Psychotherapy 2015, Vol. 52, No. 3, 298 –307

© 2015 American Psychological Association 0033-3204/15/$12.00 http://dx.doi.org/10.1037/a0038580

Determinants of Lesbian and Gay Affirmative Practice Among Heterosexual Therapists Edward J. Alessi

Frank R. Dillon

Rutgers, The State University of New Jersey

University at Albany, State University of New York

Hillary Mi-Sung Kim This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Rutgers, The State University of New Jersey The current study tested a conceptual model based on social– cognitive theory (Bandura, 1986), highlighting the influence of attitudes toward sexual minority individuals, training hours, affirmative counseling self-efficacy, and beliefs about affirmative practice on therapist engagement in lesbian and gay affirmative practice. We recruited via the Internet 443 heterosexual psychologists (n ⫽ 270), clinical social workers (n ⫽ 110), and marriage and family therapists (n ⫽ 63) residing in various parts of the United States. The majority of participants identified as female (70%) and White (88%). A path analysis indicated that beliefs and affirmative counseling self-efficacy mediated associations between attitudes and therapist engagement in affirmative practice. Furthermore, self-efficacy mediated the relation between training hours and engagement in affirmative practice. Results suggest that more affirmative attitudes are linked with higher levels of affirmative counseling self-efficacy and more positive beliefs, which in turn positively influences therapist engagement in affirmative practice. Additionally, more hours of training influence affirmative counseling self-efficacy, which in turn correlates with higher levels of therapist engagement in affirmative practice. The discussion includes implications for affirmative practice training. Keywords: lesbian and gay clients, affirmative practice, LGB-affirmative counseling self-efficacy, psychotherapy training, social– cognitive theory

Dillon & Worthington, 2003). Scholars also recommend therapists participate in training to explore their attitudes and increase their knowledge and skills in regard to affirmative psychotherapy (Croteau, Bieschke, Phillips, & Lark, 1998; Lyons, 2010). However, the mechanisms underlying the relation between attitudes and training and therapist engagement in LG-affirmative practice (hereafter referred to as affirmative practice) have not been examined in empirical research. Attitudes and training may influence social– cognitive theory factors (Bandura, 1986), which in turn may contribute to therapist engagement in affirmative practice. Social– cognitive theory emphasizes the role of selfefficacy and outcome expectations, as well as attitudes and environmental experiences, on determining behavior (Lent, Brown, & Hackett, 1994). Holding affirmative attitudes may influence therapists’ confidence to practice affirmatively (self-efficacy) and their beliefs about affirmative practice (outcome expectations), which in turn may correlate with higher levels of engagement in affirmative practice. Participating in training (environmental experiences) may influence therapists’ confidence to practice affirmatively, which in turn may contribute to higher levels of engagement in affirmative practice. Understanding these underlying mechanisms may help to improve education and training initiatives designed to prepare therapists and trainees to practice affirmatively. The current study used social– cognitive theory to examine the determinants of affirmative practice with LG clients among heterosexual therapists. This study focused on engagement in affirmative practice with LG clients to avoid the conceptual and

To provide culturally competent psychotherapy to lesbian and gay (LG) clients, therapists must practice affirmatively. According to Perez (2007), affirmative psychotherapy with LG clients requires— . . . the integration of knowledge and awareness by the therapist of the unique developmental and cultural aspects of [LG] individuals, the therapist’s own self-knowledge, and the translation of this knowledge and awareness into effective and helpful therapy skills at all stages of the therapeutic process (p. 408).

Studies indicate that certain attitudes, knowledge, and skills are needed to practice affirmatively with LG clients (Bidell, 2005; Israel, Ketz, Detrie, Burke, & Shulman, 2003). For example, holding affirmative attitudes toward LG individuals is necessary for therapist engagement in affirmative practice (Crisp, 2006;

This article was published Online First February 23, 2015. Edward J. Alessi, School of Social Work, Rutgers, The State University of New Jersey; Frank R. Dillon, Division of Counseling Psychology, University at Albany, State University of New York; Hillary Mi-Sung Kim, School of Social Work, Rutgers, The State University of New Jersey. This research was supported by funds awarded to Edward J. Alessi through the Rutgers University Faculty Research Grant Program. Correspondence concerning this article should be addressed to Edward J. Alessi, School of Social Work, Rutgers, The State University of New Jersey, 360 Martin Luther King Jr. Blvd, Hill Hall, Room 401, Newark, NJ 07102. E-mail: [email protected] 298

DETERMINANTS OF AFFIRMATIVE PRACTICE

methodological problems that may arise from combining LG identities with bisexual identities in one study. Engagement in affirmative practice with bisexual individuals requires therapists to understand the unique experiences of bisexual populations and to be aware of the effect of prejudice and discrimination (i.e., biphobia) on this population (Mohr, Israel, & Sedlacek, 2001; Mohr, Weiner, Chopp, & Wong, 2009; Scherrer, 2013). We acknowledge that studies examining the determinants of affirmative practice with bisexual individuals are clearly needed, though we limited this study to practice with LG clients.

