“ Stepping up the Ladder in Safety ” : An Interpretative Phenomenological Analysis of how LGB Clients Experience Their Therapists ’ Sexual Orientation

Relevant literature has explored the issue of disclosure of Lesbian, Gay and Bisexual (LGB) therapists to heterosexual or LGB clients. But how do homosexual or bisexual clients understand and experience their therapist’s heterosexual orientation, known or assumed, in relation to the therapeutic alliance and the therapeutic process? In this qualitative study, we used the Interpretative Phenomenological Analysis to examine eight semi-structured interviews with LGB clients in a family-oriented therapy in Greece. Analysis revealed two themes of higher order, each having three subordinate themes depicting the client’s experience of the therapist’s sexual orientation: 1. Focus on the therapist’s sexual orientation: (a) as a hypothesis (b) as a factor of acceptance (c) as a factor of professional capability and 2. Focus on other therapist features: (a) gender (b) personality traits (c) practice of professional role. The therapist’s sexual orientation or the one perceived by the client was not a neutral issue in therapy and the cultivation of the therapeutic relationship but was only one part of the process. The way all these issues were processed and approached by clients was related to their personal history and phase of therapy. Suggestions for future research include conducting a research on clients from different therapeutic perspectives since it was carried out only on participants in long-term systemic family therapy.


Therapist's Sexual Orientation
The therapist's sexual orientation is an important part of therapy, especially when working with lesbian, gay and bisexual clients.According to Guthrie (2006), the therapist's sexuality or the one perceived by clients does not constitute a neutral issue in therapy as a therapist's disclosure might have an impact on various levels of the process and affect the client.Hence, the therapist's sexual orientation issue has been mainly addressed in literature with a focus on homosexual/bisexual therapists and the dilemma of whether and how to disclose their sexual orientation to lesbian, gay, bisexual or straight clients (see Russell, 2006;Carroll, Gauler, Relph, & Hutchinson, 2011;Guthrie, 2006;Moore & Jenkins, 2012).All research evidence points to issues of complexity and relativity that occur in these cases of disclosure as to whether it is intentional or unintentional, suggesting that there is no right or wrong answer and that each case should be treated separately.However, as in every case of a therapist's self-disclosure, therapists should always carefully consider the implications of disclosure on the therapeutic process as it might have both facilitative and impeding effects to therapeutic relationships (see Audet & Everall, 2010;Levitt et al., 2015).
The European Journal of Counselling Psychology ejcop.psychopen.eu| 2195-7614 In reference to heterosexual orientation, there are particular guidelines provided by the American Psychological Association to therapists working with lesbian, gay and bisexual clients (APA, 2012).To be more specific, heterosexual therapists are encouraged to reflect on and understand their personal prejudices and biases when working with homosexual clients and to be informed and trained on issues related to homosexuality.This constant flow of information seems to be important so that differences related to sexual orientation are not overvalued or devalued by therapists (Androutsopoulou & Economou, 2005;Bernstein, 2000;Green, 1996), taking into account the effects of stigma on LGB orientations (Kelleher, 2009).Also, in the field of family therapy, studies of lesbian and gay family relations offer new perspectives in traditional family therapy norms challenging many of its assumptions and showing how important it is to deepen the clients' understanding of lived experiences (Green, 1996).

Therapist's Sexual Orientation as a Criterion for Choosing a Therapist
Also, research has shown that some homosexual clients choose homosexual therapists because they think this choice will make them feel at ease, safe and accepted and that it will help them develop their sense of selfacceptance (Galgut, 2005;Jones & Gabriel, 1999).Other research has shown that homosexual clients prefer heterosexual therapists in order to avoid sexual attraction (Ryden & Loewenthal, 2001) and to openly express negative thoughts about homosexuality (Mair, 2003).Finally, some clients don't wish to know their therapist's sexual orientation, hence such disclosure of their sexual orientation can only take place after careful thinking and processing (Guthrie, 2006).

