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September 2009 – Tips & Topics

Volume 7, No. 6
September 2009

In this issue
— SAVVY – Understanding Sexual Minorities

— SKILLS – “Transgender, Transvestite, Transsexual”

— SOUL – Attractivism!

— STUMP THE SHRINK – Motivational Interviewing; The Among people

— SHAMELESS SELLING – Getting Healthy in 2010!

— Until Next Time

Welcome to the September edition of TIPS and TOPICS. Thanks for reading.


The behavioral health field has focused on cultural competence, working with ethnic minorities, other cultural groups based on religious background, age, gender, social class, education level, parental status and justice system involvement.  But earlier this month at the Cape Cod Symposium of Addictive Disorders in Hyannis, Cape Cod, Massachusetts, one workshop caught my eye: “What Every Counselor Needs to Know When Working With Sexual Minorities.”  This was one minority population I have a lot less experience with and don’t hear talked about as much.

Rather than summarize some of the highlights myself, I thought I’d let an expert do that much better.  So I asked Joseph M. Amico, M.Div., CAS, LISAC to draw from his workshop and guest-write this month’s SAVVY section. Each of his five points is rich with information but these just scratch the surface.  Nevertheless it’s a good start to getting educated about sexual minorities.


** Top Five issues counselors need to know when working with sexual minorities

ONE:  Be aware of today’s accepted terminology for this population:
–> Lesbian
–> Gay
–> Bisexual
–> Transgender (an umbrella term that includes cross dressers and transsexuals)
–> Questioning
–> Queer (a preferred term by younger generation even though older GLBT’s may wince)
–> Intersex (for more info- go to the Intersex Society of North America –
–> 2S  (Native American term for Two Spirited individuals considered twice blessed for having special insight into both male and female spirit.  Often chosen as the Medicine Man, Medicine Woman or Shaman for the tribe)

TWO:  Best Clinical practices indicate that you NOT work with this population if your religious or moral values dictate that homosexuality is sinful, an abomination, “sick” or that homosexuals can change (known as reparative therapy which is not accepted by American Psychiatric Association or Psychologists).

THREE:  Familiarize yourself with the Stages of Coming Out:

Several Theoretical Models are available:
–>  Most popular is Vivienne Cass’ version which is explained with examples in the book “10 Smart Things Gay Men Can Do To Improve Their Lives” by Joe Kort
–>  Another accessible version is in the book  “Counseling Lesbian, Gay, Bisexual, and Transgendered Substance Abusers:  Dual Identities” by Dana Finnegan and Emily McNally
–>  Also see articles by Eli Coleman, University of Minnesota, Program on Human Sexuality

FOUR:  Be aware of cultural and ethnic differences in understanding.
–>  African American men who are married and have sex with men often refer to themselves as “on the Down Low” or “DL” and do not identify as bisexual or gay
–>  Latino/Hispanic men who engage in anal sex will often say the “top” or anal inserter is not gay, while the “bottom” or anal receiver is considered gay.
–>  In addition to Two Spirited, other Native American terms include Third and Fourth Gender (see Will Roscoe’s book, “Changing Ones: Third and Fourth Genders in Native North America” )

FIVE: Know the difference between Homophobia and Heterosexism
–>  Homophobia is defined as ‘the irrational fear of homosexuals’
–>  Most of the time we really mean heterosexism, which means a prejudice or bias against LGBT individuals just like racism, ageism, classism and sexism.

Joseph M. Amico, M.Div., CAS, LISAC
Senior Consultant, Brattleboro Retreat
President, NALGAP:  The Association for Lesbian, Gay, Bisexual, Transgender Addiction Professionals and Their Allies


Here are some more clinical tidbits that came from “What Every Counselor Needs to Know When Working With Sexual Minorities.”