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dignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults toward members of oppressed groups” (Nadal, 2008, p. 23). A study of the psychotherapy experiences of sexual minority clients revealed that therapists committed sexual orientation microaggressions such as avoiding or minimizing sexual orientation, overidentifying with clients, or making sexual orientation the focus of treatment even when it was unrelated to the presenting problem (Shelton & Delgado-Romero, 2011).

Training This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Attitudes Attitudes are reflective of an individual’s patterns of likes, dislikes, and indifferences (Lent et al., 1994). Early studies revealed that some psychologists and social workers hold negative attitudes toward LG individuals (Berkman & Zinberg, 1997; Garnets, Hancock, Cochran, Goodchilds, & Peplau, 1991); however, a more recent study indicated that psychologists and social workers tend to hold very positive attitudes toward this population (Crisp, 2006). Monitoring one’s attitudes toward LG clients (henceforth referred to as attitudes) is a key component of practice with sexual minority clients. A systematic review of research on psychotherapy for sexual minority clients indicates that helpfulness was associated with clients’ perception of their therapists’ attitudes, and that negative attitudes predicted lower satisfaction (King, Semlyen, Killaspy, Nazareth, & Osborn, 2007). To underscore the importance of holding affirmative attitudes, the American Psychological Association’s (APA, 2012) revised Guidelines for Psychological Practice with Lesbian, Gay, and Bisexual Clients reiterate that (a) stigma and prejudice increase sexual minority individuals’ risk for mental health problems, (b) LG sexual orientations do not indicate pathology, and (c) heterosexist attitudes and bias may affect assessment and treatment with sexual minority clients. For instance, the revised Guidelines now emphasize that efforts to change sexual orientation (i.e., conversion or reparative therapies) have not been shown to be safe or effective. The National Association of Social Workers (NASW, 2000) and the American Association of Marriage and Family Therapy (AAMFT, 2005) have also issued statements against the use of reparative or conversion therapies. Furthermore, the codes of ethics of these three professional organizations include sexual orientation in their nondiscrimination clauses (AAMFT, 2012; APA, 2010; NASW, 2008). However, practicing affirmatively requires more than practicing without discriminating (Crisp, 2006). Affirmative therapists move beyond mere acceptance of LG people to affirming their identities, communities, and lifestyles, advocating for LG clients, and assisting them with accessing community resources that are sensitive to their needs (Dillon & Worthington, 2003; Worthington, Dillon, & Becker-Schutte, 2005). Affirmative therapists also are distinctly aware that societal norms privilege heterosexual behavior and relationships (Bieschke, Perez, & DeBord, 2007; Davies, 1996; Greene, 2007; Kashubeck-West, Szymanski, & Meyer, 2008; Pachankis & Goldfried, 2004; Tozer & McClanahan, 1999). Even well-intentioned therapists may express attitudes that communicate subtle forms of discrimination, commonly referred to as microaggressions (Sue et al., 2007). Microaggressions are “brief and commonplace daily verbal, behavioral, or environmental in-

Lent et al. (1994) propose that environmental influences, which we conceptualize as training in sexual minority issues, stimulate interests and provide opportunities to perform behaviors that enhance learning. In general, psychologists appear to receive some training in sexual minority issues. Murphy, Rawlings, and Howe (2002) found that psychologists most commonly received this type of training by reading articles, obtaining supervision, taking continuing education classes, attending presentations, and reading books. Additionally, Murphy and colleagues found that these psychologists believed that receiving training on various topics (e.g., coming out, living with HIV/AIDS, internalized homophobia, and parenting/adoption) would improve their work with sexual minority clients. In recent years efforts have been made to incorporate training in sexual minority issues into clinical and counseling psychology, social work, and marriage and family therapy programs (Edwards, Robertson, Smith, & O’Brien, 2014; Martin et al., 2009; Sherry, Whilde, & Patton, 2005). Many scholars have discussed the importance of training graduate students to practice affirmatively with LG clients (Biaggio, Orchard, Larson, Petrino, & Mihara, 2003; Croteau et al., 1998; Godfrey, Haddock, Fisher, & Lund, 2006; Kashubeck-West et al., 2008; Morrow, 1998; Phillips & Fischer, 1998; van Den Bergh & Crisp, 2004). There is evidence that affirmative therapy training may improve graduate students’ self-reported clinical competency when working with LG clients (Rock, Carlson, & McGeorge, 2010). However, only 17% of clinical and counseling psychology programs incorporated LG competencies in yearly or end-of-program evaluations for students (Sherry et al., 2005), and only 19% of social work of programs formally assessed students’ competence to work with sexual minority clients (Martin et al., 2009). In addition, Edwards and colleagues discussed the continued need for marriage and family therapy programs to increase inclusiveness and affirmation of sexual minority identities and to develop plans for addressing situations where students express homophobic attitudes or refuse to work with sexual minority clients. In fact, graduate programs will need to create policies for managing situations where students refuse to work with LG clients. State legislation in Arizona and Michigan, referred to as “conscience clauses,” allows a student enrolled in a psychology, social work, or counseling program to refuse to counsel or serve LG clients when doing so conflicts with his or her religious beliefs (Anastas, 2013). This legislation may interfere with the ability of graduate programs to impart the knowledge and skills students need to practice in a nondiscriminatory manner and also may create additional barriers in accessing culturally competent mental health services (APA, 2014).

