Strengthening the Therapy Relationship with Gay Men

Strengthening the Therapy Relationship with Gay Men

by Rick Miller
The keys to successful therapy with gay men are connection, support, and attunement. Excerpted from Unwrapped, Integrative Therapy with Gay Men...the Gift of Presence. 


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gay men have grown up feeling diminished in their families and beyond
In general, gay men have grown up feeling diminished in their families and beyond. The way in which they interact in the world is shaped by these experiences and so the stakes are high when they come see you. Comfort and compassion are essential components in successful treatment with gay men, and the immediate goal is to create a positive alliance. Growth takes root in this alliance, regardless of which therapeutic models or specialties you offer.

Because connection takes precedence in this moment, the paperwork that comes with this professional interaction can be put aside in favor of establishing rapport. Paperwork can wait, connection cannot.

When the client shows up to your office for psychotherapy, he will already be in a vulnerable state. His presenting issue, which is often a source of failure or shame, is accompanied by the internalized feeling that being gay is to blame. Thus, the association formed by the two of you must serve as a foundation of ongoing trust in order to explore what inherently feels dangerous to explore.

Sizing You Up

Gay male clients will be sensitive to certain aspects of interaction and particular qualities in you. Gay men are well versed in detecting safety concerns.

Do you understand him?

Are you reassuring?

Do you accept him being gay?

If you do, are you conveying it in a way that feels accepting and loving? (If he is coming to therapy based on issues pertaining to sex, intimate relationships, or compulsive behaviors, this will be especially salient).

If you are gay, do you share enough similar viewpoints for the relationship to feel safe and satisfying?

Is there a way in which the fact that you are gay actually evokes a sense of competition him?

Are you the kind of gay man he feels comfortable with — a therapist who understands his values within the community?

Is your style something he judges you for or reacts to?

If you are not gay, what are your biases, and how or when will they show up?

Are you open enough?

Whatever your orientation, do you offer the right balance of familiarity, professionalism and freshness?

your client’s needs may have him looking outside of himself for acceptance, and your job at the beginning is a tough one
As I said, the first goal at the start of new treatment is to make the connection. Remember the gay male’s history. Your client’s needs may have him looking outside of himself for acceptance, and your job at the beginning is a tough one. It is easy to fool ourselves into thinking we are doing what is right in order to make a connection, but paying attention to subtle interactional qualities is a crucial aspect of creating that necessary sense of trust. Dr. Zeig asks clinicians to imagine themselves in the consulting room: “What postures do you habitually assume? Are you unnecessarily rigid? What flexible postures can you adopt that can enhance your effectiveness?” (1)

If the client has been in therapy before, his explanation, “I wanted something new,” may warrant some exploration. Did he have a sense that his previous therapist disapproved of aspects related to him being gay? Did he come to some kind of therapy impasse? Was he having trouble translating insight into action? Whatever the reason for his having left the previous context, you’re it now, and in order to meet him where he is, you will need to appreciate his dilemma, figure out his relational style and provide the right amount of what he needs.

Keep in mind that most gay men are used to sitting on the sidelines. Showing sincere enthusiasm is inspiring, though it may take some time for him to adjust to the attention. Most clients come to therapy wanting to resolve a problem. Some are clear that it is crucial to have a good connection with the therapist in order to accomplish this, but others may not be aware of how important this aspect of therapy is.

Most gay men have grown up in unempathic environments. Thus, empathic resonance and responsiveness from the therapist are of particular importance. At the same time, the therapist’s empathic responses may fall on deaf ears as the client questions the genuineness of the interaction (2). Gay males suffering from low self-esteem are accustomed to deflecting energy from themselves and may have a knack for not accepting positive feedback. I also attribute the reaction to internalized homophobia. People with low self-esteem are more comfortable with critical feedback than praise, and they elicit values that confirm their negative self-view (3).

A quick story: A client who is not new to therapy but has just joined a group I lead reveals the tenaciousness of his low self-esteem even as he is receiving very positive feedback. This man is upbeat, attractive, articulate, and warm. When it is pointed out by the group that he exhibits these traits, his face becomes flushed, he breaks eye contact, looks down, and his posture transforms into that of a vulnerable child. Exploration of this response only brings out more embarrassment and shame. This is a man who is successful in business and to whom others respond with interest. His mysteriousness — a façade developed to hide behind — only evokes greater interest. In this moment, the uncertainty that lurks just beneath the surface is glaring.


