Psychiatry

Interpersonal and Biological Processes

ISSN: 0033-2747 (Print) 1943-281X (Online) Journal homepage: http://www.tandfonline.com/loi/upsy20

Ethics, Risk Management, and an Intersectional

View of LGBT Mental Health

Richard Ruth

To cite this article: Richard Ruth (2017) Ethics, Risk Management, and an Intersectional View of
LGBT Mental Health, Psychiatry, 80:1, 99-102, DOI: 10.1080/00332747.2016.1275946

To link to this article: http://dx.doi.org/10.1080/00332747.2016.1275946

Published online: 14 Apr 2017.

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Psychiatry, 80:99–102, 2017 99
Copyright Ó Washington School of Psychiatry
ISSN: 0033-2747 print / 1943-281X online
DOI: 10.1080/00332747.2016.1275946

Ethics, Risk Management, and an Intersectional

View of LGBT Mental Health
Richard Ruth

Several years ago, the Washington
School of Psychiatry began work to bring
an awareness that our community was not
only far from immune to ethical problems
but in some ways a fertile medium for their
occurrence. Perhaps we should not have been
surprised; a psychodynamic community com-
mitted to engaging the new, unexpected, and
ever more complex clinical realities of the
contemporary mental health landscape
needs to be prepared and equipped for the
prodigious ethical challenges that come
along with embracing this professional ter-
rain.
Among the measures that have been
helpful was launching a series of yearly ethics
workshops. We did not want the too-typical
mental health ethics training that recites inti-
midating lists of ethical principles and stan-
dards to alienated audiences who
predictably, in response, emerge untrans-
formed. Rather, we wanted to craft ethics
learning that creates space for thinking and
to evolve our community toward a different,
better ethical center of gravity. We held the
hope that a critical mass of professionals,
from the Washington School community
and beyond, could come to see ethics codes
as tools, not obstacles, in our clinical and
research work and become empowered to
shape the evolution of the mental health pro-
fessions’ ethical frameworks.
This year’s workshop took up issues of
ethical challenges specific to work with les-
bian, gay, bisexual, and transgender (LGBT)
patients/clients. This focus stemmed from an
observation that more and more mental
health professionals in the Washington
School community hold LGBT-affirmative
values and are sought out by LGBT persons
for mental health services, but few clinicians
approach this facet of their work equipped
or grounded by depth of informed, reflective
training about what is entailed in work with
these populations. Importantly, we wanted
the workshop content to reflect the experi-
ences the broad community of mental health
professionals encounters working with a
range of LGBT populations, including per-
sons from diverse cultures, races, and ethni-
cities; diverse sexual orientations and gender
identities and expressions; and both privi-
leged and disempowered population sectors.
Flowing from and scaffolding this objective,
the content of the workshop drew heavily on
intersectionality theory (Cho, Crenshaw, &
McCall, 2013; Crenshaw, 1989, 1991) and
psychological work on multiple minority
identities (Nettles & Balter, 2011), and was
sponsored by the Washington School’s