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ALESSI, DILLON, AND KIM

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Affirmative Counseling Self-Efficacy and Beliefs About Affirmative Practice Examining the role of social– cognitive theory factors may assist in identifying the factors contributing to engagement in affirmative practice with LG clients. Our discussion of social– cognitive theory is informed by Bieschke, Eberz, Bard, and Croteau (1998), who focused on self-efficacy and outcome expectations as they relate to fostering research on LG-related issues. We will use these same constructs but focus on their use in fostering affirmative counseling with LG clients. Self-efficacy influences the selection of an individual’s behaviors and environments and the effort and persistence that an individual expends on a task, especially when confronted with a challenge (Bandura, 1986). When applied to the counseling situation, studies demonstrate that self-efficacy was associated with counselor performance, counselor anxiety, and the supervision environment (Friedlander, Keller, Peca-Baker, & Olk, 1986; Larson et al., 1992). Counseling self-efficacy refers to the therapist’s “beliefs, or judgments, about his or her capabilities to effectively counsel a client in the near future” (Larson & Daniels, 1998, p. 180). Holding affirmative attitudes is likely to influence therapists’ confidence to practice with LG clients (i.e., self-efficacy), which is likely to contribute to higher levels of engagement in affirmative practice. Dillon and Worthington (2003) developed a measure to assess therapists’ confidence in their ability to help LG clients cope with heterosexism, establish a therapeutic environment that consists of trust and affirmation, and recognize when heterosexist bias interferes with therapists’ treatment of LG clients. Affirmative counseling self-efficacy positively relates with more affirmative attitudes, number of training hours, years of practice experience, number of multicultural counseling courses taken, as well as number of clients and sexual minority clients seen in treatment (Dillon & Worthington, 2003; Flores, O’ Brien, & McDermott, 1995; O’Shaughnessy & Spokane, 2013). The relationship between affirmative counseling self-efficacy and training in sexual minority issues may be particularly relevant. Training in sexual minority issues may influence therapists’ confidence to practice affirmatively (affirmative counseling self-efficacy), which in turn may contribute to therapists’ level of engagement in affirmative practice. However, with the exception of an analogue study by O’Shaughnessy and Spokane (2013), relations between affirmative counseling self-efficacy and therapist engagement in affirmative practice remain unexplored. While self-efficacy is concerned with one’s beliefs in his or her ability to perform an act, outcome expectations (conceptualized as beliefs about the effectiveness of affirmative practice; henceforth referred to as beliefs) involve beliefs about the “consequence of an act, not the act itself” (Bandura, 1986, p. 391). Therapists who hold negative attitudes are likely to hold negative outcome expectations about affirmative practice, which may lead to avoidance or rejection of affirmative practice behaviors. For example, therapists who pathologize LG identities or who are unaware of their heterosexist bias are unlikely to believe in the importance of practicing in ways that affirm the identities, relationships, and lifestyle choices of LG clients (Crisp, 2006). Therapists with negative attitudes may also not believe that practicing affirmatively results in better treatment outcomes for LG clients. Finally, as a result of unexamined bias

toward LG people or negative outcome expectations, therapists may commit microaggressions, or use techniques that are contrary to affirmative practice (e.g., dissuading LG clients from pursuing same-sex relationships or adopting children).

The Current Study The goal of this study was to examine factors that may influence heterosexual therapists’ engagement in affirmative practice. We examined a conceptual model of affirmative practice based on social– cognitive theory (Bandura, 1986; Lent et al., 1994) through which attitudes, environmental influences (training hours), outcome expectations (beliefs), and affirmative counseling selfefficacy would relate to therapists’ engagement in affirmative practice (see Figure 1). We hypothesized that (a) beliefs would mediate the relation between attitudes and therapist engagement in affirmative practice, (b) affirmative counseling self-efficacy would mediate the relation between attitudes and engagement in affirmative practice, and (c) affirmative counseling self-efficacy would mediate the relation between training hours and engagement in affirmative practice.

Method Procedure We used two direct marketing firms to recruit a nationwide sample of licensed mental health practitioners (psychologists, clinical social workers, and marriage and family therapists) via e-mail from September to October 2012. The first firm sent our study announcement, which included a description of the study and a link to the study’s webpage, to the e-mails of 5,000 psychologists. The second firm sent it to the e-mails of 5,000 clinical social workers and 5,000 marriage and family therapists. Potential participants’ e-mails were selected from the direct marketing firms’ e-mail lists, which are compiled from various sources including professional associations, directories, and state licensing boards. Within three weeks, the direct marketing firms sent another

Beliefs about LGaffirmative practice

Engagement in LGaffirmative practice

Attitudes toward sexual minority individuals Training hours Affirmative counseling selfefficacy

Figure 1. Proposed model. LG ⫽ Lesbian and gay.

