#71501: The Bisexual Client: Trauma-Focused Care

The American Institute for Bisexuality, formerly called the Klein Institute, was founded by Dr. Fritz Klein, a pioneer of bisexual visibility, in 1998. The Institute's mission is to educate the public, including human service professionals, about the needs of those who identify as bisexual. The Institute also seeks to promote and fund research on bisexuality and to engage in public discourse on bisexuality and issues of sexual identity. In his book, The Bisexual Option, Dr. Klein offers a set of concepts to describe bisexual identity and the bisexual experience [3]. In essence, a bisexual person has the capacity for romantic and/or sexual attraction to more than one gender. For most people, this means they can be attracted to both men and women. If one honestly feels he or she meets this criterion, then he or she is bisexual.

It is important to remember that bisexual persons are not required to feel the same kind or intensity of attraction to all genders. There is nothing for bisexual persons to prove, nothing to consummate, and no requirement to "maintain" their bisexuality. Understanding and acknowledging one's sexuality is a personal process and is about living with integrity and being true to oneself.

Bisexual and other non-binary sexual identity advocates have long embraced the Klein definition for its inclusivity and lack of emphasis on labels, categories, or boxes. The well-known Kinsey Scale was a step in the right direction, offering a continuum (on a scale of 0 to 6) as a measure for describing sexual identity (0 being exclusively heterosexual and 6 being exclusively homosexual, with various degrees expressed in between). However, Klein found the Kinsey scale too limiting and developed his own alternative—the Klein Sexuality Orientation Grid (KSOG), a more nuanced measure of the fluidity and complexity of sexual orientation (Table 1). The KSOG takes seven key variables into account—sexual attraction, sexual behavior, sexual fantasies, emotional preferences, social preferences, heterosexual/homosexual lifestyle, and self-identification (which can include sexual identity and political identity)—and recognizes that a person's preferences may change over time. According to Klein, recognizing that sexual orientation is an ongoing dynamic process is necessary in order to understand a person's orientation properly in its entirety [3]. After completion of the KSOG, a point score is issued that gives some insight into where an individual falls on the continuum (21 being exclusively heterosexual and 147 being exclusively homosexual), with more specific findings than the Kinsey Scale.

Professionals and bisexual advocates also cite the definition of activist Robin Ochs. Ochs was one of the first individuals to declare herself a bisexual advocate in response to the little attention she witnessed being paid to the unique needs of bisexuals in LGBT+ discussions in the 1980s. The Ochs definition of bisexuality reads as follows [4]:

In educating clients and clinicians about the bisexual experience, offering this definition is often a solid place to start.

The National Gay and Lesbian Task Force definition of bisexuality can be especially helpful for professionals new to learning about bisexuality. The Task Force notes that bisexuality is not an extension of homosexuality, and bisexuality does not require both male and female partners [5]. Behavior and identity can be, and often are, very different; a person can have a bisexual identity even if he or she is celibate or involved in a monogamous relationship with a person who identifies as gay, lesbian, heterosexual, or bisexual. Knowing whether a person identifies as heterosexual, gay, lesbian, or bisexual is not an accurate method of predicting sexual behavior.

Many bisexuals embrace a bisexual identity because, especially if one adheres to the Klein definition, it defies the concept of a binary. Being bisexual challenges larger societal messaging that everything must fit nicely into predetermined categories or labels. Klein commented on this phenomenon in The Bisexual Option [3]:

Oregon governor Kate Brown, America's first openly identified bisexual governor, described her experience of being bisexual as such: "Some days I feel like I have a foot in both worlds, yet never really belonging to either" [6]. Brown's experience resonates with many bisexual-identified individuals. Marich explained that such an identity and life experience poses a major problem when bisexuals seek clinical treatment services [7]:

Part of rejecting the damaging effects of labeling and categorizing is to also recognize that people who have traditionally been described as or have identified as bisexual may no longer find that term to fully embrace their identity and their experience. A growing momentum to change the traditional LGBT abbreviation to a more inclusive LGBT+ is one way this sea change is manifesting in larger discourse. As discussed, LGBT+ is an alternative to the traditional LGBT abbreviation that has come into popular use in the 2010s as a gesture of optimal inclusion to all individuals who may identify as being part of a sexual or gender minority group; this recognizes that the abbreviation could continue to expand indefinitely as understanding about the diversity of sexual identity and gender expression evolves. A running commentary is that if the LGBT community continued to embrace all sexual identity, gender identity, or lifestyle identity minorities into the abbreviation, it would be an excessively long acronym. LGBT+ is a growing alternative to be inclusive for all persons who do not feel like they belong in the sexual identity or gender identity mainstream. Heteronormative refers to traditional norms and mores for sexual identity and expressions being assessed by the heterosexual ideal of how things should be; people who reject heteronormativity often identify with one or more descriptors embraced by the LGBT+ abbreviation.