As therapists, we always appreciate the significance of the therapeutic relationship or we wouldn’t be working in this field. The topic is endlessly captivating. “The therapy relationship is more than a staging ground for technique, it is the primary factor in successful psychotherapy” (3).Our chief goal is to provide a meaningful experience with our clients. It is that simple. For gay men, this meaningful experience provides the greatest opportunities for change. Remember, using body awareness through experiential work, focusing on clients’ resources, and using the strength of the therapy relationship creates optimal change.

we always appreciate the significance of the therapeutic relationship or we wouldn’t be working in this field
You and your client will simultaneously enjoy the rewards of using this three-prong approach. Attunement refers, in part, to this palpable shared experience. The term attunement has become popularized largely based on remarkable neuroscientific findings. Mutual physiological changes take place when people are attached to, and are in sync with, each other (4).

Your Natural Self

Whether it be your areas of expertise or your reputation that brought a client to you, being appreciative of the dynamic of the relationship is crucial. How you exhibit warmth and interest in him makes a difference. It is your natural strengths that create the greatest comfort and promote closeness. How you interact is far more important than the exact words you use. Techniques that you learn are helpful but perfecting them might be more significant for you than for your client. Your stance is that of a healer, respectful and sacred in your intentions. You are an important figure to your client, perhaps in ways he has never had in his life before.

Literature delights in affirming the significance of this relatedness. Successful therapy depends much more on the connection, empathy, and mutual fondness that develop between a gay client and therapist than any other attribute of the therapist. “What is healing as the client experiences being at one with the therapist.” (5). It is more important that the therapist direct efforts towards appreciating the client’s experience than focusing on what really happened. This perspective centers on the client’s affective experience.

Now, in current work with gay men, we can explore sensory experiences too. This opens up a treasure chest of possibilities because somewhere inside are his resources. Perhaps they have been dormant for years, but with caring guidance they can be elicited from deep inside. Research indicates that within the context of healthy relationships, individuals are able to gain experience of identity, meaning, choice, and love. The combination of these produces hope and resiliency. We discover our value, stretch our limits, gain new abilities, and collaboratively create a meaning for our existence (Short, 2010, pp. 301, 302). Authenticity opens to creativity and collaboration; the powerful mixture leads to success in the therapy.

Attunement in Action:

Create an inviting, informal atmosphere.

Use your eyes to make contact with your clients.

Be aware of your body language and show yourself to be open and welcoming.

Use your intuition to create a relational match by joining the client in his ways of perceiving things and living life.

Trust the unique ways in which information comes to you as you sit with your client. Utilize them.

use humor with purpose in order to promote closeness or emphasize a point
Use humor with purpose in order to promote closeness or emphasize a point.

Strive to make a powerful connection that is profoundly experienced by both of you.

Focus on experience rather than technique.

Authority Figures

For gay men, positive experiences with authority figures are few and far between. Most gay men have concealed their identity or behaviors, recognizing that there was always the danger that people in positions of authority would be disapproving. I still find that many clients don’t tell their physicians they are gay, despite being sexually active. They are afraid their physician will react negatively, and the need for interpersonal harmony surpasses anything else. Of course, it is of the utmost importance to maintain good physical health, get regular HIV tests and immunizations for hepatitis, and to have safe-sex discussions. If a physician or therapist is perceived as being disapproving, the option of another provider is always a good one, yet secrecy is the default mode for many men. They forget that they have other options. This scenario happens just as often in psychotherapy, especially where sex and use of substances are concerned.

What Does it Mean to be Gay Affirmative?

I have highlighted that gay male clients flourish through your ability to notice and utilize their resources. This is the magic you can easily provide. Although it isn’t difficult, it often is forgotten amidst the therapy protocols and the current emphasis on identifying treatment goals. Clients are the best at self-pathologizing. Gay liberation itself is still fairly young (early 1970s); affirmative therapy for gay males is even younger.

clients are the best at self-pathologizing
Before 1990, there was ample literature to support the idea that conversion from homosexual to heterosexual was a preferred intervention. Some therapists believed it was in the best interest of their clients to change their sexual orientation, given that it is impossible for a gay man to live a happy life or have a stable relationship (6). There is still conservative religious literature that supports this perspective, but it is less common than before.

There is now consensus that it is damaging to a person to attempt reparative or conversion therapy with him. I am surprised at how often I get referrals of men who were treated with conversion as the goal. However, more common these days than outright suggestions for conversion is the perception of disapproving attitudes from psychotherapists that negatively reinforce a client’s feeling about being gay. Often these therapists are seen as rejecting and uncaring, though I would guess that many of them are actually just unaware of how they are coming across to their clients.