Richard Ruth, PhD, is an associate professor of clinical psychology at The George Washington University and a
member of the faculty and steering committee of the Child and Adolescent Psychotherapy Program, Washington
School of Psychiatry.
This text is a summary of a Washington School of Psychiatry workshop that was held June 26, 2016.
Address correspondence to Richard Ruth, Center for Professional Psychology, The George Washington University,
1922 F Street, NW, Ground Floor, Washington, DC 20052. E-mail: rruth@gwu.edu
100
Center for the Study of Race, Ethnicity, and
Culture. We were pleased to have attendees
from counseling, nursing, psychology, and
social work backgrounds; a mix of early-
career and more senior clinicians; and collea-
gues working in LGBT health centers,
school-based mental health programs, and
hospital and community mental health set-
tings, as well as private practice.
The format of the workshop drew on
practice-based evidence (Barkham &
Mellor-Clark, 2003; Fox, 2003) the
Washington School has developed—that
mental health professionals often learn
ethics best through working with scenarios
drawn from clinical “real life” rather than
beginning from more abstract ethical rules
that don’t always map readily onto compli-
cated clinical realities. Small discussion
groups met four times throughout the day,
interspersed with large group discussions,
to afford time and space for reflecting on
and metabolizing the scenario material and
attendees’ experience of it. Stacey Dershe-
witz, JD, PsyD, and Michael Magenheimer,
PsyD, from The George Washington Uni-
versity, and Reginald Nettles, PhD, and
Nancy Reder, MSW, from the Washington
School’s Center for the Study of Race, Eth-
nicity, and Culture, facilitated these groups
and are owed a debt of gratitude.
Scenario topics included the following:
● A European American lesbian therapist
is treating a biracial lesbian medical stu-
dent. At first the therapy goes well, but
then an impasse develops when the
patient feels the therapist is misattuned
to both her racial and cultural realities
and her treatment goals, which focus on
managing stressors more than underly-
ing personality change. The therapist
seeks consultation from a senior, male,
heterosexual clinician and comes to feel
there may be a parallel process—that he
is misattuned to her in ways evocative of
the patient’s feelings of misattunement
in the therapy.
Washington School of Psychiatry Workshop Summary
● A newly graduated, male, cisgender,
heterosexual, White clinician in a com-
munity mental health agency seeks to
work with a transgender, African Amer-
ican patient with serious, multiple diffi-
culties—and substantial resiliency and a
history of positive treatment response—
whose previous long-term therapist has
left the agency. The therapist’s eagerness
is genuine but not aligned with relevant
training and experience; when this is
raised with him, he becomes anxious.
A supervisor/administrator struggles to
work out whether this willing clinician
is the right fit for the patient and, if so,
what kinds of preparation and support
can equip him for the work.
● A White, heterosexually married, U.S.-
born psychoanalyst has a gay son,
whom he wholeheartedly loves and
affirms. A professionally renowned,
White, European-born, post-surgical-
transition transgender woman seeks
him out for an analysis, which at first
seems to proceed productively. Difficul-
ties emerge when the analyst feels he has
inadvertently misgendered the patient,
and apologizes, and the patient reacts
with intense, seemingly disproportionate
anger at what she perceives, instead, as
his insensitivity to her social class and
cultural background. The analyst has to
consider whether unexplored issues of
shared privilege, his limited knowledge
of transgender issues, and possible over-
sights in his initial diagnostic formula-
tion of the patient may be involved in
the rupture that develops.
● A professionally successful dot-com
professional—an Asian American, HIV-
positive, and medically healthy gay
man—seeks treatment with a White,
out, gay male therapist. When the ther-
apy seems to stall, the therapist works
to confront whether unexamined thera-
pist/patient cultural and generational
differences, impinging countertransfer-
ences, and differences between what
the patient came seeking and what
Ruth
modality of therapy was offered may
be at play. The process is difficult for
the therapist and evokes defensiveness,
which he seeks to overcome through
consultation.
While the clinical complexity of these
scenarios initially seemed the compelling focus,
it became clear to the workshop participants
that there were also prominent ethical dimen-
sions and, indeed, that considering these offered
perspective on some of the clinical issues. We
came to appreciate that our professions’ ethical
principles commit us to proactively affirming
our patients’ diversity and to conveying our
respect for their lived experience and the various
components of their intersectional identities.
Our ethical standards invite clinicians to enter
into new areas of practice as long as we seek the
necessary education, training, supervision, and
consultation; mandate that we take ongoing,
affirmative steps to become aware of the limits
of our knowledge and competency and of our
biases, and to address these so that they do not
impair our clinical effectiveness; and insist we
ground our clinical work in up-to-date scientific
knowledge bases, while recognizing that the
kinds of patients who come to us and the
kinds of problems they bring in will constantly
change and evolve.
My process observation as workshop
leader (and as an out, gay psychologist) was
that our professions, if the workshop attendees’
experiences were indicative, have definitively
shifted in the ways we understand and work
clinically with LGBT patients, but that our
training programs too often have not gotten
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Barkham, M., & Mellor‐Clark, J. (2003). Bridging
evidence‐based practice and practice‐based evidence:
Developing a rigorous and relevant knowledge for
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101
ahead of this shift and recalibrated to provide
necessary training and leadership. Each work-
shop attendee was LGBT affirmative and
involved in work with LGBT clients and
patients; several identified as lesbian, gay, or
bisexual. At the same time, once we entered
into the work of the workshop, it became clear
to us that almost none of us had had training
that equipped us for the work we are under-
taking with LGBT populations but that this
need not be an impediment as long as we recog-
nize our training and professional development
needs and find ways to come together as com-
munities of clinicians, supported by our training
institutions and professional organizations, to
address them in their ethical as well as clinical
dimensions. Thus, our experience of being on
unfamiliar terrain together proved more
empowering than dislocating and led to shared
optimism that we can move forward, amid the
complexities and uncertainties that surround
us, as we step into more affirmative engagement
with the diversity of LGBT populations who
seek us out, grounded in a more confident
sense that our ethical values support and scaf-
fold our evolution than we had before this
workshop.
I close with a poignant personal
moment. Leaving the workshop, I passed
by the portrait of Harry Stack Sullivan—a
founder of the Washington School who
lived a brilliant, sometimes tortured, clo-
seted life (Blechner, 2005; Evans, 2006;
Perry, 1982). I think he would have been
amazed at our workshop, and delighted at
what the school he helped birth has come
to embrace and propel.
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work, and theory. Contemporary Psychoanaly-
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