There is also a growing movement of individuals who are rejecting the term or the label of bisexual as being too limiting. Because the nature of sexual identity is ever-evolving, many, particularly members of younger generations in the LGBT+ community, may choose less restrictive identities to challenge what it means to label and to identify. It is important that some of these identifiers be explored, as they may be more comfortable for clients. Queer is a term that has come into wider use in recent years as an umbrella term for sexual, gender, or lifestyle identity that defies heterosexual or mainstream norms. Originally used as an insult, many members of younger generations have reclaimed it as an empowering word, although those outside the community should be careful using it widely, as members of many older generations, especially gay men, still associate it as a term of insult and shaming.

Fluid is another term coming into wider use in recent years. In an open forum posed for readers, the American Institute for Bisexuality offers this useful description [8]:

The Institute explains that the term bisexual remains the more scientific identifier for describing sexual fluidity, especially when the intricacies of Klein's work are embraced [8].

In discussing the concept of heteroflexibility, the concept of straight men who have sex with men also arises. Several research studies have been conducted on this construct of men who identify as straight and have also disclosed encounters with men that are purely recreational in nature or in response to intoxication. As with many identifiers, it is important to refrain from judgment when men disclose such behaviors (e.g., do not assume that a client is a closeted or "in denial" gay man).

The American Institute for Bisexuality also explains that newer terms such as pansexual, polysexual, omnisexual, and ambisexual are now preferred by individuals who may have traditionally identified as bisexual. They offer this very succinct explanation [8]:

The editors make an interesting link to the shifts that the larger community is making around gender identity.

Belous and Bauman conducted an academically rigorous content analysis of online content referencing pansexuality, attempting to make comparisons and contrasts between bisexual identity and pansexual identity [9]. They explore themes such as whether or not the term pansexual carries less stigma than the term bisexual (which may explain why many young people are opting for this identifier) and whether people are opting for the term pansexual because it is fundamentally more inclusive and not as binary. In an era in which wider acceptance is growing for gender fluidity and transition, such a term may be more relevant to certain experiences. Belous and Bauman challenge a long-held notion that pansexuality falls under the bisexual umbrella, suggesting that bisexuality may better be examined as a subset of the pansexual identity, and not the other way around [9].

Working with the needs of transgender clients is beyond the scope of this specific course, but it is worthy to note the similarities between the bisexual struggle and the problems with discrimination and alienation that many trans-identified individuals have experienced within the larger LGBT+ community. While bisexual individuals have often referred to themselves as the "silent B," transgender or other gender non-binary individuals have referred to themselves as the "silent T." The LGBTQIA Resource Center at the University of California, Davis, provides a succinct definition of transgender/trans/trans* [10]:

Scholarship and advocacy around trans issues have brought an additional term—non-binary—into wider use. As it relates to gender, non-binary (often stylized as ENBY) is a gender identity and experience that embraces the full universe of expressions and ways of being that resonate for an individual. It may be an active resistance to binary gender expectations and/or an intentional creation of new unbounded ideas of self within the world. For some people who identify as non-binary, there may be overlap with other concepts and identities, like gender expansive and gender non-conforming [10]. While discussions around the fluidity of gender have shaped the terminology around experiences traditionally described as bisexual by ushering in the new terminology (e.g., pansexual, polysexual, omnisexual, ambisexual), many bisexual and sexually fluid individuals are choosing to adopt the term non-binary to describe their sexual identities as well. Non-monosexual is another option being utilized, a contrast to monosexual, or having sexual attractions/feelings to only one gender.