People who grow up with healthy authorities may not recognize that a gay man has tended to the needs of the authority figures (including parents) in his life by keeping quiet and hiding his secrets. Therefore, a client may recreate in therapy a dynamic he had with his parents by remaining hidden. The need to be compliant or good prevails. Therapists need to be on the lookout for such a dynamic and create a tone that implies mutual openness and acceptance.

the bottom line is that accepting your client for being gay is essential
The bottom line is that accepting your client for being gay is essential. A wonderful description of gay-affirmative therapy states: “Psychotherapy can result in change, although this is the secondary goal to creating an experience of empathic contact for the patient, whether or not change takes place” (2). Right on. Making this connection will be as useful as anything else.

Perhaps the best way to provide affirming therapy is to accept and affirm that you care for your client. Then you find a way to join him in his views and sensibilities. The therapist’s ability to be reliable provides a milieu that aids the patient in experiencing “twinship.” Sensitivity and empathy affirm that patient’s sense of self (2). Internalization of these interactions can lead to significant internal structural expansion and cohesion.

A Gay Affirmative Perspective in Action

You want your client to feel comfortable, valuable, proud about being gay, and for him to know that you are in accord with his true self. You can do this by finding avenues of connection with him, as a person, not just as a client.

there is no need to try too hard to win him over, the way that you effortlessly relate is the win
Allow yourself to appreciate how you respect him, where your commonalities intersect, and how your differences are intriguing to each other. This way of relating is not didactic, but rather it is intuitive and emotional. Either you both will feel it, or you won’t. There is no need to try too hard to win him over, the way that you effortlessly relate is the win.

Script: Seeing and Knowing You

This script was inspired by a client sharing his difficult experiences of coming out in college. Because these struggles were having an effect on his coursework, his professor asked to meet to offer him support. His memory of receiving nurturance all those years ago was so profound that he describes it as a turning point in his life. Ironically, he remembers nothing about what was said. Instead, he vividly recalls the feeling of being cared for in this special relationship. The lamp that was shining on his professor’s desk figures prominently in his memory. The visual representation of this lamp still captivates him and represents the richness of this experience, even 30 years later.

I am struck by how other clients report similar types of childhood or young adult memories, often with neighbors, grandparents, aunts, uncles, or other people who shared their love.

This script can be used as a reminder that there were people in the past whose nurturance made a lifetime of difference. In addition, I use this script at conferences and with therapists to remind them about having had significant moments like this in their own past.

For traumatized clients who cannot conjure up anybody who provided this type of experience, a family pet or a childhood toy can be used.

“Allow a time in your past to come to you when you may have felt awkward, just a little bit different from others, or perhaps you felt alone. It might have been as a child or as a teenager, and you can look back and appreciate what it was like for you then, remembering the ways that you may have held yourself back, or constrained yourself. You can even assume that position in your body right now.

You can also appreciate how time has shifted for you now, since you are no longer at that place anymore.

Now, remember a person back then who could see you and know you for who you really were, and for what you needed at that moment in time. You can appreciate how it feels that you knew that he or she cared about you, how lucky you were and are to know that he or she cared. This caring person may not have even verbalized the ways that he or she could appreciate you, or the ways that you mattered, but you just knew this was so. You simply knew this by the way the person looked at you, spoke to you, or did something special, just for you. Appreciate the way it feels inside.

It may have been a teacher, a doctor, an aunt or uncle, or perhaps a neighbor who noticed you and took care of you in just the right ways. In your mind, you can see what this person looks like, where you were back then, and what the surroundings looked like back then. You might even remember the sounds or smells back then. That is right.

This person could see you for who you really were and really are, and was able to offer you love and support, and it felt so very special. It was just what you needed. Appreciate how it feels now and assume that position in your body. That is right.”

“If I Can, So Can You”

I provide experiences that help my clients feel alive through my own interactive stance. Near the start of treatment I say: “What you see is what you get.” In addition, I am mindful of my posture, movements, tone of voice and use of eye contact, all to imply an available informal stance that encourages the same of them. This mindset provides gay men with new opportunities. It is met with great relief, especially for clients who have had more aloof therapists in the past.

my informal use of self serves as a role model with its intrinsic message of acceptance of being gay
Clients are grateful to experience this positive energy and it elicits a new way of being: My informal use of self serves as a role model with its intrinsic message of acceptance of being gay. Just being myself has proven to be the most successful therapeutic tool in the room. Again, behind the curtain of any therapy technique should be authenticity: this is what allows for the power of any given technique to come through.