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DETERMINANTS OF AFFIRMATIVE PRACTICE

follow-up announcement to the same e-mail list of psychologists, clinical social workers, and marriage and family therapists. To participate in the study, participants had to: (a) identify as a psychologist, clinical social worker, or marriage and family therapist, (b) have practiced psychotherapy for at least one year following completion of their educational program, and (c) identify their sexual orientation as heterosexual/straight. At the end of the description and consent page, we informed participants that continuing to the questionnaire indicated consent to participate and instructed those who did not want to participate not to proceed. Participants responded to items directly via an online questionnaire. Raw data were stored in a password-protected account using SNAP survey software. Participants could withdraw from the study at any point, and to safeguard participants’ anonymity we did not collect IP addresses or use cookies. We used a US$20 Amazon.com gift certificate as compensation for participation. Following completion of the questionnaire, participants who chose to receive the gift certificate supplied an e-mail address where they wanted to receive the gift certificate. We received study approval from the first author’s university’s institutional review board.

Participants A total of 476 participants completed the survey. We excluded two participants who did not identify their sexual orientation as heterosexual/straight, and one participant who lived abroad, as we limited our sample to therapists practicing in the United States. We excluded an additional 30 participants who responded to a validity check-item stating: Do not answer this item. The final sample consisted of 443 participants. Sixty-one percent were psychologists, 25% clinical social workers, and 14% marriage and family therapists. The participation rate was 5.4% among psychologists, 2.2% among clinical social workers, and 1.3% among marriage and family therapists. Participants’ ages ranged from 26 to 83 years, with a mean age of 50 (SD ⫽ 12). Seventy percent identified as female and 29% identified as male; three participants did not identify their gender. The majority (88%) of participants identified their race as White, while 4% identified as African American/Black, 4% as Latino/Hispanic, 3% as Asian/ Pacific Islander, and 1% as other. Participants resided in varying parts of the United States; 31% were from the Northeast, 29% from the West, 26% from the Midwest, and 14% from the South. The practice experience of participants ranged from 1 to ⬎20 years, with 36% practicing for ⬎20 years, 14% for 16 to 20 years, 20% for 11 to 15 years, 19% for 6 to 10 years, and 11% for 1 to 5 years.

Measures Demographic form. Participants reported their professional identification, age, gender, race/ethnicity, region of the United States in which they lived, and years of practice experience. Training hours. We used a question used by Dillon and Worthington (2003) to assess training hours. We asked participants how many hours of lesbian, gay, and/or bisexual issues in psychotherapy/counseling-focused instruction they received (e.g., actual hours in a course, in-service training, workshop attended) and asked them to choose from the following options: none, 1 to 5 hours, 6 to 25 hours, 26 to 35 hours, and more than 35 hours. There was no significant relationship between training hours and

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professional identification, ␹2(10, N ⫽ 441) ⫽ 9.41, p ⫽ .49, ␩2 ⫽ .08. Attitudes. To assess heterosexual attitudes toward sexual minority individuals, we used four subscales from the Lesbian, Gay, and Bisexual Knowledge and Attitudes Scale for Heterosexuals (LGB-KASH; Worthington et al., 2005). The subscales include— Hate (6 items), LGB Civil Rights (5 items), Religious Conflict (7 items), and Internalized Affirmativeness (5 items). Participants used a 5-point Likert scale (1 ⫽ very uncharacteristic of me and my views to 5 ⫽ very characteristic of me and my views) to respond to statements such as “LGB people deserve the hatred they receive” (Hate subscale), “I think marriage should be legal for same-sex couples” (LGB Civil Rights subscale), “I can accept LGB people even though I condemn their behavior” (Religious Conflict), and “Feeling attracted to another person of the same-sex would not make me uncomfortable” (Internalized Affirmativeness). A total scale score was calculated by reverse scoring the Hate and Religious subscale items and summing all LGB-KASH items to arrive at a total score. Higher total scores indicated higher levels of positive attitudes toward LGB people. Unlike frequently used scales that measure heterosexual attitudes toward LGB individuals, this scale was designed to capture a wide range of attitudes that have emerged due to changing social conditions for LGB people (Worthington et al., 2005). The LGB-KASH has demonstrated good internal consistency for the Hate (␣ ⫽ .81), LGB Civil Rights (␣ ⫽ .87), Religious Conflict (␣ ⫽ .76), and Internalized Affirmativeness (␣ ⫽ .83) subscales and has shown evidence for discriminant, convergent, and construct validity (Worthington et al., 2005). In this study, Cronbach’s alpha was .82 for the LGB-KASH total score. Affirmative counseling self-efficacy. We used the Lesbian, Gay, and Bisexual Affirmative Counseling Self-Efficacy Inventory (LGB-CSI; Dillon & Worthington, 2003) to assess therapists’ beliefs in their abilities to perform affirmative counseling-related tasks and behaviors. The LGB-CSI consists of five subscales: Knowledge (13 items), Advocacy Skills (7 items), Awareness (5 items), Assessment (4 items), and Relationship (3 items), which reflect the central components of affirmative counseling (Dillon & Worthington, 2003). Participants used a 5-point scale (1 ⫽ not confident to 5 ⫽ extremely confident) to rate their ability to perform certain counseling-related tasks and behaviors among the five domains, for example: “Facilitate a LGB-affirmative counseling or support group” (Knowledge), “Refer LGB clients to affirmative legal and social supports” (Advocacy), “Examine my own sexual orientation/identity process” (Awareness), “Complete an assessment for a potentially abusive same sex relationship in a LGB-affirmative manner” (Assessment), and “Establish an atmosphere of mutual trust and affirmation when working with LGB clients” (Relationship). Total LGB-CSI scores were computed by summing all items across all subscales. Higher total scores indicate higher levels of affirmative counseling self-efficacy. The LGBCSI demonstrated good internal consistency in previous studies: .96 (Knowledge), .93 (Advocacy), .86 (Awareness), .89 (Assessment), and .87 (Relationship) and has shown evidence for discriminant, convergent, and construct validity (Dillon & Worthington, 2003). In this study, Cronbach’s alpha was .95 for the LGB-CSI total score. Beliefs about and engagement in affirmative practice. We used the Gay Affirmative Practice Scale (GAP; Crisp, 2006) to