For professionals, it is important to respect the terminology that clients choose to embrace, if they choose any terminology at all. Professionals can get overly enthusiastic about getting clients to label themselves, but part of what the bisexual movement has always been about is embracing the nuances and fluidity of human experience. Other professionals, either implicitly or explicitly, are dismissive when a client, especially a young client, comes into session using a newly evolving term in identifying themselves. For instance, many individuals who historically identified as bisexual began using the term pansexual when it came into wider use, resonating with an increasingly popular axiom that "I am attracted to hearts, not parts." When this change in terminology became more noticeable, there was commentary (from both heteronormative people and others in the LGBT+ community) about how this term was another trend or a cry for attention. As a clinician, it is paramount, in the spirit of doing no harm, to educate oneself on the evolving terminology and to respect how clients describe themselves or identify. Many reputable websites are available for the purposes of educating oneself on evolving terminology (Resources).

Seeking to understand the perspectives of the younger generation, Flanders, LeBreton, Robinson, Bian, and Caravaca-Morera conducted an extensive, mixed-methods study of 60 identified bisexuals and pansexuals between 18 and 30 years of age [11]. The content analyses led them to overwhelmingly conclude that, for this sample, sexual behavior is not part of the comprehensive definition. Rather, identifying as either bisexual or pansexual has more to do with attraction and recognizing the fluidity of attraction over time. They also conclude, "The data do not support the stereotype that all bisexual people conceptualize gender as binary, or view their own sexuality as binary" [11].

For the sake of continuity and editorial clarity, the term bisexual or bisexual umbrella will be primarily used throughout this course. The bisexual umbrella is a term that has been in popular use for many years, although it is now gaining more ground in the academic literature to encompass all the related identities explained in this section [11,12,13]. Bisexuality still being the most widely recognized, scientifically validated term is the main reason for this decision. However, it is important to honor and recognize new identifiers as being valid paths of identity that clients may use to describe themselves, and also to acknowledge each person's right not to identify or label themselves.

A significant barrier for many bisexual individuals presenting for health care or clinical care is the fear of being truthful when asked certain questions. There can be a significant fear of being judged or further marginalized, especially when questions are asked about sexual history. Many individuals withhold truthful information that, in an ideal world in which the spectrum of sexuality is largely understood, may help professionals to better serve them. Biphobia (i.e., others' fear of bisexuality and misunderstanding about bisexuals) pushes many bisexuals further into the closet. This self-imposed isolation is generally to avoid ridicule and rejection, affecting well-being and sense of identity.

A 2015 study done in Scotland found that 48% of 518 individuals surveyed described receiving biphobic comments from healthcare professionals within the National Health Service (the United Kingdom's national healthcare network). Unwanted sexual advances by healthcare professionals were reported by 38% of the respondents. What is further compelling is that 66% of the respondents felt pressure to identify as straight and 42% of the participants found that it was easier just to identify as gay when presenting for healthcare services [14].

Discriminatory messages that bisexuals are likely to receive can be further damaging when a helping professional makes them. While this will be explored later in this course, at this juncture, it is important to understand that barriers exist about being truthful with any healthcare or clinical professionals, originating from this fear of judgment, ridicule, or misunderstanding.

Bisexual individuals can have even greater struggles with depression, mental health symptoms, and suicidal ideas than individuals who identify solely as gay or lesbian. According to a 2016 study from Drexel University that included responses of 2,500 LGBT+-identified individuals between 14 and 24 years of age, bisexual and questioning girls/women endorsed significantly higher scores on the depression, anxiety, and traumatic distress subscales than heterosexual girls/women. Lesbians, bisexual females, and questioning females all exhibited significantly higher lifetime suicide scores than heterosexual females. Interestingly, bisexual females exhibited the highest current suicide scores. Gay and bisexual males endorsed significantly higher scores on the depression and traumatic distress subscales than heterosexual males. Gay males also exhibited higher scores on the anxiety subscale than heterosexual males, with bisexual males exhibiting a nonsignificant trend toward higher scores as well. The research conclusion is that LGBT+ mental health needs should be individualized, calling for specific attention to be paid to bisexual clients [15].

The findings of this article likely come as no surprise to those who have been researching bisexual mental health and social conditions for years. Research has consistently found poorer health outcomes, mental health outcomes, and poverty levels/income inequality among bisexuals when compared with monosexual peers [16,17,18,19,20].