A quick story about my client Thomas: He was raised Mormon and says he envies the confidence of his Jewish friends. Turns out, his therapist, me, is Jewish and gay. I was excited from the start that he was willing to use the energy between us as a part of therapy; it is just how I love to work.

While exploring career stagnation, he describes a scene in hypnosis that suggests a dynamic between us. It hadn’t occurred to me until months later when I re-read my notes that the person he described might be me. It reflects how powerfully the relationship in therapy is experienced, even when it isn’t in full conscious awareness.

“There is a man in the foreground, standing in water. It is some kind of a pond or a lake. There is a reflection of a forest behind him, and the background is green and black. The sun is focused on this man. He is smiling with his head tilted, looking friendly, but strong and inviting.”

Perhaps the sun that focuses on me symbolizes the success he perceives in me, or me in him. I often am inviting him to leap into the depths of the water, either with me, or for himself.

The next excerpt brings Brad back. Here you get a glimpse of what the weave of therapeutic alliance, experiential work, and calling forth the client’s resources looks like in session.


love is wanting someone who truly wants me, rather than my settling for his approval of me
Thinking about his growth in therapy, Brad is very clear: “Love is wanting someone who truly wants me, rather than my settling for his approval of me. I have been waiting too much for permission from men. I deserve to have a man offer me what it is that I want, and it is exciting that I am beginning to be self- directed now. I am going against the old voices I have lived with for years.”

In exploring ongoing themes, he describes, “When I am faggy, I am faggy by choice, no more editing of myself!”

Knowing how much he enjoys being creative in hypnosis, I decide to embrace his “faggy” stance in a way that symbolizes resourcefulness. I ask him to describe a memory when feeling this way was wonderful. (This was all with his eyes closed, in hypnosis, where he could let himself go more than usual.) He recalls going to the disco in the late 1970s: “Everybody was happy, celebrating their gayness and having a ball on the dance floor, uninhibited and free.”

When I ask which “faggy” song was playing — reflecting back his use of the word “faggy” in a light and easy way — he answers: “‘I Feel Love’ by Donna Summer.” Since we grew up in the same era, we spend a few moments mutually sharing our enjoyment of these times. I continue with this theme.

I ask him to bring this feeling of being free to a time in his past when he would have liked or needed more of it.

“I am in the way back of my parents’ station wagon. This was a place where I would go to in order to escape from them and try my best to feel free from them.” Knowing that he is a wonderful singer, and assuming that his singing will be a powerful experiential moment, I then ask him to sing the song out loud. I am right. It is a powerful and intimate moment. I push him to push himself further than he usually does, and I also participate in enjoying the depths of this intimate moment, one of the more intimate moments in my career.

He begins meekly:


It's so good, it's so good It's so good, it's so good It's so good


You and me, you and me

You and me, you and me You and me


It's so good, it's so good It's so good, it's so good It's so good

I feel love, love, love, love, I feel love.”

He is very self-conscious, but he continues. It is incredible. I ask him to describe what happens next. “You are driving the car, the music is blaring, I am in the way back and the lights are blinking, like the lights in the disco. We are now at a red light, where the people in other cars watch us.”

He is emphatic: “Turn up the volume, Rick!”

I had turned up the volume by asking him to sing, and gladly turn up the volume again in this important moment.

With tears, he says, “This is so incredibly hard. I want to be somewhere where all of this is okay, and it is right here.”

Experiences Unite

The success you achieve with your clients comes from your ability to join your client in his world. This often feels like a trance state or state of flow where everything else goes away and it is just the two of you. This ability to join involves the challenging task of putting your own perceptions and experiences aside.

the success you achieve with your clients comes from your ability to join your client in his world
However, in a trance state it can feel effortless. Martha Stark describes the tension between decentering in order to lose herself in the client’s experience, while recentering in order to give her authentic self to her client. Though she does not do hypnosis, it certainly is hypnotic.

A client sitting with his eyes closed and allowing the therapist to guide his experience is in a vulnerable position. In these moments, the client is no longer able to reference the therapist’s facial expressions to judge how the emotional interaction is proceeding. Trust is paramount and should be well established before embarking on this type of work, and one should only proceed with the client’s full permission.

The payoff for those who can establish comfort with vulnerability is that therapist and client together have greater access to the richness of the client’s internal world. This happens through joint exploration and joint experience. Clinician and client follow each other’s leads, and at the same time, each takes the lead.