Other Features of Therapy
Although, as mentioned above, the therapist's sexual orientation is not considered an impartial issue in therapy, most evidence shows that there are other parameters and features of therapy that are very important when working with homosexual/bisexual clients.For example, factors such as the therapist's knowledge about their clients' difficulties which are related to homosexuality (Jones, Botsko, & Gorman, 2003), the view of homosexuality as non-pathological (Pixton, 2003) and the quality of the therapeutic relationship (Lebolt, 1999), all seem to play an important role for an effective therapy when working with LGB clients.

How Clients Understand and Process Their Therapist's Sexuality
However, there is not much understanding on how clients themselves experience and understand a therapist's sexual orientation and, more specifically, a heterosexual orientation, known or perceived.Existing research regarding LGB clients' therapeutic experiences is sparse and both nationally and culturally limited, focusing mostly on the UK and the US.In Greece, a qualitative research exploring in depth the therapeutic experience of five gay men has shown that neither the therapists' sexual orientation nor their gender seemed to be an important factor in terms of the therapists' perceived effectiveness (Spiliotis, Brown, & Coyle, 2011).However, this study involved a small number of participants which was limited to gay men.It aimed at enriching the existing literature through an in-depth investigation of psychotherapeutic experiences of both gay and lesbian clients in Greece and to explore their understandings and perceptions when working with heterosexual therapists, actual or assumed.As Bernstein (2000, p. 443) says, "When therapist and client differ in sexual orientation there is an initial sense of 'otherness'".But how, if it is felt, is this "otherness" perceived by the clients?Hence, an important question that arises is how a therapist's heterosexual orientation is being perceived or processed by a ho-Qualitative Analysis of LGB Clients' Experiences 212 mosexual/bisexual client and another is how this experience is related to the therapeutic relationship and process.

Aim of the Study
The aim of our research was to "give voice" and understand in depth how homosexual/bisexual clients experience their relationship with a heterosexual therapist.We focused on the personal and subjective understanding of a therapist's sexual orientation as perceived, imagined or understood by clients.Our qualitative study's specific research questions were: 1) How do homosexual/bisexual clients experience their relationship with a heterosexual therapist?2) How does a therapist's sexual orientation relate to clients' perception of the therapeutic relationship and process?

Method
The method we used was the Interpretative Phenomenological Analysis (IPA).This qualitative research method focuses on the way people give meaning to their lives based on their lived experiences (Smith et al., 1999) and tries to develop a rich and in depth understanding of the perspectives of participants, with an interpretive account (Smith, Flowers, & Larkin, 2009;Smith & Osborn, 2003).Hence, the understanding of the experience is phenomenological in the sense that it not only focuses on the experience per se, but it is also interpretative as the researcher tries to interpret and make sense of the individual account of a person who tries to interpret themselves (Smith et al., 2009).Also, this approach takes into account issues of complexity and relativity while understanding that individual accounts are embedded in the social and cultural context in which they are generated (Larkin, Watts, & Clifton, 2006).Finally, IPA, as a form of qualitative research, creates and enhances links between research and clinical practice (see McLeod, 2001).In a number of qualitative inquiries that used IPA on both clients' and therapists' accounts (Friel, 2016;Tapson, 2016;Thompson & Cooper, 2012), the results enriched theory and could be applied to counselling and therapeutic practice.

Procedure
Participants were informed of the confidentiality procedures and they all read and signed their informed consent prior to the interviews.Research questions were open, focusing on the participants' personal accounts and allowing their inner experience to be expressed.The interview questions reflected the process by focusing on the concepts of meaning and understanding.Also, emphasis was given to probing questions about the issues of time, space and embodiment; for example, by asking how the clients' experience changed over time and in the context of therapy (e.g.individual or group therapy) and whether they could mention a somatic experience or feeling.

Materials
The interview was semi-structured and the questions were the following: "Have you made an assumption about your therapist's sexual orientation?","How did you process this assumption and what did it mean to you?", "Which were the criteria of choosing your therapist?","What were the aspects of the therapeutic relationship that were more helpful to you?", "Where there any aspects of the therapeutic relationship that were not helpful to you?", "Which aspects of your therapist's personality did you find more helpful?".