ALESSI, DILLON, AND KIM

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assess beliefs about and engagement in affirmative practice. Although all other measures used in the study refer to LGB clients/ issues and training, the GAP only assesses beliefs and engagement in affirmative practice with LG clients. The GAP Scale consists of two 15-item domains—Beliefs and Engagement. The Beliefs domain assesses mental health practitioners’ beliefs about treatment with LG clients, and the Engagement domain assesses how frequently mental health practitioners engage in affirmative practice behaviors with these clients. The Beliefs domain asks participants to use a 5-point scale to rate (1 ⫽ strongly agree to 5 ⫽ strongly disagree) whether they agree or disagree with statements such as “Practitioners should make an effort to learn about diversity in the gay/lesbian community” and “Practitioners should help clients to reduce shame about homosexual feelings.” The Engagement domain asks participants to use a 5-point scale to rate (1 ⫽ never to 5 ⫽ always) how frequently they engage in certain practice behaviors such as “I provide interventions that facilitate the safety of gay/lesbian clients” and “I facilitate appropriate expression of anger by gay/lesbian clients about oppression they have experienced.” Subscale scores were computed by summing items for each subscale. We reverse coded the data so that higher scores indicated more positive beliefs about treating LG clients and engagement in affirmative practice. Among a sample of psychologists and social workers, the GAP Scale demonstrated high internal consistency for both the Beliefs (␣ ⫽ .93) and Engagement (␣ ⫽ .94) domains and has also shown evidence of discriminant, convergent, and construct validity (Crisp, 2006). In this study, Cronbach’s alpha was .92 for the Beliefs scale, and it was .88 for the Engagement scale.

Results Preliminary Analyses Before conducting our primary analysis, we examined the data for missing values, which were ⬍10% across all variables, except for the LGB-KASH (10.6%). To test whether data were missing completely at random (MCAR), we used Little’s MCAR test (Little, 1988), which indicated that the data were missing at random, ␹2(37) ⫽ 51.49, p ⬎ .05. Next, we computed z-scores for raw scores to assess for outliers among the main variables (LGBKASH, LGB-CSI, GAP Beliefs, and GAP Engagement). To avoid

contaminant influence on parameter estimates, z-scores needed to be ⬍3 (Tabachnick & Fidell, 2007; Wainer, 1976). Seventeen cases had z-scores ⬎3, and as a result we removed these cases from the analysis. After deleting these outliers, the skewness and kurtosis of the main variables were within normal range (i.e., ⬍ ⫾ 1); however, the data did not meet the assumption of multivariate normality. An examination of the plots of each of the main variables revealed that a large proportion of participants’ scores on the GAP Beliefs and GAP Engagement scales were at the high end. We used reverse log transformation for these scales and then tested the data for multivariate normality. Mardia’s coefficient of multivariate kurtosis was 34.31 (p ⫽ .46), indicating that data met assumptions of multivariate normality. Thus, our final analytic sample resulted in 426 participants. Table 1 presents descriptive statistics for the variables used in the proposed analytic model (see Figure 1 for analytic model). We correlated all variables in the proposed model to test for discriminant validity and multicollinearity across constructs by ensuring that correlation coefficients between mediators were ⬍.70 (Tabachnick & Fidell, 2007). Bivariate correlation coefficients between all variables were all ⬍.70 (see Table 1).