Trauma derives from the Greek work traumatikos meaning "wound." Professionals and diagnosticians continue to develop labels and technical rubrics for studying trauma and its clinical manifestations. Many are well-acquainted with diagnoses like post-traumatic stress disorder (PTSD), acute stress disorder, reactive attachment disorder, and other clinical labels from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) that generally suggest the presence of trauma. While many individuals who fall under the bisexual umbrella carry such diagnoses due to adverse life experiences, the problem with DSM-5 conceptualizations of trauma is that they are event-centric. In other words, trauma is only recognized if a traumatic incident that meets DSM-5 standards for an established condition occurred. This has created a barrier in recognizing and addressing adverse life events that may not meet the criteria for a formal diagnosis of a trauma-related disorder but that have had a serious impact on a client's life, mental health, and well-being.

From a humanitarian standpoint, trauma may be simply defined as a wound—physical, emotional, verbal, sexual, or spiritual—whether or not a precise DSM-5 definition is met for the suffering due to unhealed trauma. In the case of physical injury, there is often an initial wound, which may appear innocuous. However, if proper treatment is not received or if that wound continues to get agitated, further problems and complications can result. With physical injury, one large wound that gets treated properly may be less of an issue for a person in the long-run than a series of cuts or scrapes that continue to fester and infect.

According to the adaptive information processing model developed by Dr. Francine Shapiro, the creator of eye movement desensitization and reprocessing (EMDR) therapy, people learn things about themselves and the world as a result of adverse life experiences and wounding. The messages that come with these learnings are internalized and can result in either an enhanced ability to adapt (e.g., "I'm a survivor") or a paralyzing belief structure (e.g., "I am defective," "I am weak," or "I am permanently damaged"). Shapiro offers an interesting definition of trauma in the 2015 update to her adaptive information processing model [21]:

In light of this definition, consider how the life experiences that LGBT+ people, specifically bisexual individuals, may qualify as traumatic, especially when the messaging that accompanies the experiences happens at developmentally vulnerable periods of life.

For many bisexuals, the messages themselves may cause the wounding, further crystallizing negative core beliefs in the limbic brain, the center of emotions and learning. These negative beliefs are also referred to as oppressive cognitions.

Any minority group, especially those traditionally discriminated against by family members, the community, faith organizations, and society at large, is extremely vulnerable to being traumatized or wounded. In some cases, these traumatic experiences are public and large, such as in the case of hate crimes, physical violence, or pointed vandalism. For each of these public experiences, there are hundreds more that have remained uncovered. Moreover, much of the wounding faced by LGBT+ persons is experienced in the form of bullying, snide comments, and spiritually abusive messages by religious leaders or parents. For members of the LGBT+ community, dismissals and invalidation of personal identity and selfhood make up a large part of their trauma histories. Many individuals who identify as LGBT+ have also been forced into "reparative therapy," or variations thereof. These damaging religious programs are used to try to force change upon the individuals and how they love and express themselves in the world. It is essential that clinicians validate these subtler, yet equally insidious, experiences as traumatic.

Two concepts that are widely discussed in the trauma scholarship over the last decade—complex trauma and developmental trauma—may further help in the process of working with any LGBT+ client.

The HRC conducted a follow-up survey of nearly 5,000 youth who identified as part of the bisexual umbrella [25]. According to this survey, 10% of bisexual youth report that they "fit in" in their community, with 58% believing that they will need to move away at some point to experience fulfillment. In addition, bisexual youth report having experimented with drugs and alcohol at a slightly higher rate (56%) than gay or lesbian youth (50%) and at a significantly higher rate than straight youth (22%) [25].

Bisexual youth who participated in this survey reported the following experiences of how their sexuality is misunderstood by others, as expressed in messages that are very common to the bisexual experience overall [25]:

These statements gleaned from the HRC survey reflect many of the struggles that bisexual clients presenting for services have voiced over the years. These and similar messages reflect a reality that bisexuality is misunderstood by the public, in the context of a larger society that has traditionally been discriminatory against any sexual minority in the first place. To understand how these wounding messages can crystallize for clients who identify as being part of the bisexual umbrella, it is important to explore a newer concept in the trauma literature: oppressive cognitions.

Levis and Siniego first published the concept of oppressive cognitions in 2016. This term emerged from Levis' work as a trauma specialist/EMDR therapist and as a specialist in multicultural issues and providing culturally attuned psychotherapy. In EMDR therapy, the construct of negative cognitions, or the maladaptive messages that people receive about themselves or how they are in the world because of traumatic experiences, is critical. Levis took this a step further to suggest that when these negative cognitions or messages are received due to oppression, cultural trauma, or bias, they can crystallize more insidiously. Oppressive cognitions may be relevant to both the individual and to the specific minority group [26]. Furthermore, oppressive cognitions are sociopolitically influenced and culturally reinforced in an ongoing and insidious manner by the dominant majority and the media.