Participants
The participants recruited came from the researchers' professional network and two out of the three researchers were their actual therapists.However, the interviews were organised in such a manner so that a therapist would not interview one of his clients.Participants were also informed that their therapist would not have access to the recordings and that their personal information would be changed for anonymity reasons.Eight people in total were interviewed; five of them were male and three female, five gay men and three bisexual women and their age ranged between 28-45 years old (see also Table 1).They were all in long term systemic familyoriented therapy but in different stages of the therapeutic process.None of the participants started therapy in order to address their sexuality.The specific initial concerns are not mentioned here for anonymity reasons in order to avoid identification of the clients.

Analysis
A line by line data analysis revealed individual themes at the same time, maintaining a sense of the whole, while a cross-case analysis captured the interconnected high-ordered and lower-ordered themes that will be presented in this article.The researchers reflected on their own experiences and were aware that their perceptions could only be partially bracketed from their analysis of the data (Smith et al., 2009).A separate analysis from the three researchers was conducted and the themes presented here were developed through discussion and negotiation.Specifically, their effort to reassure the research's quality was based on the guidelines of Elliott, Fischer, and Rennie (1999): self-reflection, situating the sample, grounding in examples, providing credibility checks, coherence and resonating with the reader.
Qualitative Analysis of LGB Clients' Experiences 214

Results
The analysis revealed two high order themes each connected to three subordinate themes, briefly presented in Table 2.The therapists' sexual orientation as an assumption.8 out of 8 The therapists' sexual orientation as a factor of acceptance.8 out of 8 The therapist's sexual orientation as a factor of capability 6 out of 8

Focus on other therapist features 8 out of 8
Therapist's gender 7 out of 8 The therapists' personality attributes 8 out of 8 Therapist's enactment of the professional role 6 out of 8 Both first-order and secondary-order themes will be presented in more detail in the following section.

Focus on the Therapist's Sexual Orientation
This specific theme refers to the different ways clients processed and experienced their therapist's sexual orientation.Most clients had a prefixed idea or assumption about their therapist's sexual orientation that did not seem to play an important role either in the process of selecting a therapist or in the therapeutic relationship.
However, this assumption seemed to be an important factor of acceptance and for some, a factor that was related to therapeutic capability.Three distinct factors that were identified as secondary order themes are presented below:

The Therapist's Sexual Orientation as an Assumption
This theme reflects different assumptions and thoughts that clients have about the therapist's sexual orientation.All clients seemed to have questioned or made a hypothesis about the therapist's sexuality.However, the way each of them processed and tackled with this assumption differed.
Lidia had a prefixed idea before meeting her therapist that he would be gay, since there is a stereotype that men psychotherapists are usually homosexual.This assumption seems to have changed after their first meeting, showing that the therapist's sexual orientation becomes less important over time.Hence, although sexual orientation initially was an issue for Lidia, this changed when other therapeutic factors came to the surface.
Lidia: "Well yes…When I first went to therapy, I assumed that he was gay because of the subject and the fact that very few men are therapists.Nevertheless, I went to the session with this thought in mind…This was before the session, but after it was finished I was not sure after all...I actually did not care and just delved into my issues." In Stefanos's case, the stereotype of a homosexual male therapist becomes apparent once again, as well as the assumption that the female therapist was married and had a child with a man.These stereotypes, as men-Bafiti, Viou, & Tarasis 215 tioned above, play a role at the beginning of therapy in a phase where a therapeutic relationship has not been established yet.Also, Stefanos seems to be concerned with other people's sexual orientation, including his therapist's, in an effort maybe to accept his own.
Stefanos: "I knew that she was married and had a child before going to therapy, but I don't think we are much different because of that… However, I did wonder about the male therapist's sexuality because of the existing stereotype that people working in theoretical professions such as psychology and philosophy are usually gay (…) I always wonder about the sexuality of people I meet.I don't know why I am interested in that kind of information, it isn't gossip though." The Therapist's Sexual Orientation as a Factor of Acceptance This sub-theme reveals how the clients' perception of a therapist's sexuality is related to the issue of being accepted by the therapist, as well as to self-acceptance and understanding of sexuality as part of a person's identity: For example, Vicky said her therapist's non-judgmental reaction regarding her sexuality was very important to her indicating that she was expecting and was actually afraid of a different reaction.For LGB clients, including Vicky, the acceptance of one's sexual identity is a very serious issue.She seemed prepared to see a negative reaction on her therapist's face when she "came-out".However, her therapist's acceptance was the initial step towards building a strong therapeutic relationship: Costas: "The fact that two straight persons had no problem at all with gay people helped me understand that not all straight people are homophobic and to accept myself even more."