Primary Analysis We used structural path analysis to examine hypothesized associations among hours of training, attitudes, affirmative counseling self-efficacy, beliefs, and therapist engagement in affirmative practice (see Figure 2). Because we included an ordinal variable (i.e., training) in the structural model, it was specified as such for analyses using the Mplus statistical software program. The default estimator for this type of analysis in Mplus is a robust weighted least squares estimator (Muthén & Muthén, 2010). We controlled for age in the main analysis because it was significantly correlated with attitudes, r ⫽ ⫺.17, p ⫽ .001, and engagement in affirmative practice, r ⫽ .11, p ⫽ .026. Our primary path analyses comprised three steps: (a) testing our proposed model to determine model fit, (b) estimating the significance of the hypothesized direct effects, and (c) estimating the significance of the hypothesized indirect effects using bootstrapping procedures (Cheng & Mallinckrodt, 2009; Shrout & Bolger, 2002). The bootstrap procedure resamples from the original sam-

Table 1 Descriptive Statistics and Correlations Among Variables (n ⫽ 443) Variable

Age

Training hoursa

LGB-KASH

LGB-CSI

GAP Beliefsb

GAP Engagementb

M (SD) Training hoursa LGB-KASH LGB-CSI GAP Beliefsb GAP Engagementb

50 (12) ⫺.02 ⫺.17ⴱⴱⴱ .07 .02 .11ⴱⴱ

3.14 (1.48)c

4.23 (.51)

3.04 (.36)

.97 (.39)

.68 (.47)

.28ⴱⴱⴱ .27ⴱⴱⴱ .26ⴱⴱⴱ

.37ⴱⴱⴱ .53ⴱⴱⴱ

.58ⴱⴱⴱ

ⴱⴱⴱ

.16 .46ⴱⴱⴱ .16ⴱⴱⴱ .24ⴱⴱⴱ

Note. LGB-KASH ⫽ Lesbian, Gay, and Bisexual Knowledge and Attitudes Scale for Heterosexuals; LGB-CSI ⫽ Lesbian, Gay, and Bisexual Affirmative Self-Efficacy Inventory; GAP ⫽ Gay Affirmative Practice Scale. a Training hours were measured on an ordinal scale in which 1 ⫽ none, 2 ⫽ 1 to 5 hr, 3 ⫽ 6 to 15 hr, 4 ⫽ 16 to 25 hr, 5 ⫽ 26 to 35 hr, and 6 ⫽ ⬎35 hr. b Reverse log transformation of scale scores. ⴱⴱ p ⬍ .01. ⴱⴱⴱ p ⬍ .001.

DETERMINANTS OF AFFIRMATIVE PRACTICE R2 = .10 GAP Beliefs .41***

.31*** R2 = .03 LGBKASH

GAP Engagement

.16**

.30*** Training hours

.13**

.46***

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R2 = .47

.05 (.29 *** )

.38***

LGB-CSI R2 = .37

Figure 2. Proposed model controlling for age. Values represent standardized path coefficients. Direct effect coefficient in parentheses. LGBKASH ⫽ Lesbian, Gay, and Bisexual Knowledge and Attitudes Scale for Heterosexuals; LGB-CSI ⫽ Lesbian, Gay, and Bisexual Affirmative Self-Efficacy Inventory; GAP ⫽ Gay Affirmative Practice Scale. ⴱⴱ p ⬍ .01; ⴱⴱⴱ p ⬍ .001.

ple to obtain a more precise standard error estimate (MacKinnon, Lockwood, & Williams, 2004). We followed the procedure of McDermott and Lopez (2013) and others by creating 2,000 bootstrap samples. We evaluated our proposed path model using standard model fit criteria: the comparative fit index (CFI), the Tucker Lewis Index (TLI), and the root-mean-square-error of approximation (RMSEA), with a 90% confidence interval. CFI values above .90 reflect adequate fit (Hu & Bentler, 1998), and those above .95 represent excellent fit (Tomarken & Waller, 2005). TFI values over .90 are considered acceptable (Hu & Bentler, 1998). RMSEA values below .08 represent adequate fit (Hu & Bentler, 1998), and those below .05 represent excellent fit (Hancock & Freeman, 2001).

Test of Proposed Model Standard model fit criteria suggested that the proposed model provided excellent fit to the data, CFI ⫽ .98, TLI ⫽ .94, and RMSEA ⫽ .04, 90% confidence interval [.00, .08]. The structural model accounted for 47% of the variance in therapist engagement in affirmative practice. The direct path between attitudes and engagement was significant (␤ ⫽ .29, p ⬍ .001) when hypothesized mediators were removed from the model. As shown in Figure 2, attitudes (␤ ⫽ .13, p ⫽ .006), hours of training (␤ ⫽ .46, p ⬍ .001), and beliefs (␤ ⫽ .30, p ⬍ .001) were positively associated with higher levels of affirmative counseling self-efficacy.

Significance Testing for Indirect Effects We hypothesized three indirect effects in the proposed model. First, we hypothesized that beliefs would mediate the relationship between attitudes and therapist engagement in affirmative practice. Second, we hypothesized that affirmative counseling self-efficacy would mediate the relationship between attitudes and engagement. Third, we hypothesized that affirmative counseling self-efficacy would mediate the relationship between training hours and engagement. Results indicated that the three mediation paths in the

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proposed model were significant: (a) beliefs mediated the relationship between attitudes and engagement (␤ ⫽ .13, p ⬍ .001, 95% CI [.08, .18]); (b) affirmative counseling self-efficacy mediated the relationship between attitudes and engagement (␤ ⫽ .05, p ⫽ .025, 95% CI [.01, .09]); and (c) affirmative counseling self-efficacy mediated the relationship between training hours and engagement (␤ ⫽ .18, p ⬍ .001, 95% CI [.11, .24]).

