation and sexual minority issues.
                                1        2          3          4          5
2.  I have come to a have a more accepting relationship with my sexuality.
                                    1          2          3          4          5
3. I have been given tools in this group which I believe will continue to benefit me.
                                    1          2          3          4          5
4. I have decreased feelings of shame and negativity surrounding my sexuality.
                                    1          2          3          4          5
5. I have an increased self-love/ self-confidence.
1              2          3          4          5

6. Being in group has increased my knowledge of resources available to me should I need counseling or group support again in the future.
1          2          3          4          5
       7.  During my time with the group I felt respected, heard and understood.
                                    1          2          3          4          5
       8. I felt that my group was well facilitated by group leadership.
                                    1          2          3          4          5
       9. I would recommend a group like this to others whom are dealing with similar problems to those discussed in group.
                                    1          2          3          4          5
       10. I felt that I could speak freely in group and do my work without feeling judgment from group facilitators or members.
                                    1          2          3          4          5








Appendix C: Informed Consent Form
Informed Consent & Agreement to Treatment Form
            Group counseling can be an effective tool in offering reduction of internalized homophobia; this is the purpose of the proposed group. Treatment will be structured around a combination of psychoeducation and therapeutic intervention.  The techniques used in the group will work from a cognitive behavioral perspective, offering a structure which will work toward reduction of symptoms via cognitive restructuring, and intervention.  The treatment plan will be supplemented with Acceptance and Commitment Therapy techniques and Gay-Affirmative techniques to encourage growth and self-love.  As the process component is highly experiential, attendance at group sessions is strongly encourage. Group counselors are held to the ethical standards of the American Counseling Association as such confidentiality and safety of group members is a foremost importance to group leadership.  Confidentiality can potentially be broken by the group leadership under special circumstances in which a group member is a danger to themselves or others and instances of abuse.  In the case of abuse of a child (which is defined here as any individual under the age of 18) the group leader must act as a mandatory reporter on behalf of the child and file a report with Child Protective Services. Unlike individual counseling a group setting presents an extra potential for confidentiality breech in that group members are not trained counselors and may breech group trust. To minimize this risk all group members are explained the following group expectations:
1)      By signing below and agreeing to take part in this group you understand that confidentiality is an expectation presented in the group environment and agree not to breech confidence of the group.  This means that all group members will abstain from disclosing anything group related (topics, identities of group members, etc.) outside of the group setting or to anyone not in the group. As a group member, it is expected that you will hold to the group agreement to confidentiality.

2)      Group members will avoid unnecessary confrontation and unnecessary aggression in dealings between group members.  Group members will be taught how to engage each other in a respectful, caring and warm way.

3)      Group members understand that inability to abide by above mentioned expectations may result disciplinary action including termination from treatment


Any and all questions may be directed toward group leadership, Jared Smith via email or to his program director via email in the case of possible conflict of interest.

Jared Smith: jred0143@gmail.com  Pat Polanski ppolanski1@udayton.edu
Acknowledgement and Consent
I have read and understood the synopsis of this group and I hereby consent to participate in group treatment and to follow the aforementioned guidelines.



_______________________________________________              _________________
                        Signature of Client                                                                  Date



















Appendix D: Resource Examples
Excerpt describing Internalized Homophobia Scale (Greene & Britton, 2012)
“INTERNALIZED HOMOPHOBIA SCALE Martin and Dean (1987) developed the Internalized Homophobia Scale based upon criteria for ego-dystonic homosexuality as defined by the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 1980). The nine-question instrument asks questions such as, “I feel alienated from myself because of my being lesbian/bisexual [gay/bisexual]” or “I feel that being lesbian/bisexual [gay/bisexual] is a personal shortcoming for me”. Items are measured on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree), with higher scores indicative of greater internalized homophobia. Originally written for gay and bisexual males, the scale has been expanded to also include lesbians and bisexual women (Herek, Cogan, Gillis, & Glunt, 1997). Internal consistency has been demonstrated to be adequate for gay men and lesbians (α = .85; .71, respectively), and validity is evidenced with IHP correlative to lower self-esteem and outness in gay men and lesbians (Herek et al.), and lower importance attached to community involvement, higher dissatisfaction with the local gay and bisexual community, and higher depressive symptoms in gay men. Cronbach’s α in the present sample was .90”.
Excerpt describing Cass Stage Allocation Measure (Greene & Britton, 2012)
“STAGE ALLOCATION MEASURE: The Stage Allocation Measure (Cass, 1984) consists of paragraphs describing characteristics typifying Cass’s theoretical stages of identity development and a noncoded or 0-coded description of heterosexual identity that begins, “You believe that you are heterosexual and never question this.” Stages of identity are defined as Stage 1 (Identity Confusion), Stage 2 (Identity Comparison), Stage 3 (Identity Tolerance), Stage 4 (Identity Acceptance), Stage 5 (Identity Pride), and Stage 6 (Identity Synthesis). The Stage Allocation Measure was determined by Cass (1984) to have content, concurrent, and construct validity. In her validity study, while some blurring was found between Stages 1 and 2 an between Stages 5 and 6, discriminate analysis evidenced stage differentiation and accuracy of stage sequencing through comparison with the Homosexual Identity Questionnaire, an additional instrument developed by Cass (1984). Participants rate themselves as to which description “best fits you currently” from 0 to 6. The Stage Allocation Measure (SAM) produces categorical data based upon self-definition, as well as a scale score of stage development given assumptions of linear progression.”
Excerpt Describing Experience of Shame Scale (Greene & Britton, 2012)
“EXPERIENCE OF SHAME SCALE Shame was assessed using the Experience of Shame Scale (Andrews, Qian, & Valentine, 2002), a 25-item questionnaire assessing characterological shame, behavioral shame, and body shame. The Experience of Shame Scale also includes a total score indicative of shame-based identity, which was used for this study. Characterological shame includes items involving shame and personal habits, shame and manner with others, shame about what sort of person you are, and shame about personal ability. Behavioral shame includes items referring to doing something wrong, saying something stupid, and failing in competitive situations. Bodily shame measures shame regarding one’s body. For each shame area presented, there are three questions addressing experiential, cognitive, and behavioral components. Items include “Have you felt ashamed of any of your personal habits?” and “Have you tried to conceal the sort of person you are?” with respondents answering from 1 (not at all) to 4 (very much). Total scores showed a high internal consistency (Cronbach’s α =.92), and test-retest reliability was .83. Validity was demonstrated by testing for depression using the SCL-90 (Derogatis, 1983) at time 1 and time 2 at an interval of 11 weeks. Both time periods evidenced significant moderate correlations, as well as a significant moderately high correlation between the Experience of Shame Scale and the Test of Self-Conscious Affect-Shame (Tangney, Wagner, & Gramzow, 1989). Cronbach’s α in the present sample was .95.”
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