The Therapist's Sexual Orientation as a Factor of Capability
Vicky refers to her therapist's sexual orientation and, more specifically, to the perceived heterosexual orientation as a factor of capability since she believes that being homosexual might cause a therapist to be subjective and influenced by his own issues.This indicates that an internalized stereotype of homosexuality is related to the therapeutic relationship but in a reversed way than we might have expected.

Vicky: "I don't mean to sound racist, but I think that if the other person is straight then they are more
objective and open-minded (…) because homosexuality is something that is repressed, and, in my mind, therapists are human beings like everyone else, so they might as well express some kind of weakness." Katerina said that, although she wanted her therapist to be happy, she thought that if she (her therapist) was a lesbian she would have her own issues to deal with.This shows one more time the internalized stereotypes about homosexuality that Katerina and other LGB clients express: Qualitative Analysis of LGB Clients' Experiences 216 Katerina: "I wanted her to be happy and in love; I did not care if she would be in a relationship with a man or a woman, she was a role model to me (…).However, if she was a lesbian, she could have her own issues and difficulties to deal with… I don't know, maybe I also felt safe that being straight she would not have any sexual feelings for me and vice versa."

Focus on Other Therapist Features
This second higher order theme focused on and referred to other attributes of the therapist that interviewees considered important in the therapeutic process and in cultivating a strong therapeutic alliance.These attributes were the therapists' gender, their personality traits and the ways they act in their professional role.

Therapist's Gender
Most clients had a preference on the therapist's gender and also acknowledged it to be an important factor in the therapeutic process and the relationship with their therapist.However, the way each client thought of gender influenced their choices related to their personal history.
To start with, Panos focused on specific female or male features.In this case, we see stereotypes about gender being expressed that are related to issues of capability or personality:

The Therapist's Personality Attributes
This sub-theme focused on specific personality traits that clients considered important in the process and their relationship with the therapist such as humour, morality and stability.
For example, Costas thought that a therapist's calmness and other personality features were important to him.
All these features were related to the admiration he seemed to feel when talking about his therapist and could also have been a part in the process of building a secure therapeutic alliance: Costas: "Her calmness, and the fact that she was soothing and confident, made me feel that she was always stable and self-assured.

Therapist's Enactment of the Professional Role
This sub-theme refers to the different ways clients process the therapist's professional role and the different ways in which this influences the therapeutic process.
For example, Katerina mentioned that she appreciates the fact that her therapist sets boundaries without being too rigid, as well as the way she handles the coexistence of many clients in a group.This shows how boundaries together with empathy can create a safe place, a safety net in the therapeutic context in which the therapeutic relationship could flourish: Katerina: "I like that she sets boundaries.She shows professionalism, but at the same time allows me to go crazy (…).What also helped me was that she cared for other people in the group as well.In the beginning it was hard, but after a while that made me feel safe and understand that she is a good per-son… She does not leave someone behind.I appreciated her because she helped the other members as well and I learned not only from her sayings but her actions as well." Panos also referred to the issue of flexible boundaries: Panos: "I appreciated that she was not cold but professional.I would not have liked it if a therapist was strict and set very rigid boundaries.She does set boundaries and gives me a context, which is important but not that rigid ones."

