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from What do clinical studies say?
Treatment of Male Homosexuality:
A Cognitive-Behavioral and
Interpersonal Approach
A. Dean Byrd, Ph.D.
The author is Vice President of NARTH and holds a position as a clinical professor
of psychiatry at the University of Utah.
It is difficult to accurately label therapeutic approaches to
treatment, because there are few purists among us. That is,
although we might label what we do as reparative therapy,
how we actually intervene may vary from therapist to therapist.
The term I most often use for my own work is "gender-
affirmative therapy."
Although I do not have extensive training in the psychoanalytic
model of treatment, I do find the reparative, psychoanalytical
approach to be helpful theoretically and conceptually.
But the practical approach to treatment that I have
adapted for use with homosexual men over my work of the
past twenty years would most aptly be described as cognitive-
behavioral/interpersonal.
I have found the cognitive-behavioral interventions to be
useful in working with the symptoms, while interpersonal
interventions provide the key to real healing. Although I
appreciate the importance of childhood development, I
have found it useful to place a greater emphasis on the biopsycho-
social explanations for homosexual development.
Childhood development, in this model, likely provides the
context in which temperament and personality traits interact
with family and social surroundings to usher in the
emergence of an individual's sexuality.
Perhaps I should first describe the patient population that I
have treated for more than 20 years. They primarily have
been men between the ages of 30 and 45 who have spent
significant time in the gay lifestyle and have been unhappy.
Many describe the lifestyle as being unfulfilling, lonely,
depressing, distracting, and lacking in meaningful relationships.
Frequently, I hear these men say that homosexual
activity serves as an antidepressant for them.
Before I focus on several specific interventions, I will
describe the treatment approach that I have found to be
helpful. I have divided treatment into four phases. Please
note that these phases are not discrete but are very adaptable
and flexible; however, they do represent the general
flow of therapy. As with all therapies, the patient must
have some degree of motivation, must come to understand
the origins of his homosexual attractions and must be fully
committed to the therapy process.
PHASE I
The prerequisites noted above are determined during the
first phase of treatment. During this phase, a thorough
assessment is completed, taking into account the possible
presence of psychological disorders
that may co-exist with
homosexual struggles.
I frequently find varying
degrees of narcissism,
dependency, hysteria, anxiety, and depression. A
social/sexual history is a "must" during this phase and is
routinely completed. I always conduct the sexual history in
the contest of the social history because I want the patient
to conceptualize his struggle in this perspective. For many,
this provides a new look at an old struggle.
Emphasis during this phase is placed on the patient's global,
social and emotional functioning and does not focus narrowly
on the patient's homosexuality. Frequently, information
is shared about the origins and treatment of homosexuality
and questions are entertained about change and
"cure." Journaling begins in this phase and is used
throughout the treatment process.
PHASE II
Phase II is characterized by a strong behavioral approach.
The goal of this phase of therapy is to help patients organize
and stabilize their lives. A clear majority of these men
are "out of control." Efforts are made through behavioral
strategies to help them gain some control. In this phase,
behavioral control is viewed as a prerequisite to behavioral
change. Patients are helped to set behavioral goals to
improve socially, intellectually, spiritually, emotionally,
physically, and sexually. Specific interventions might
include monitoring, reinforcement strategies, distraction,
modeling, response inhibition and paradoxical
strategies. The individual is empowered through selfcontrol.
The establishment of control, experience of success
and some degree of stability are important in this
phase of treatment.
PHASE III
Phase III focuses on interrupting homosexual arousal patterns.
The emphasis during this phase of therapy is to help
the patient explore, interrupt and eventually break the
homosexual arousal processes. During this phase of treatment,
the focus shifts from a behavioral to a cognitive
emphasis. Cognitive interventions such as relaxation and
guided imagery are used to help patients become more
aware of and gain control over their cognitions, fantasies
and feelings.
Interventions such as emotional tracing, defragmentation,
and discrimination of feelings are employed to interrupt
the neuro-psychological processes. Many of these men
have sexual addictions and emphasis is placed on correcting
faulty belief systems, breaking myths, expanding
options for being nurtured, handling anxiety and developing
a lifestyle that is congruent with personal values.
Patients are taught how to ask for help and how to develop
self-affirmations.
PHASE IV
During Phase IV of treatment, a combination of individual,
group and family therapy approaches may be used
depending on the needs of the patients. The emphasis during
this phase of treatment is quite affective and interpersonal
and is geared at helping patients better understand
and engage in the appropriate relationship process (i.e.,
friendship, non-sexual intimacy with men).
Problems with intimacy, self-worth, self-love, love of others,
love of God, defensive detachment, distortions
(unequal relationships with men as well as intensity in relationships),
developing non-erotic support systems with
men, assertiveness, anger (with men and women), masculinity,
guilt, shame, loneliness and abandonment are
explored and resolved in a group therapy context.
Frequently, during this phase, I introduce each patient to a
married couple to function as special companions. Desired
outcomes include the absence of homosexual behavior,
reduction or elimination of homosexual attractions, a sense
of congruence or inner peace resulting from integration,
and development of comfortable and appropriate relationships
with men and women. Spiritual (not religious) interventions
are frequently used in this phase (although they
may be employed in the other phases, too.)