The experience is mutual: a deep state that is creatively assembled and experienced with and for each other. This is interpersonal trance. The therapist’s unconscious mind tunes into the client’s unconscious messages, feelings, and needs. The therapist involved in this trance activity is better able to resonate empathetically with the client, and to meet his unconscious needs. As both experience a receptive trance, the client is also experiencing an interactive, interpersonal state of high resonance. The internal resources of therapist become available to him.

Even though this is done experientially, the experience is processed consciously, and the client not only has the benefit of what came up while doing this work, but also has the benefit of expanding on the respectful and loving experiences within him.

Often, while doing hypnosis, I am aware that I am talking to the child, and that he is responding to me both as child and as adult. Thus, I exaggerate the softness or the kindness in my voice during these moments. The client is often nodding his head, receiving my voice — its cadence and tone — as though listening to a lullaby. Inevitably the experience of being understood and appreciated moves clients to tears. Milton Erickson believed the therapist’s role to be a surrogate parent, and I concur.

The brief excerpt that follows provides a snippet from a much longer hypnosis in which I placed emphasis on being relational and tailoring the session to build on the solidity of my connection with the client.


Bud was having difficulty moving out of his parents’ home and establishing an independent life. Together we go on a journey, traveling by car.

Me: “And even though I am driving the car, I wouldn’t know where to go unless you gave me directions, because you are the navigator and all I am doing is following your directions.”

Bud: “We are still in the car; you are continuing to drive me past all the dark places. And you know exactly where to go, you know where to take me, I can’t do this alone. Please don’t leave.”

Me: “And you can trust, Bud, that I am here for you, that I am not going to drive away. And I wonder if you can appreciate moments when you sit here with me during a session, and moments when you leave a session, and I am not with you anymore, and yet I am with you at the same time.”

Bud: (Nodding his head) “That feels very manageable, very reassuring. Not so scary. Manageable. It doesn’t feel as scary, or lonely. I can hear you in the back of my mind telling me I can do this; I can manage this. It feels good. It makes me feel like I can do this. I can hear you saying, ‘You can do this; you can get through this.’”

“I Am Here for You”

Earlier I talked about the significance of maintaining a “You can” position for our clients. Another important stance is “I am here for you.”

If a client is struggling with pain, I want him to know that he doesn’t have to hold it by himself
I say or imply this often, and with great sincerity. It cuts through many protective layers when offered at the right moments. Sometimes I directly say this in hypnosis. If a client is struggling with pain, I want him to know that he doesn’t have to hold it by himself. This is a hard allowance for men who have been denied and have denied themselves the availability of others and of love.


Jason is a client with a painful history of sexual abuse, alcoholism, physical abuse and emotional neglect. He has learned to quietly excel in his own private world. Although it appears that he is successful and gregarious, and has many close friends, he is actually a loner and keeps himself well hidden from others.

Over the course of his sessions, it is clear that he is doing with me what he does with others, deflecting and hiding. One day I decide to take a big risk.

I ask him if he knows that I am really there for him. Tears come to his eyes. “I am here for you, Jason. And I will continue to be here for you.” These words are magic to him. He continues to weep, relieved and moved.

Later he expressed many times that this was a pivotal moment in his life. “It was the first time I could believe the truth of this: Rick is and was there for me.”

Going Deeper into the Relationship: Dealing with Conflict

When you sense that your client is having a struggle with you, do you encourage him to speak about it?

Do you ask him to describe what he needs from you?

Are there times that you avoid these kinds of conversations?

Do you find yourself giving in to your fear about pushing your client?

How many times has your client had struggles with an authority figure and not been able to discuss it?

we hope that the connections with our clients provide lasting changes, and that our relationship provides the love of a parental figure
Many of us simply prefer to avoid these kinds of discussions and instead stay focused solely on the client’s symptoms and presenting problems. In doing this, we miss out on rich moments. We hope that the connections with our clients provide lasting changes, and that our relationship provides the love of a parental figure. It does, and yet there needs to be more: working through the resolution of conflict is a crucial piece. It adds richness to the therapeutic experience, particularly with clients who stay for longer treatment.

Dealing and working through conflict in the context of the therapy relationship is a must because a gay client’s history with conflict may simply consist of avoidance. But in life conflict is inevitable; now is his chance to move through it in a different way. The question is, will you meet him there?

Whose Fault Is This Anyway?