  • Distinguish between “transgender”, “transsexual” and “transvestite

–>  “Transgender ” is an umbrella term that includes cross dressers and transsexuals

–> “Transsexual” and “Transvestite”- Here’s a quote from Miss Noxzema Jackson which explains simply in lay language, the other two terms”:

“If you wear the clothing of the opposite sex, you are a transvestite.  If you believe you are a member of the opposite sex and have your plumbing rearranged accordingly, then you are a transsexual,  If, however, you have more fashion sense than should be allowed by law, then you are a drag queen.”

Here is another quote that was shared at the workshop which helps empathize with those in sexual minorities:

“When I was a kid, everyone else seemed to know they were boys or girls, men or women.  That’s something I’ve never known, not then, not today.”
Kate Bornstein, author of “Gender Outlaw”.

  • Include psychosocial questions in assessments to address sexual minority issues where necessary.

    Once you have screened for sexual minority issues, here are some questions to further understand your client’s history and experience:

    –>  How old were you when you had your first thoughts about being gay (or lesbian, bisexual, transgender)?
    –>  How old were you when you first acted on those thoughts?
    –>  Describe for me your first sexual experiences (may or may not be the same as the previous question)
    –>  When was your first sexual experience with an adult?
    –>  Who are you “out” to? (Be sure to ask about friends, family or work companions to whom you have opened up about your sexual orientation)
    –>  How do you feel about being gay?
    –>  If you could change your sexual orientation, would you?


Sometimes when listening to a speaker they make a point which totally changes how you view something from that time on.  It can be a pleasantly surprising nugget of truth. It can be a disturbing, discombobulating awareness you weren’t quite ready to hear.

When I heard Joe talk about the difference between Homophobia and Heterosexism (see point #5 above in SAVVY) it was one of those pleasant surprises.  I am fascinated with how our language reveals our underlying attitudes.  So when Joe illuminated that most of the time when we use Homophobia, we really mean Heterosexism it got me thinking.  I think he is right that what is really going on is a prejudice or bias against LGBT individuals just like racism, ageism, classism and sexism.

If a major feature of the “isms” is inequality and rejection of people who are different from the majority population; or different from those who the prevailing culture deems superior, then I can think of another “ism” that I don’t hear talked about much: “Attractivism”.  I mean physical beauty in contrast to that inner attraction of a beautiful mind or personality. I don’t know if that is a recognized term. In fact I Googled it and found only one site where they seemed to be using it in the way I mean.

What keeps a lot of people down is that they don’t fit the prevailing cultural view of what is physically attractive, whichever culture you are in.  With Attractivism what elevates people unequally above others is not their inherent beauty but their external appearance.  I’m not railing against that as if it is evil to enjoy “eye candy” – being attracted to looking at someone physically beautiful.  But I am saying that Attractivism creates a lot of self esteem problems for people who feel like the ugly duckling; hurts a lot of people who don’t fit the model-thin stereotype or the buff, muscular hunk, or whatever is “attractive” in your culture.

I don’t want to feel guilty for enjoying “eye candy”, but it is good to remember that beauty is in the “eye of the beholder” and that candy rots your teeth.


The Question:

Dear David:

“I’d love you to comment on regarding cultural considerations when using Motivational Interviewing.  The problem situation we’re working on is how to adapt Motivational Interviewing with Hmong clients who are culturally bound to respect the opinion of “the expert” over their own.  In the below scenario the client has presented at a Mental Health clinic on the advice of her medical doctor who, after running various tests, strongly suspects clinical depression.

The client is first motivated by family – she will want to do whatever she needs to do in order to fulfill her role within the family and by extension her culture.  That is very clear and really quite easy. This is her motivation.

Now, how she gets there is trickier because she will defer to “the expert” in all situations (hierarchical thinking and problem solving). In the first instance, the Shaman was the expert – she didn’t get better, but that isn’t because the expert was wrong, it’s because that wasn’t the problem (Spiritual stuff now ruled out – it’s not the demons). The doctor was the next expert, but although he couldn’t help, he also wasn’t wrong, it’s just that physical stuff couldn’t have been the problem (physical stuff ruled out).