Test of a Competing Model We compared the proposed model to a competing model that tested different directional paths (Schwartz, Zamboanga, Weisskirch, & Wang, 2010; Martens, 2005). This is essential in crosssectional research where it is not possible to test causality or directionality (Schwartz et al., 2010). We tested a competing model by reversing the mediation paths so that (a) beliefs mediated the relationship between engagement and attitudes, (b) affirmative counseling self-efficacy mediated the relationship between engagement and attitudes, and (c) affirmative counseling efficacy mediated the relationship between engagement and training. To compare the proposed model with the competing one, we removed all the direct paths in both models to only allow for indirect effects through the main variables. We removed the direct paths specified in the proposed model because keeping these paths and reversing their direction would result in a competing model with identical fit (Keith, 2006; Schwartz et al., 2010). For a strong mediation effect to be present, the model should fit well with only the indirect paths included (Holmbeck, 1997; Schwartz et al., 2010). Standard model fit criteria for the competing model suggested it provided poor fit to the data, CFI ⫽ .64, TLI ⫽ .31, and RMSEA ⫽ .14, 90% confidence interval [.12, .16]. Model fit criteria for the proposed model with direct paths removed suggested better fit to the data, CFI ⫽ .93, TLI ⫽ .86, and RMSEA ⫽ .06, 90% confidence interval [.03, .09]. This suggests that the competing model should be rejected in favor of the proposed model.

Discussion The current study tested a conceptual model based on social– cognitive theory (Bandura, 1986; Lent et al., 1994), highlighting the influence of attitudes, environmental influences (training hours), affirmative counseling self-efficacy, and outcome expectations (beliefs) on therapist engagement in affirmative practice. This study provides empirical support for the essential mechanisms through which attitudes and training relate with therapist engagement in affirmative practice with LG clients.

Self-Efficacy and Beliefs as Mediators Between Attitudes and Engagement in Affirmative Practice The results indicate that more affirmative attitudes contribute to higher levels of affirmative counseling self-efficacy and more positive beliefs, which correlate with higher levels of engagement in affirmative practice. Our results highlight the importance of considering the role of social– cognitive theory factors when developing educational and training interventions. Targeting beliefs and affirmative counseling self-efficacy may strengthen the relation between affirmative attitudes and therapist engagement in affirmative practice.

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Training interventions can influence beliefs by helping therapists and trainees to understand why practicing affirmatively results in better treatment outcomes for LG clients and why holding negative beliefs about affirmative practice can have adverse effects on their treatment. To help foster affirmative counseling selfefficacy, therapists and trainees need to be given opportunities to provide psychotherapy to LG clients. These opportunities should be used to teach therapists and trainees how to establish an affirmative environment, manage their heterosexist bias, and advocate for LG clients. To maximize these learning experiences, educators need to promote vicarious learning through modeling and to use supervision to provide verbal reinforcement (Dillon & Worthington, 2003). The direct effect of attitudes on affirmative counseling selfefficacy and beliefs was consistent with previous research (Crisp, 2006; Dillon & Worthington, 2003), and provides further support for developing training interventions to improve the attitudes of therapist and trainees. However, certain attitudes may be easier to modify than others. For example, increasing therapists’ and trainees’ understanding of the LG community’s struggle for civil rights through lectures, readings, and visual media may be easier than changing deeply held religious attitudes. Changing these attitudes requires graduate programs to offer training in sexual minority issues throughout the curriculum, not just in diversity, multicultural counseling, or elective courses. Inviting an affirmative clergy member to class to serve as a guest speaker or arranging a presentation by an affirmative religious group may also help to challenge some therapists’ or trainees’ deeply held religious convictions. It may also help to ask LG individuals, who are active members in affirmative churches, synagogues, or mosques, to discuss their experiences with trainees. Future studies should assess whether changes in attitudes, affirmative counseling selfefficacy, and/or beliefs impact engagement in affirmative practice over time, particularly in response to training interventions. The results raise further concerns about recent “Conscience Clause” legislation in Arizona and Michigan that allows a student to refuse to counsel or serve LG clients when doing so conflicts with his or her religious beliefs. The findings suggest that the processes through which therapists engage in affirmative practice require training initiatives to target social– cognitive factors (affirmative counseling self-efficacy and beliefs) as well as attitudes. However, it may be difficult to target these areas when trainees are exposed to environments that allow students to refuse to serve or counsel LG clients. Graduate programs must strive to create learning environments that promote cultural competence and help trainees to understand the ways in which social forces (e.g., discrimination) contribute to or exacerbate mental health problems among sexual minority individuals (Alessi, 2013).