Now, with this summary, I would like to briefly describe
several of the interventions noted above.
- Journaling
- Emotional tracing
- Defragmentation
- Spiritual interventions
Journaling
Journaling is a useful way of helping homosexual men clarify
their thought processes, experience and release their
feelings, and generally explore issues in their lives. Instead
of letting thoughts buzz around in their head, they make
journal entries.
Initially, in the process, most of these men use journaling as
a way to monitor their homosexual thoughts, fantasies and
attractions. This awareness frequently results in a decrease
of homosexual attractions. Later, journaling becomes a
form of self-help as they are able to make connections, make
shifts in perception and confront distortions.
Patients typically purchase two notebooks. Journal entries
are made in the first book and given to the therapist for
comment. They begin entries in the second notebook which
is exchanged with the therapist during the next session. I
make fairly extensive notes for them to consider.
One advantage to journaling is that it not only encourages
greater involvement in the therapy process but empowers
the patient to address significant issues regarding his struggles.
At the end of the treatment, the patient edits the journals
and this edited version is uses as a means of relapse
prevention.
Emotional Tracing
Homosexual activity represents, symbolically or otherwise,
attempts to meet legitimate needs. Many of these men are
affectively governed and are quite reactive as they attempt
to meet these needs through the eroticization of same-sex
relationships. Many have a talent for histrionics.
Emotional tracing is an intervention that is designed to
identify and appropriately respond to primarily emotional
needs. I simply ask them to explore what they were feeling
prior to the homosexual attraction. Oftentimes, they report
feelings of boredom, depression or anger, the latter most
often being a reaction to hurt, pain, fear or frustration. I will
have them re-experience these earlier feelings, and explore
their origins. Frequently, this process helps them to clarify
the origins of their homosexual attractions and results in a
diminishing of these attractions.
Defragmentation
This intervention is related to emotional tracing but is more
active. Its purpose is to assist in the de-eroticization of
same-sex relationships. Van den Aardweg talks about the
psychology of envy as central to the struggles of homosexual
men. Homosexual men eroticize that which they are not
identified with. Many of these men whom I have treated
have multiple partners, with no ongoing relationships.
Oftentimes, free-floating anxiety attaches itself to particular,
desired characteristics. These men do not deal with other
men, heterosexual or homosexual, in a holistic or complete
way. I suspect that this is one of the reasons for the instability
of their relationships. It's like incompleteness struggling
with incompleteness.
The defragmentiaton process addresses the issue of fragmenting
or incompletely dealing with others which I reflect
back to them. It works this way: in an individual session, I
will often ask that they focus on a past relationship and
examine their attraction. This attraction is often focused on
a particular trait or characteristic with which they are unfamiliar,
they view as lacking in themselves or which they
regard with simple envy. Most often these envied characteristics
are perceived masculine traits.
I have them explore other traits, both physical and otherwise,
so as to deal with this man in a holistic way.
Questions such as, "What were his other physical traits?"
"What was he like as a person?" are aimed at surfacing the
emotional needs particularly as they relate to intimacy
issues.
The need to get close to another man can be met without
sexualizing that man. This intervention helps the client
to equalize the relationship and focus on mutuality to
develop non-erotic relationships with significant heterosexual
men.
Spiritual Intervention
Aclear majority of men I have treated have a deep sense of
disconnectedness. They feel an alienation from God.
Freud indicated that God was an extension of the father
figure. This seems to hold true for these men's own view
of God. When describing their relationship to a Deity,
many of these men describe a "mean-spirited Santa Claus"
image. There is a certain fear of God.
Individuals in positions of authority such as ecclesiastical
leaders often unwittingly trigger feelings of anxiety and
resultant responses of fear and detachment. I work very
closely with ecclesiastical leaders who often provide
father/son nurturing relationships for these men. Such
relationships are very valuable in addressing issues such as
forgiveness.
Specific spiritual interventions include:
- The personalizing of scriptures.
- Imagery involving God as a loving, caring father
whose love is unconditional.
- Older, wiser self scenario. Service to others.
Particularly, this intervention helps these men learn
to give. They often feel unworthy to give of themselves.
They often report wanting to feel that they
are "acceptable to God."
Spiritual interventions help these men enjoy the process of
discovery and to articulate the true self, their core values,
and the basic purpose of life and to develop their spiritual
nature to its greatest fulfillment. Such interventions help
them clarify and trust their deepest values in a quiet way
through attentive contemplation and mediation.
These interventions also allow these men to commit to their
values and to identify with them in the present tense, and
to find the strength to live by them. I help them to visualize
themselves doing well and, through regular meditation,
doing well comes to feel natural. Many of these men
report experiencing love, joy, peace and fulfillment and
help others to do the same. Spiritual interventions
involve issues of integrity, personal empowerment and
control, becoming connected with others, and finding
greater purpose in life. It is through spiritual interventions
that these men are really anchored and receive
strength to resolve their struggles through what they call
their "personal healing process."
Updated: 2 September 2008
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