Metaphorical Images
Interviewees were also asked to think and describe a metaphorical image of the therapeutic relationship.The reason for adding a metaphorical image of the therapeutic relationship was to further explore their experience on the therapeutic alliance and identify whether it was related or not to therapists' sexual orientation.None of the participants made a reference to the therapist's sexuality as playing a role in the image they had about the therapeutic relationship.In contrast, all metaphorical images, regarding the therapeutic relationship, referred to Qualitative Analysis of LGB Clients' Experiences 218 the alliance with the therapist, the feeling of security in therapy, the personality of the therapist and her professional role.Two of them are illustrated below: George: "I don't know why, but it just crossed my mind; it's like the therapist holds a ladder and I am stepping up the steps while she is holding it for me." Interviewer: "And how do you feel?" George: "I feel insecure, but then I look down, I see her and I feel better and safer that she is there to hold the ladder for me." Costas: "Therapy is like giving birth; even though our parents bring us to this world and we are their biological children, therapists and therapy itself can help you learn how to live, to discover what life is all about and at the same time discover yourself.I think a therapist is like a parent who brings you to life emotionally."

Discussion
The analysis of the research material showed two higher order themes, each including three sub-themes: 1.
Focus on the therapist's sexual orientation: (a) as an assumption, (b) as a factor of acceptance (c) as a factor of capability and 2. Focus on other therapeutic attributes: (a) the therapist's gender (b) the therapist's personality attributes (c) the therapist's practice of the professional role.
The findings of our research reveal the diversity, complexity and wealth of the LGB clients' experiences related to a therapist's sexual orientation.These findings are in accordance with Guthrie (2006) who highlighted that a therapist's sexual orientation is not a neutral issue in therapy and has an impact on the therapeutic process.
More specifically, our analysis showed that the therapist's orientation might be perceived and processed as a question and hypothesis, as a factor of acceptance and/or therapeutic capability, especially in the early phases of therapy.In some cases, the known or assumed heterosexual orientation of a therapist seemed to be connected with both a greater self-acceptance and a therapeutic capability.
Also, our analysis highlighted the fact that, although for clients the relationship with their therapist could enhance their self-acceptance (Galgut, 2005), the therapist's sexual orientation was not an initial criterion of choice.In some cases, the non-explicit disclosure of therapists' sexual orientation, whether homosexual or heterosexual, seemed to be helpful for some clients as they expressed their wish "not to know" supporting also Guthrie's point of view (Guthrie, 2006).
The study's findings also agree with the current literature, stressing the importance of a therapist's knowledge and information about issues and difficulties related to homosexuality (see, for example, Jones, Botsko, & Gorman, 2003;Bernstein, 2000;Spiliotis, Brown, & Coyle, 2011), a non-pathological view of homosexuality (see Pixton, 2003) and the quality of the therapeutic relationship (see, for example, Lebolt, 1999).Furthermore, one very important feature related to the clients' experience of the process and the therapeutic relationship is their therapist's gender, which seems to contribute to an initial judgment regarding their competency while the meaning attached to it depends on the clients' experience and history (Harris & Busby, 1998).
Finally, some other features of therapists seem extremely important for the experience of therapy and are perceived by clients as helpful.These are: empathy, use of self-disclosure, genuineness, warmth, flexibility, confi-  Hilsenroth, Cromer, & Ackerman, 2012).The current analysis highlighted additional characteristics and personality traits of therapists that contributed to the therapeutic relationship.These were: humour, morality, calmness and stability.Also, another feature that seems to be important for all clients is the way a therapist enacts and conducts their professional role with the most important of all being the setting of boundaries in the therapeutic context.The perception of these attributes as most helpful highlights the importance of a therapist's "human identity" that makes him a person with specific personality attributes who accepts, empathises and enacts their professional role.
At this point, the situated character of our study should be acknowledged.It is a research conducted in Greece, positioned in a specific historical and social context reflecting particular ideas about counselling, psychotherapy and sexual orientation.The social and national context, cultural ideologies and socially induced stressful conditions for LGB people seem to play an important role in the way LGB issues are being experienced and understood (see, for example, Kelleher, 2009).
Finally, it should be mentioned that our choice of a semi-structured rather than an open-ended interview schedule had possible constraints on the data provided by the research.But we made this choice because of the specific topic's sensitivity, and because we wanted to have a specific focus on the interviews and help the participants speak freely about their therapist's assumed orientation.However, we acknowledge that this decision restricted the richness of information that could be provided if the participants were given the opportunity to delve into and speak freely of their experience.

