Why understanding minority stress matters
The history of the study of both risk and prevalence of mental health problems within gender, sexuality and relationship diverse (GSRD) communities has been one which reflects wider societal attitudes, first to homosexuality, and then to other GSRD people.
As medical science tried to frame homosexuality as an illness rather than a sin, it looked to an easy to study group, those who had already sought treatment for mental ill health. Given the prejudices held, it took until the late twentieth century for research to move away from an automatic conflation of being homosexual and mentally ill. It is worth noting that lesbians and bisexuals were barely acknowledged to exist, and trans research was devastated by the destruction of the Institute of Sex Research by the Nazis in Berlin. With the removal of homosexuality from the DSM in the 1970's it was no longer listed as a mental illness, but old prejudices still had to be fought.
One of the side effects of fighting these prejudices is that there was a vacuum in understanding why LGBT people suffered with worse mental health than the general population. The conventional view was that stress, as a cause of poorer mental health, came from within an individual as a state of mind, and was thus treated cognitively, by changing the states of mind. A vital challenge to this idea came from Ilan Meyer, who argued that the experience of being LGBT within our society leads to what he called 'minority stress'. He argued that the concrete reality of living within a prejudiced society caused the higher observed rates of mental ill health among LGBT people.
One of the strengths of the model is that it accepts that there is a genuine experience of negative treatment by minorities and does not claim it is “all in the mind”. One of the building blocks of the therapeutic experience is that of being heard. Carl Rodgers believed this experience of being heard, often for the first time, could be transformative for a client. Historically GSRD people were treated as either sinful, or more recently, sick. Any experiences of mental ill health were due to aberration, or abnormality. Treatment was to “return” them to normality, which was assumed to be mean being cisgender, straight and monogamous. By acknowledging that both the lived experience, and their reaction to the lived experience, is real, the therapist is no longer trying to treat the client for being GRSD but instead trying to help them navigate a world which is often hostile and unwelcoming.
In understanding the minority stress model, that experience of prejudice leads to anxieties about expected prejudice and internalised stigma and shame, meaning that we're able to work with people without dismissing their experiences, or fears of how the world might treat them for being LGBT.
Even after ideas such as LGBT affirmative therapy were proposed there was, and often still is, a focus on the client being in some way wrong in how they interact with the world. Many of the models of coming out are based on the idea that any stress or mental ill-health will be resolved at a magical moment of integration of the individual’s identity. This positions the problem as within the client rather than the wider world.
This may of course have its own problems. A client may feel that it is hopeless to exist in a world where structural transphobia/biphobia/homophobia or monosexual privilege seem intractable. It may lead to despair, or a belief that being their authentic self is too high a price to pay. It is therefore important for clients to work on self-esteem, and an internal locus of evaluation. If the storms of minority stress are inevitable, then part of the therapeutic work is to ensure the “ship” is able to weather the storms.
In a wider social context, if we are to seek the best outcomes for our clients, it may be that we have to engage in some way with challenging the prejudices which lead to minority stress. In challenging prejudice outside of the therapy room, we are being congruent when we say to clients that they deserve to exist in a world where they are not the target of ill treatment due to their identity. As clients come to believe this truth, then their own resilience and ability to cope with micro and macro aggressions is given the space to develop.
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