CASE STUDY 1

Client A: Stage 1

Client A presents for clinical services to address two primary life concerns: her escalating drinking/drug use (prescription pills) and her recent divorce. Client A had been prescribed a benzodiazepine medication (lorazepam) by a psychiatrist for years to deal with what she describes as chronic anxiety stemming from early childhood sexual abuse. The client was never properly evaluated for PTSD. Client A has grown concerned by how her drinking is starting to affect her work performance and seeks counseling to obtain further guidance on the matter. Client A's clinician begins by educating her on trauma and how her symptoms seem to meet the criteria for PTSD based on her early child sexual abuse experiences. In talking about trauma, Client A starts to connect the dots with other aspects of her life that also seem traumatic or wounding for her, including her sexuality.

Client A relays to her therapist, a trauma-focused eclectic, that she first knew she was bisexual around 14 years of age, when she became cognizant of the fact that she was attracted to both boys and girls. At the time, a therapist prodded Client A to come out to her conservative, Catholic parents. When Client A would not do it, her therapist outed her to her parents, justifying it as a safety measure. This premature disclosure ushered in several years of discord at home. Although Client A's parents never considered sending her for any kind of religious intervention (e.g., reparative therapy), they thought it was a phase she would outgrow. At 18 years of age, Client A's siblings told her that they would support her in coming out, but that there was no such thing as bisexuality. One sibling even encouraged her, "It's okay to come out as fully gay; I'm here for you."

While this support meant the world to her at the time and eventually helped her to live her life openly and publicly as a lesbian, now Client A is recognizing how invalidating and misinformed her sibling's statement was. Client A identifies that the stressors of her six-year marriage to a woman impacted her alcohol consumption, although by the time she presents for services she does not need to be convinced that she has a substance use problem and is open to a referral to attend a local 12-step group. Client A finds a sponsor at a local meeting that affirms her bisexual identity, and as she grows to trust that her therapist is not going to try to talk her out of being bisexual, the quality of her work begins to deepen. Client A also accepts a recommendation to attend a local "recovery yoga" class and begins working to develop a set of coping skills, like breathing and meditation. Client A is encouraged by her therapist's suggestion to begin exploring some stories of other bisexuals published online on advocacy websites. Every time Client A reads stories of people who were originally out as gay or lesbian and began to own the truth of their bisexual identity, she finds herself nodding her head in agreement.

Client A: Stage 2

Client A's therapist is certified in EMDR in addition to being a registered expressive arts therapist, and she works with Client A in both modalities to help her target the oppressive cognition of "I do not exist." This oppressive cognition is connected to her siblings' comments invalidating her bisexual identity and her parents' treatment of her coming out as "a passing phase."

According to the World Health Organization [38]:

EMDR therapy is based on the idea that negative thoughts, feelings, and behaviors are the result of unprocessed memories. The treatment involves standardized procedures that include focusing simultaneously on (a) spontaneous associations of traumatic images, thoughts, emotions, and bodily sensations and (b) bilateral stimulation that is most commonly in the form of repeated eye movements. Like CBT with a trauma focus, EMDR aims to reduce subjective distress and strengthen adaptive beliefs related to the traumatic event. Unlike CBT with a trauma focus, EMDR does not involve (a) detailed descriptions of the event, (b) direct challenging of beliefs, (c) extended exposure, or (d) homework.

The EMDR process allows clients like Client A to make connections between memories that they did not consciously realize had an impact. In targeting the memories related to the cognition "I do not exist," and her siblings' invalidating comments, Client A also recognizes that her therapist outing her to her parents made her feel like she did not exist and that her feelings did not matter.

Through her engagement with EMDR therapy and visual art making, Client A fully embraces the beliefs of "I do exist, and I matter." She accepts these beliefs as they relate to her sexuality, and she translates them to other scenarios in her life as well. Client A also finds that making music playlists helps her reclaim her sexual identity, and sharing music that meaningfully expresses her journey of sexual development eventually helps her to share what it means for her to be bisexual with her mother.

Client A: Stage 3

After two years, Client A is two years sober, is working in a job that she loves, and is in a relationship situation that makes her happy. However, she has no plans to stop seeing her therapist. Their work together is largely maintenance at this point, but Client A finds it helpful to be able to work through the petty, spiteful comments she hears from others (especially old friends who knew her and her ex-wife) with professional assistance.

Another issue of navigation for Client A is being in a polyamorous relationship. Client A reports that engaging in this lifestyle is helpful and meaningful to her at this point in her journey of sexual development. She has a boyfriend, the first major relationship with a man she has enjoyed in her life, although he is open to her having relationships with other people.

While Client A is happy with this open and polyamorous arrangement for now, there are logistical issues and some jealousy to navigate, which she does with the help and support of her therapist. Moreover, Client A does not envision herself being polyamorous long-term, as she would like to settle down with a primary/exclusive partner (of any gender) and raise a family at some point. Client A is enjoying the journey of exploration for the moment and finds it very helpful to be guided by a non-judgmental, affirming therapist in the journey.