Levis and Siniego contend that treatment of oppressive cognitions requires a broadening of therapeutic focus [26]. Successful resolution depends on an acknowledgment of the impact that historic and ongoing social oppression have upon the presenting problem. For clinicians working with bisexual clients, recognizing the damaging messages that have traditionally been received by individuals identifying as part of the bisexual umbrella is paramount. While all of the messages reported from the HRC survey could apply, in this course, four specific messages are isolated for further exploration as oppressive cognitions:

The Joint Commission recommends facilitating disclosure of sexual orientation and gender identity, but practitioners should be aware that disclosure or "coming out" is an individual process.

(https://www.jointcommission.org/-/media/tjc/documents/resources/patient-safety-topics/health-equity/lgbtfieldguide_web_linked_verpdf.pdf Last Accessed: April 8, 2022)

Level of Evidence: Expert Opinion/Consensus Statement

The concept of coming out is more widely recognized as a phrase and a concept in modern society. However, it is rarely simple to define. Coming out is typically described as the process of revealing one's non-heteronormative sexual or gender identity to others. While coming out is often portrayed as a rite of passage or a dramatic event in the lives of LGBT+ people, the reality is that people who identify as LGBT+ are "coming out" their entire life in a society that is still largely heteronormative: to new friends, in new relationships, and in new work settings. When an individual decides to come out, it is generally a multi-layered process that usually begins with "coming out" to one's self first. People may then choose to come out to those closest to them, such as family, or may need to first come out to people they feel are safer than family, such as friends/a peer group, a school counselor, a clinical professional, or another ally. An ally is generally described in the LGBT+ community as someone who is affirmative, supporting, and accepting of diversity in sexuality and gender identity and does not attempt to change or steer the individual away from being who they are. Some people are outed without their consent or permission due to others in the community making assumptions about them or their behaviors. Such forced coming-out experiences generally qualify as traumatic or wounding for the individuals affected by this invasion of personal privacy.

It is important for medical, human services, and other clinical professionals to understand several key concepts about coming out. First, an individual identifying as LGBT+ must decide when and how to come out in health and mental health settings. In some cases, the coming-out process is unintentional and awkward, like when the provider asks about sexual preference and activity during the intake process. Clients may stammer with uncertainty about how to answer as they decide whether they feel safe enough to disclose important aspects of themselves, such as sexual orientation and gender identity. A client may also be uncertain about who they are and how they identify. In LGBT+ circles, the term questioning is often used to describe such individuals. Many questioning individuals present for clinical services to sort out their thoughts and feelings about how they identify and if/how to come out to others. Thus, being received by an affirmative (at minimum) and LGBT+-competent professional is imperative to making sure that therapy does not become a retraumatizing experience.

The coming-out process, even under positive and affirmative conditions offered by friends, family, and a faith community, can still be traumatic on some level, particularly when mainstream society is heteronormative and many people carry biases and hateful opinions. Realizing this second truth is a vital step for professionals. In working with bisexual clients, it is important to recognize how the previously discussed myths and biases against bisexuals can complicate the coming-out process. Many bisexuals choose to stay in the closet, fearing judgment from those in the mainstream while believing that they will find inadequate support among other LGBT+ people.

There is still a widespread assumption by many professionals and those in society at large that coming out as bisexual is just a step on the way to coming out as "fully" gay or lesbian, and some research suggests that coming out as bisexual may be a stepping stone for some, a construct referred to as transitional bisexuality [29]. However, professionals can do a great deal of damage by assuming that bisexuality is just a transition for everyone identifying as part of the bisexual umbrella. For many, being attracted to both or many genders and in various degrees is an accurate reflection of who they are and how they love in the world. It can be retraumatizing if a bisexual person seeking help encounters a professional who either minimizes or fails to appropriately validate their experience of coming out.

While a discussion of all of the issues connected to the coming-out process is beyond the scope of this course, there is one more vital issue to cover related to coming out for bisexual clients: the prospect of coming out again. Professionals who work in LGBT+-specific treatment routinely report the experience of educating their clients on bisexuality and hearing traditionally identified gay men or women state that they chose to be out as gay, rather than their actual bisexual identity, because everyone assumes they are gay. In particular, bisexual men are vulnerable to a great deal of prejudice and spiteful commenting, in some cases from gay men, about not being brave enough to admit that they are gay and come out of the closet fully [7].

