Members of the lesbian, gay, bisexual, transgender, queer, and questioning (LGBTQQ) communities seek psychotherapy for help with the same clinical and life issues that members of the heterosexual mainstream community do - depression and other mood disorders, anxiety disorders, bereavement and grief, relationship difficulties, career stress and work dissatisfaction, etc. Many of the presenting problems of these LGBTQQ clients have little to do with their sexual orientation while other issues will potentially be closely connected to their sexual identity. How treatment will unfold - even if the patient's chief complaint seems to be unrelated to his or her LGBTQQ orientation on the surface - will clearly be influenced by issues around sexual orientation. A therapist working with this community should have some specialized LGBTQQ knowledge (work experience with the community, life experience, research experience, etc.) in order to be most helpful to this patient population.

Positive and gay-affirmative psychotherapy assumes that LGBTQQ identities are normal and that changing a patient's sexual identity and/or orientation should not be a goal of treatment. There are two important elements to effective gay-affirmative psychotherapy:

• The therapist needs to be willing to examine anti-homosexual attitudes in him- or herself and in the patient as they potentially emerge in treatment (for example internalized elements of homophobia). Anti-gay attitudes include but are not limited to homophobia, heterosexism, anti-gay violence, and moral condemnations of homosexuality.

• The therapist needs to familiarize himself or herself with issues specific to an LGBTQQ identity. Particularly a focus around the issue(s) of coming out is important. The good and positive assumption that LGBTQQ identities are normal need not lead to faulty and premature "cheer leading," nor should the therapist encourage clients who are questioning their identities to come out prematurely. Simply reassuring clients that "it is just fine to be gay" can be counter-therapeutic as homophobia unfortunately continues to exist in society at large. Part of the coming out process and the work around it is the confrontation with still existing homophobia and how to deal with it. Therapists can clearly be most helpful if they have no set agenda as to how patients will and should resolve complex issues of identity, community and/or group affiliation, and openness. Therapists should not push for premature resolution in these areas.

Open disclosure of a therapist's own orientation can be helpful, as in the case of patients who may be struggling with the question of whether to come out. First and foremost, therapists should evaluate a patient's need for the therapist to come out on an individual basis, and then they should be prepared disclose when necessary and when it makes therapeutic sense.

I have extensive experience working with members of the LGBTQQ communities and I take a very positive and gay-affirmative stance in my work with gays, lesbians, transgenders, queer identified and questioning clients. My approach is based on the above spelled out rules and recommendations and I formulate my treatment plans based on each client's specific needs.

(Some of the information on LGBTQ therapy is taken from the LGBT Mental Health Syllabus, a website created by the LGBT Issues Committee of the Group for the Advancement of Psychiatry (GAP). Copyright © 2007 Group for the Advancement of Psychiatry)