Apologies and countertransference disclosers are crucial to successful therapy with gay men. The shame that gay clients feel is often manifested in accepting responsibility for painful experiences that are externally prompted. An empathic lapse by the therapist often becomes a source of self-criticism for the client.

I recall once in a group I was leading that I made a joke that turned out to be at one of the participant’s expense. As soon as I blurted out the joke, the group came to Todd’s rescue making clear that my comment was too gruff. It would have been tempting to rush to my own defense, “explaining” what I really meant, in order to save face. Of course, this would have also further isolated the participant and put the group in a dilemma.

Instead, I contacted him immediately following the meeting and apologized. And in the next meeting I took responsibility by reiterating to the group what Todd and I had talked about. It was important for the group, and Todd verified how important it was for him to have me apologize.

Martha Stark discusses “The New Good –The Old Bad;” The unconscious wish on the client’s part to engage the therapist in a reenactment of his internal dramas, with the therapist assigned the position of the powerful parent, and at times the position the client once had as a vulnerable child in relation to his powerful parent. She asserts that “Good is internalized as a consequence of surviving the experience of being failed.” Keeping this in mind can be a useful way of reminding ourselves why it is important to understand the client’s needs rather than simply to defend our actions. The goal is to have a resolution of relational difficulties through reworking “bad.”

My insensitivity in the form of a joke made Todd feel shame and being able to own this allowed him to not to blame himself. Job poorly done (the joke), and then well done (the apology).

a truly empathic perspective is never an issue of who is right, or who is wrong. Rather, what matters is the client’s perception
Again, Stark: “A truly empathic perspective is never an issue of who is right, or who is wrong. Rather, what matters is the client’s perception, the perception of having been failed. She further describes the inevitability of conflict in the therapeutic relationship and refers to a “corrective provision” that needs to happen, hence, the new good. The emphasis is not so much on intellectual understanding, but on emotional experiencing.

Script: The Calm After the Storm

“Frequently after a disagreement there is uncertainty or tentativeness in any relationship. Based on the significance of the therapeutic relationship, when a client is willing to stay in therapy after a conflict, we want to reassure him (and ourselves) that things can and will be okay again. Even though we know that working through conflict is essential, gaining confidence afterward is also important. This can be healing for client and therapist and serves as a reminder about the importance of the mutual relationship.

You can appreciate that when there is a heavy rainstorm just how loud and intense it seems. As you listen to the sound of the rain beating on the ground or the building that you are seeking refuge in, it seems as though the storm is never going to end. Roads or walkways get flooded, plants get beaten down, and that unsettling feeling inside feels endless.

However, there is always a time when the storm abates. You know that from your own life experiences, yet in the midst of it, it seems as though the waiting is endless.

Sometimes summer storms are the most intense. You can watch the sky turning darker and darker, with the winds getting heavier, and then, the rain comes.

But, as quickly as it appears, it also passes with the same speed and the same gusto. Sometimes you can see the sky split between darkness and lightness. Not only do you know that the lightness and the sun will re-appear, you await it. That is right.

Appreciate that really calm feeling in your body as the rain stops and you see the sun coming out again. Everything is brighter, quieter, and even the birds quickly start chirping again. Notice the ways in which things shine as the sun reappears. That is right.

When you were a kid, or when you were on vacation, you might have even ventured outdoors after the storm to walk around. Walking barefoot, feeling the warmth from the earth or pavement on your feet, seeing the mist rise from the ground, and taking in those post-rain smells. It feels so quiet and so calm now, so different from just a few moments before. Really appreciate the ways in which your body absorbs the calmness and the quietness. The worst is over, you now feel a quiet and a peace inside. Excellent.”

The Other Side of the Coin

If the relationship is at the center of successful therapy, what happens when the relationship doesn’t hold? Like most any therapist, I have had this experience.

it the relationship is at the center of successful therapy, what happens when the relationship doesn’t hold?

David’s initial reasons for coming to therapy involved social anxiety and depression, which kept him from developing friendships and intimate relationships with other gay men, which he craved. For months, our relationship was wonderful. I was the stand-in for a good enough parent, chiefly his father. Interestingly, when he would visit his father, he would return and be more reticent with me. It was as though he were being forced to choose between us — his rigid father and the more accepting figure he found in me — and rather than choose, he simply shut down until we were able to once again open our communication.

Our sessions were very satisfying. We spoke at length about his family and the significance of his independence. We also spoke about his social involvements in gay sports and the local gay gym as ways of meeting people. He slowly took risks and began to develop his social confidence.