For bisexuals across the gender spectrum, coming out to friends and their community as bisexual after initially coming out as gay or lesbian can be difficult. Consider the case of Client A, who initially came out as bisexual and was told by her family, "There is no such thing as bisexuality." Affected by this judgment, Client A chose to come out as a lesbian and ultimately to marry a woman. After her marriage ended, in exploring her relational dynamics in her own therapeutic process, Client A reclaimed her bisexual identity. Coming out as bisexual proved challenging, as she was still met with comments about "picking a side" and "switching teams." Yet, describing her sexuality authentically as a bisexual woman ushered in a new era of growth for her. Mental health professionals can help guide clients on this journey instead of keeping them stuck in those patterns of shame by practicing from a place of bias, assumption, or misinformation.

Do not re-traumatize—clinicians most often do this by prodding for too many details too soon or coming across as interrogatory. This relates to both the general biopsychosocial history as well as gathering information about sexual orientation or identity. Do not ask questions out of morbid curiosity or simply with the urgency to fill out clinical forms.

Do consider that getting an exact, chronologic trauma history may be unsafe or impractical because of how the memories are stored. Instead, determining presenting issues and corresponding themes is of utmost importance. If the topic of sexuality comes up in an initial session, exploring issues related to the coming-out process as a theme (as an example) may be more useful than getting a detailed history around sexual development.

Do ask open-ended questions. Questions that start with the words "what" and "how" generally allow clients to provide as much or as little detail as they are ready to give. Questions such as, "What are you willing to share today about your sexual orientation or sexual identity?," or "How has coming out as bisexual impacted your life?" are examples of how to avoid limiting clients to yes/no answers.

Do be non-judgmental. This does not mean endorsing maladaptive or unhealthy behaviors, but it does mean respecting the dignity of the person at all times. For LGBT+-affirmative therapists, it is imperative not to explore a person's sexual identity or orientation as a "problem" or the maladaptive response. However, a person may disclose engaging in problematic or addictive behaviors to cope with internalized shame and homophobia. If these phenomena are explored in the treatment plan, take care not to make sexual identity/orientation the problem—the heterosexist mainstream is the problem. With bisexual clients, discrimination from the larger LGBT+ community may also be part of the problem, although identifying as bisexual and claiming a bisexual identity is not. If one finds that their own biases are getting in the way of practicing non-judgment, seek further supervision, consultation, or training.

Do be genuine and build rapport from the first greeting. Forging a solid therapeutic relationship is essential for clinical success, especially in trauma-informed clinical services. Again, internal biases about LGBT+, specifically bisexuality, impede this process and should be addressed through supervision, consultation, or training.

Do consider the role of shame in bisexual clients presenting for treatment of addiction, trauma, and/or grief. Most clients identifying as LGBT+ carry some type of internalized shame about who they are and/or what they may have done to deal with the pressure of being who they are in a heterosexist society (e.g., substance use, acting out, hurting others while closeted). Recognizing this reality is an important competency for professionals who are in positions of power to further shame clients by making assumptions and judgments about being bisexual. Instead, professionals should help clients to see new, healthier truths about themselves and their capacity to love.

Do make use of the "stop sign" when appropriate. Let clients know that they can opt out of answering questions in the history, with the possible exception of questions related to suicidality/harm to others. Some of the greatest harm that clinicians can do with all clients, especially clients who identify as LGBT+, is to prod for too many details out of curiosity or because it is believed to be required to meet all the standards with paperwork. Those working for a highly regulated agency should determine how often statements like "client chose not to disclose" or "defer to further assessment" may be used in paperwork. Much of the detail that certain assessment tools require from clients about sex and sexuality should only be obtained in the context of established trust and rapport; this can be very difficult to do in a first session. Assess how medically and psychologically necessary a piece of information is to address the issue at hand. Although the answer may be "yes," in certain contexts (e.g., in diagnosing and treating a sexually transmitted infection [STI]), in many contexts it is not. If the latter, avoid prying.