Self-Efficacy as a Mediator Between Training and Engagement in Affirmative Practice The results suggest that affirmative counseling self-efficacy is the mechanism through which training in sexual minority issues influences therapist engagement in affirmative practice. Specifically, more hours of training contributes to higher levels of affirmative counseling self-efficacy, which in turn positively impacts engagement in affirmative practice. Previous studies also indicate that training was positively associated with affirmative counseling

self-efficacy (Dillon & Worthington, 2003; O’Shaughnessy & Spokane, 2013). Scholars suggest that training in sexual minority issues assists therapists with obtaining the attitudes, knowledge, and skills necessary for working with sexual minority populations (Crisp, 2006; Israel et al., 2003; van Den Bergh & Crisp, 2004), which in turn may contribute to higher levels of engagement in affirmative practice. The attitudes, knowledge, and skills needed to practice affirmatively may be developed by increasing levels of affirmative counseling self-efficacy behaviors, which include maintaining awareness of heterosexist attitudes, applying LGrelated knowledge, and using LG-focused assessment and advocacy skills (Dillon & Worthington, 2003). Substantive variance in affirmative counseling self-efficacy may also be explained by other variables that we did not assess in this study. For example, studies indicate that affirmative counseling self-efficacy positively correlates with gender self-confidence and sexual identity commitment among therapists (Dillon, Worthington, Soth-McNett, & Schwartz, 2008). In addition, affirmative counseling self-efficacy was associated with number of LG clients seen and number of LG family members and friends (Dillon & Worthington, 2003; O’Shaughnessy & Spokane, 2013). Finally, given the differences in graduate training among the different types of mental health professionals (i.e., psychologists tend to hold doctoral degrees, while clinical social workers tend to hold master’s degrees and marriage and family therapists tend to hold a doctoral or master’s degree), future research is needed to examine whether professional identification is responsible for within-group differences among the variables.

Limitations The current study had some important limitations. First, given the cross-sectional nature of the data, causal interpretations cannot be made. For example, although we have no reason to doubt that receiving training in sexual minority issues increases affirmative counseling self-efficacy, it is also possible that higher levels of affirmative counseling self-efficacy increase the likelihood that therapists will participate in training. Second, findings cannot be generalized to the population of therapists in the United States because we recruited participants through e-mails obtained through nonprobability-based Internet panels. Recruitment into these panels is not based on a defined sampling frame, and the number of people invited to join the panel is not usually known (American Association for Public Opinion Research [AAPOR], 2010, 2011). Furthermore, our study participation rate (calculated by dividing the number of e-mails sent by the number of completed surveys; AAPOR, 2011) was low (3%), suggesting that our findings must be considered preliminary at best. The low participation rate may indicate that those completing the survey were motivated by interest in the topic, the incentive, or both, leading to potential selection bias. It is possible that the length of the survey (95 questions) contributed to nonparticipation in our study, as longer surveys may place more of a burden on respondents. Although our participation rate was low, the demographics of the sample appear to be representative of therapists in the United States. More specifically, psychologists, social workers, and marriage and family therapists tend to be White, female, and in their 50s (APA Center for Workforce Studies, 2014; NASWCenter for Workforce Studies, 2006; Northey, 2005). Furthermore, Web sur-

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veys tend to have lower response rates than mail surveys (Shih & Fan, 2008), with the authors of one e-mail study reporting a response rate of 22% after three waves of solicitation (Sills & Song, 2002). Third, the scale used to measure therapist beliefs about and engagement in affirmative practice did not include questions about bisexual clients; thus, caution should be used when relating the findings to affirmative practice with bisexual clients. Although we assessed attitudes toward LGB individuals and affirmative counseling self-efficacy with LGB clients, future studies need to specifically examine beliefs and engagement in affirmative practice with bisexual clients. Fourth, findings were based on therapists’ self-report, which is subject to response bias; that is, therapists’ self-report regarding certain affirmative practice behaviors may not always correspond with what occurs in actual practice (Worthington, Mobley, Franks, & Tan, 2000). Fifth, to assess sexual orientation, we asked participants to identify whether they were straight/heterosexual or lesbian/gay/bisexual/queer. However, given the fluid nature of sexual orientation it may best to use measures that assess sexual orientation along a continuum (Epstein, McKinney, Fox, & Garcia, 2012). Finally, the large number of therapists identifying their racial background as non-Latino White may limit the study’s findings. Future studies need to include more racially and ethnically diverse samples of therapists to allow for a better understanding of therapists’ attitudes and practices with LG clients and to strengthen the external validity of results.

Conclusion This study provides a better understanding of the processes influencing the relationship between attitudes, training, and therapist engagement in affirmative practice with LG clients. Results indicate that therapist engagement in affirmative practice is determined by a multitude of factors, including affirmative counseling self-efficacy and beliefs. Therefore, training and education that focuses on improving attitudes may only be the first step toward ensuring that therapists practice affirmatively. Fostering affirmative counseling self-efficacy and influencing beliefs via training interventions may increase engagement in affirmative practice. It is essential that graduate and continuing education programs evaluate whether therapists and trainees have developed the attitudes, knowledge, and skills to practice affirmatively with LG clients. These evaluations can be used to identify therapists’ and trainees’ knowledge of affirmative practices and subsequently target areas for further learning.

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Received February 28, 2014 Revision received October 20, 2014 Accepted November 3, 2014 䡲