When he felt ready to take on a new challenge, we agreed that a gay interpersonal therapy group would be the next step for him.

But at a certain point, he became angry with the group and with me for not having protected him in the way that he wanted.

This was painful for me. I was accustomed to being a savior with him, and knowing some of his self-destructive impulses, such as drinking or isolating himself, had me worried. I contacted him and asked him to agree to come in for at least one session before making any final decisions.

I practiced and practiced what I would say. I also got some supervision and coaching. I wrote a letter that I read out loud when he came in. This showed David how much time and care I put into thinking about him. It also allowed me to say what I needed to say without getting sidetracked. Yes, I wanted him to grow, but I also wanted us to be okay.

I wrote: Thank you for your willingness to be honest, contemplative, and truthful. Can you hear my viewpoint, experience my judgment, and trust that I still care about you? Can you give yourself the gift of experiencing a disagreement and love at the same time? Do you accept that I (unlike your father) can tolerate your outbursts and still embrace you? Can you use your heart, rather than your hurt and your pain to make a decision? Can you stick with the relationships that bring you love, recognition, and feeling understood?”

David melted with tenderness. Our mutual stalemate had now loosened up. Experiencing me as the old bad, David would have fled from treatment and almost did. But with hard work, he allowed the opportunity for the new good, and as a result, was able to stay in therapy with me.

sadly, a couple of years later another conflict occurred and David left treatment without our being able to mend our frayed edges
Sadly, a couple of years later another conflict occurred and David left treatment without our being able to mend our frayed edges.

In hindsight I realize that by constantly defending myself, I inadvertently chipped away at the empathy that David needed from me. He knew this and continued pointing it out, yet I kept defending my stance, which in the long run broke the connection. However, in understanding this now, and no longer hanging on to the need to defend myself, there is a kind of reconnection too. It is my hope that he also finds this and can reclaim what he received from our work together.

Script (for therapists): Reclaiming Your Balance

This script is used to remind us, as therapists, that we have our unique abilities to care for our clients in ways that are intimately and mutually experienced.

However, when we get stuck in a struggle with our clients, or when they get stuck in a struggle with us, we sometimes forget that as therapists we can often make the shift that promotes closeness. This is a satisfying reminder of the implicit bond that exists between therapist and client.

“Allow a client who you sometimes struggle with to come into your awareness. Remind yourself that the love that comes from warmth and acceptance is what makes you a very good therapist in your own unique and special ways. That is right. Allow yourself to fully experience this inside now.

Notice the shift that you may experience as you visualize yourself sitting with this person. Feel it inside of yourself and notice how it may have shifted from the previous client who you do not struggle with.

In this moment you can really appreciate the ways in which uncertainty is experienced, perhaps by both of you. Be aware of tightness or tension inside, and how you may communicate this to your client, even in ways that may not be direct, or in ways that aren’t even verbalized. That is right.

Sometimes it is hard to acknowledge this, yet this time it may be just a bit easier to appreciate how you, as the unique therapist that you appreciated moments ago, can be available in a new or different way to this client whom you struggle with.

Even though it is hard, you can visualize yourself looking or sitting differently with this client. You can take this moment of feeling centered and bring it into the therapy session with this client. That is right.

Something about this moment right now allows you to acknowledge that there may be ways that you can carry yourself differently with your client, and you can even allow yourself to see a slight shift in the session between the two of you, all because you are able to find the strength inside of you to make a shift. And each time you make a shift like this, a change is felt between you, even though it may be little by little. Each change creates success.

As you see and feel this change taking place, just notice the ways in which you look different, feel different and are different, both inside and outside. Good.

You can bring this with you, inside of yourself to future sessions. You can enjoy the ways that you experience love and acceptance.”

We all do our best and want to be the kind of therapist who makes a big difference in our clients’ lives. We work towards making an alliance that will be profound. We don’t want there to be misunderstanding, but sometimes this happens. It is best to be honest — this is what we guide others to do.

there is always the option of another therapist who may be better suited to this particular client
Sometimes our defenses, needs, or vulnerabilities keep us from finding the right ways to settle the difficult moments. It is up to us to discover the paths to achieve resolution. If this is not possible, there is always the option of another therapist who may be better suited to this particular client. Often, verbalizing the truth of a struggle is more helpful than anything else and being honest about parting ways is easier than sifting through continual conflict or acting as though everything is fine when you both know it isn’t.


Does A Gay Male Client Need a Gay Male Therapist?