Do assure clients that they may not be alone in their experiences, but be mindful not to minimize. Examples of minimizing with a bisexual client include using statements like, "I think everyone is bisexual to a certain degree," or "Sexuality is a continuum after all; it is not black and white." While such statements can be delivered with good intention as a gesture of normalization, consider how they are inherently minimizing. In contrast, sharing with clients that one has worked with bisexual clients before and has learned from such clients about their experiences may be a better way to normalize or help new clients to see that they are not alone.

Do have closure strategies ready. Allow at least 10 minutes to close down and consider teaching a brief coping skill at the end of a first intake session. For all clients, it is important not to run any session to the last minute with questioning and content, especially about sexuality. If a client does have a big reveal that may have even taken them by surprise during an initial intake session, be sure to check in about how they are feeling for disclosing such information about their sexuality or sexual behavior before they leave and develop a plan for self-care between sessions. One can also preview for the client how treatment will help them and address any goals they may have around sexuality. The essential lesson here is to avoid ending the session immediately after the client has unloaded. The term "vulnerability hangover" has been coined to describe the feelings of shame and remorse that people may feel after a big reveal [32]. If clients are ill-equipped to handle the feelings that may come up, they may resort to default coping mechanisms that are self-destructive (e.g., substance use, acting out).

Do be mindful of how screening tools or devices are administered to clients. Be careful to adequately orient the client to the rationale for why the tool is being used. Also, avoid simply placing people in a crowded waiting room or small confined office if those environments may be too triggering/activating. If a tool like the KSOG is determined to be useful, it is imperative to fully explain the survey and to provide privacy. How answering these questions may serve the client and the overall treatment plan should be explained.

Consider that assessment is an ongoing process. Clinicians will not (and should not) obtain all the information that they need in the first session, especially about sex and sexuality. Information about sex and sexuality can be deeply personal and sacred to clients and is best shared when they feel sufficiently safe to disclose such information. Although some client-clinician interactions have that quality of rapport developing instantly, for most clients identifying as LGBT+, the process takes time. For bisexual clients, especially if they have been told unkind or untrue things about their sexuality by professionals before, this process may take even longer.

One final item to note is that another, deeper paradigm shift is happening with those who take the role of trauma and its impact on the human experience seriously. Although being trauma-informed is a good first step and should be a minimum of care for anyone who works with the public, being trauma-focused is required to bring about deeper healing, especially for those discriminated against by a heteronormative mainstream in their development.

Trauma-informed care recognizes the role that unhealed trauma plays in human behavior, provides a template for minimizing harm in the delivery of human services, and offers an education framework for human services systems [33]. In contrast, trauma-focused care assumes that unhealed trauma plays a major role in presenting issues, denotes greater action in the delivery of treatment services, and promotes proactive treatment planning to heal the legacy of trauma [33].

Professionals who believe that human suffering is caused or exacerbated by trauma will gravitate toward a trauma-focused approach. In working with bisexual clients, it is important to understand that trauma is insidious and plays a major role in causing or exacerbating the problems that LGBT+ clients report in presenting for services [5]. For bisexual clients, the inherent traumatization of being affected by oppressive cognitions can be salient, so adopting a trauma-focused treatment strategy for healing is imperative.

There are many theories, modalities, and approaches available for the treatment of mental health issues, substance use disorders, and psychopathology/problems of daily living specifically linked to traumatic stress. Approaches can include traditional modalities, like psychodynamic psychotherapy, Gestalt therapy, existential therapy, and cognitive-behavioral therapy (CBT), to newer interventions, like EMDR therapy and dialectical behavior therapy, both of which are listed as evidence-based practices by major clinical organizations like SAMHSA [31]. In addiction counseling, interventions like 12-step facilitation and motivational interviewing are still popularly used; when applied in the context of cultural considerations, both approaches are effective. Social justice counseling and therapy based on feminist theory are appealing choices for many LGBT+ clients. Newer wave, more somatically informed interventions for resolving trauma, like body-centered psychotherapy, sensorimotor psychotherapy, or somatic experiencing, are also viable options for engaging in trauma-focused care with bisexual clients.

The aim of this section is not to make a case that any one approach works best for bisexual clients. There has not been enough research done specific to bisexual populations to begin making a case for any one modality as the best. In addition, a culturally responsive approach to treatment dictates that clinicians should never force a preferred mode of intervention on a client. Rather, clinicians should blend their expertise and knowledge of effective practices with the cultural needs and preferences of the client. A culturally competent and proficient clinician is "aware of the importance of integrating services that are congruent with diverse populations and capable of meeting their needs. Diversity is valued. There is a willingness to be more transparent in evaluating current services and practices and in developing policies and practices that meet the diverse needs of the treatment population and community at large" [5]. This is in contrast to a culturally destructive clinician or organization that imposes attitudes from mainstream culture, including inflexible beliefs about "what works" for a client.