It makes perfect sense to visit with a mental health counselor now, because it must
be a mental problem. Now, she will think that in order to get better, she must do whatever the expert tells her to do. This means that when asked what she wants to do, she doesn’t know, and is confused because the expert is supposed to know.

This comes out in the interview.  If we adapt the technique so that the questions aren’t so open, but are more like picking from a range of options, is that still motivational interviewing?  Even when this is done, she will still not just pick one that “sounds good” to her, because it’s not about what sounds good to her, it’s about what sounds good to the expert.

So, at some point the expert must recommend one to try – see if it works and if not, we can try another.  So, in the interview the client chooses the option that the counselor recommends because that’s what she wants – to do what he recommends (he’s the expert). The question is, then, if the counselor recommends a treatment option, and the client goes with it because she is motivated to do whatever the expert recommends, is that still Motivational Interviewing?

Ultimately the Q & A could be (in an abstract sense):

Therapist: What do you want?

Client: I want to do what you think I should do because you’re the expert.

T: You want me to tell you what to do?

C: Yes, you’re the expert, tell me what to do.

T: Because I’m supposed to be the expert, I should be telling you what to do?

C: Yes, I came here for your help.

T: In that case, I recommend X.  If it doesn’t work, we can figure out what Y and Z would be (your next options).

C: Then I’ll do X.

T: You want to do X?

C: If you are recommending X, then I want to do X.

T: Ok, let’s do X.

C: Ok, I will.

Is this still client-centered treatment planning and motivational interviewing?  I would contend that it is, because it’s what the client wants. But what do you think?


Russ Turner, MA, MS.
Training Manager, People Incorporated Mental Health Services
St. Paul, Minnesota

My Response:

Hi Russ:

Good question and the last part you did with the therapy session dialogue is right on from my viewpoint.

The purpose of Motivational Interviewing as I apply it, is to make sure you have a working alliance with the client (= agreement on goals and strategies within a working emotional bond). If the client agrees on the goal (= to get better to fulfill her role in the family); agrees with the methods (= whatever the expert says); and is in a good working relationship with the therapist, then you have an alliance, which is the greatest contributor to the outcome.

If the “expert’s” methods aren’t working, then we change what we do, which is what all outcomes-driven work should do.  Such a client will stick with you until the outcome is positive. Her culture compels her to listen and do what you say until she doesn’t need you anymore or until you can’t help her.  At that point you would send her to another “expert”.

Let me know if this helps or not.

Davidstrong>Follow-up Comment:

Hi David,

Thanks for your reply and for helping us clarify this.

Upon reviewing this material I conclude that folks sometimes miss that one of the main purposes of Motivational Interviewing is to create a therapeutic alliance (agreement on treatment goals and methods) and a partnership that fosters trust.

If the client feels listened to, that her treatment options were explained to her, that she had the opportunity to ask questions, and that her input into the treatment plan was important (even if minimal), then you have a client-centered approach consistent with the tenets of Motivational Interviewing.



Many of you know I am a Senior Advisor to The Change Companies, along with Dr. Jim Prochaska (Stages of Change) and Dr. William Miller (Motivational Interviewing).

The Change Companies’ overall mission and business is to help you help your population make positive life change. They do this by developing curricula and other materials for the fields of health improvement, prevention, addiction treatment, impaired driving and criminal justice. The vehicles they use to deliver this “education” ranges from print and electronic media, website design and video production to consulting and training.

A good friend recently shared with me her view about what consititutes good health, and a positive life. It consists of 3 essential things:

  • What We Eat
  • What We Think
  • How We Move.

Each month I write Tips n Topics as one vehicle to support you in helping you help your population make positive change, particularly in the mental and emotional health arenas- the “What We Think” arena.

Always looking forward, and committed to holistic health, The Change Companies is offering a new product around the “What We Eat” & “How We Move” arenas of life.

So ask yourself these questions:

–> Am I in balance around the 3 areas of health?

–> Have I got too much on my plate?

–>Do I have a really Full Plate in what I take on?

Have some fun & check this out this link!

Until Next Time

See you in late October.


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