It’s all about relationship, right? A client needs to feel safe, seen, accepted, and understood. The therapist also needs to feel these things so that he or she can create an environment that promotes them. Generally, I have found that heterosexual male therapists are more homophobic than female therapists.

Many gay men would agree with this, which is why they might be hesitant to work with heterosexual men.

I am careful about whom I refer to whom. Even though referrals are frequently geographically determined, I am always certain to ascertain whether the therapist I am referring to is gay affirmative. With people I don’t know, I ask about their experiences working with gay men, and then listen closely to what they say and how they communicate with me. What I feel inside is most important, as if I were pursuing a therapist for myself. If I feel discomfort, I find another referral. I pride myself on making meaningful referrals and I suggest you do the same.

having a heterosexual therapist who is loving can be rewarding in a multitude of ways
Having a heterosexual therapist who is loving can be rewarding in a multitude of ways. Being accepted by a straight person is more powerful than being accepted by a gay man because of the painful histories with authority figures discussed earlier. Internalizing these experiences can mark the beginning of a new relationship with authority beyond therapy and into life.

If you are not gay, your gay clients will carefully and quietly assess your comfort level with them. This includes your knowledge about the gay community and what gay people experience in their day-to-day lives, internally and externally. It also matters how you communicate about this. Transformational relationships require sensitivity to differences and flexibility in responding to these differences (3). If you don’t know much about the gay community and feel comfortable acknowledging this, your sincerity will be perceived in a positive way. Pretending, on the other hand, will be detected and perceived as rejecting.

Sometimes a heterosexual therapist who doesn’t understand the gay culture will express judgment, which is hurtful, especially because a gay male has repeatedly had this experience. Skilled therapists do not challenge clients’ core beliefs.

The Four Pillars of Relationship Building

Honesty: Be truthful about the extent of your experience, no matter how limited, in working with gay clients. Your client will respond to your willingness to tell the truth. It’s the beginning of trust.

Authenticity Trumps Knowledge: Success in therapy is rooted in meaningful connection. Attention to the relationship is even more important than attention to your tools.

Being Yourself: Gay men are especially sensitized to you being who you are. Deceptiveness equals danger for gay men. And isn’t this the point of therapy, to be okay with who you are?

Therapeutic Interactions: Your love and acceptance are the wellspring of his growth and healing.


(1) Zeig, J. (2006). Confluence: The selected papers of Jeffrey K. Zeig. Zeig, Tucker, & Theisen, Inc.

(2) Cornett, C. (1993). Affirmative Dynamic Psychotherapy with Gay Men. Jason Aronson Inc.

(3) Short, D. (2010). Transformational Relationships. Zeig, Tucker, & Theisen.

(4) Yapko, M. (2012). Trancework: An introduction to the practice of clinical hypnosis (4th ed.). Routledge.

(5) Stark, M. (1999). Modes of therapeutic action: Enhancement of knowledge, provision of experience, and engagement in relationship. Jason Aronson Inc.

(6) Isay, R. (2009). Being Homosexual: Gay Men and their Development (2nd ed.). Vintage Books.

(7) Yapko, M. (2011). Mindfulness and Hypnosis: the power of suggestion to transform experience. W. W. Norton & Company, Inc.

(8) Brown, D. F. (1986). Hypnotherapy and hypnoanalysis. Routledge.

(9) Frederick, C. M. (1999). Inner Strengths: Contemporary psychotherapy and hypnosis for ego- strengthening. Routledge.

This chapter entitled, “The Therapy Relationship: Experience Expansion-Expanding Experience” comes from the book, Unwrapped: Integrative Therapy with Gay Men...the Gift of Presence, written by Rick Miller and published in 2015 by Zeig. Tucker & Theisen Publishers It is reproduced here with the explicit permission of the publisher, May 18, 2023.

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© 2023
Rick Miller Rick C. Miller, LICSW, is a psychotherapist in private practice, host of the Secrets of the Masters video series, founder and executive director of Gay Sons and Mothers, and co-host of the podcast Modern Couples: What Your Therapist Never Told You. His TEDx talk, The Mother Factor, grew out of his work with his nonprofit, which collects, celebrates, and shares worldwide narratives of gay men and their mothers to support LGBTQ+ training and awareness, enrich myriad diverse communities, and enable rapprochement, understanding, and healing. He is a frequent speaker at conferences for a myriad of academic and professional organizations and author of Unwrapped: Integrative Therapy with Gay Men and Mindfulness Tools for Gay Men in Therapy and writes a regular column for Psychology Today. His website is Rick Miller