Implications for Counselling and Future Research
The study's results can also be applied, inform and have an impact on counselling and the therapeutic practice.
Although this research explored the experiences of LGB clients in Greece, all findings could be expanded to other European countries as well, raising awareness for counsellors and encouraging further research.Specifically, in this study, the different experiences of homosexual/bisexual clients were given voice to be expressed, thus enhancing our understanding of the role that a therapist's orientation plays in the therapeutic relationship and process.Since we are all researchers and counsellors with clinical experience, we consider it essential that we further explore any implications of the therapist's sexual orientation, actual or assumed on the client's.Hence, making this way an initial step to fill the gap in bibliography.These questions were initially raised from our professional experiences, since we all have been preoccupied with the impact of our perceived sexual orientation to therapy with LGB clients, and this research was an opportunity for us to delve more into it.The findings enrich the counselling practice and suggest that therapists' sexual orientation, homosexual or heterosexual, might not be a neutral issue in therapy so special attention should be given to the issues of explicit disclosure.The findings of this study add to the literature on self-disclosure, acknowledging that therapists should carefully and with caution reveal information about themselves (see Henretty et al., 2014;Levitt et al., 2015).
However, the research also highlights the issues of gender, personality attributes and enactment of the professional role that also seem to play an important role in the therapeutic alliance and process and in the client's experience of therapeutic change.Specifically, in some cases, therapists could give room to address these issues so that clients could process in more depth the meaning they give to the issues of sexuality.Also, this study shows the importance of the "human identity" of both client and therapist, stressing once more the signifi-Qualitative Analysis of LGB Clients' Experiences 220 cance of the therapeutic alliance and treating each case separately taking into account the history of the client, the personal importance attached to the issue of sexual orientation and the specific phase of therapy.
Furthermore, our findings showed that this information might be processed in a different way, depending on the client's phase of therapy.More specifically, in a more advanced phase of therapy or after completion of therapy, the clients seemed to be able to incorporate in a more coherent framework not only their own sexual orientation as one part of their identity but also process the therapist's orientation as a small part of their identity.Also, the clients who were in a more advanced phase of therapy seemed to be reflecting on the experiences of therapy in a more holistic and synthetic manner.However, since the number of participants was small, we suggest further research on the subject in order to understand more thoroughly the diversity of the clients' experiences in different therapeutic phases.
Finally, this study highlighted the complexity and richness of the LGB clients' experiences, which are related to their therapist's perceived or known sexual orientation.In future research, it would be interesting to explore the lived experiences of heterosexual clients with therapists who have a different sexual orientation.Also, since all the participants were in a long-term systemic family therapy, we suggest that further research could focus on clients being offered different therapeutic perspectives.
for me, what matters most is for the other person to be heterosexual, open-minded and accepting.When I told my therapist that I am bisexual, I did not see any grimace on his face.He reacted as if it was the most natural and normal thing in the world and that was enough…" Also, Costas expressed how his therapist's acceptance changed his beliefs about straight people and added to his self-acceptance.This indicates the importance of his internalized fear of rejection because of his sexual identity:

Table 2 Findings Summarized High order themes / Subordinate themes Number of participants endorsing the specific theme Focus on the therapist's sexual orientation 8 out of 8
Lidia mentioned that humour and other features were very important in making her feel comfortable and talk about her thoughts and feelings.She acknowledged how the fact that her therapist had some extra pounds made her feel like he was a human she could relate to.This was also part of the therapeutic relationship: It was like she could always keep her temperament and take control of a situation.Also, what was very important to me was the fact that she did not become a psychologist just to become rich; instead, she has high standards and ethical values and what she truly wants is toBafiti, Viou, & Tarasis 217 The European Journal of Counselling Psychology 2018, Vol.7(1), 211-223 doi:10.5964/ejcop.v7i1.139help people.She has ethics; she is moral and a well-educated person with goodness and many values and virtues."ces and protected me even from my own self.I also loved her sense of humour." Some of these features have already been identified in other researches (see, for example,