Clinical flexibility that honors clients' goals and preferences for treatment is critical, and much of this means not imposing rigidity about the method for treatment. Eclectic or integrated clinicians trained in several different modalities may be in a better position to work with LGBT+ clients. In trauma-focused treatment, practitioners can still be flexible and have a framework from which to operate: Pierre Janet's Stage Model for the Treatment of Traumatic Stress [34]. Tracing back to the late 19th century, this model is still relevant in the modern era because it carries a great deal of timeless common sense. Janet's original model goes by different names in the field today, including the three-stage model, the triphasic model, and the three-stage consensus model. In the century since Janet published his ideas, nearly every major scholar writing on post-traumatic stress, regardless of their clinical orientation, can agree on the three-tiered structure. Places of consensus in a field that can be divided are valuable sources of content and clinical applicability.

Janet's original stages were [34]:

Aristotelian simplicity dictates that there should be a beginning, a middle, and an end (even if this "ending" is better conceptualized as maintenance) to the healing structure of therapy. Of course, there is room for practitioners to add a personal spin and to focus on one stage more than the others based on client readiness and need. For instance, many clients present for services reasonably stabilized and ready to dive into the deeper work of stage 2. Other clients may need to engage in some stage 2 work relatively early in the treatment process before they can come close to stabilizing, a function typically described as part of stage 1 [35]. Although exceptions exist and stage 2 treatment may need to occur sooner than usual, an attuned clinician committed to affirming the client and ensuring safety before engaging in deeper clinical work can work with the client to build an individualized treatment plan [35]. Working with client context has always been vital to understanding the consensus model. In the case of bisexual clients, their presenting problems, where they are in the coming-out process, how they have been impacted by oppressive cognitions, and the nature of the developing practitioner-client relationship should all be evaluated within clinical context to determine how to apply the consensus model for treatment.

One of the greatest misconceptions about trauma-focused therapy is that catharsis, or the second component of Janet's structure (i.e., identification, exploration, and modification of traumatic memories), is paramount. However, if an individual engages in catharsis and is actively working on trauma without having a foundation of skills for tolerating emotion or affect, further damage can result. Part of this foundation and groundwork includes a solidly forged therapeutic alliance with an affirming practitioner.

Another misconception about trauma-focused care is that after something is processed or cleared, then it is fixed and gone. This mindset promotes a misconception that trauma can be cured, but a healthier approach is to look at trauma as something that can be healed. Even after a person has a breakthrough in treatment, the process of reintegrating or adjusting to regular life after healing can be another source of trauma and/or adjustment. If a person undergoes successful major surgery but no postoperative follow-up or rehabilitation is provided, he or she could be seriously harmed. The same logic applies to healing emotional trauma, especially in working with LGBT+ individuals who are likely returning to a mainstream that is still less than friendly or affirming as a whole.

Consider how the consensus model fits with the wound metaphor addressed earlier in this course. Stabilization is the immediate attention to a wound. For example, stabilization might mean cleaning out the wound and disinfecting the area. Then, a dressing is generally applied to stop the bleeding and prevent infection or contamination. However, the wound needs to be exposed to the light and air in order to fully heal. Healing occurs from the inside and can take a great deal of time. This process is stage 2. After a wound heals, it generally leaves a scar. In cases of relatively benign wounding, that scar may resolve completely. With more significant injuries, a person may live with a scar or whatever aftermath is left after the wound heals [36].

In 2012, an expert consensus panel of the International Society for Traumatic Stress Studies issued their recommendations for addressing complex post-traumatic stress. The panel still recommends the general sequence of the three-stage consensus model as the standard for trauma care [37]. The 2013 World Health Organization report on treating trauma also makes reference to similar themes, particularly the importance of psychologic first aid (or stabilization) as a standard of care for PTSD [38].

Trauma, grief, and how wounds manifest are not linear, especially for bisexual umbrella clients whose state of being can be qualified as traumatic experience. One concern with models for clinical intervention is that the more "steps," "numbers," or "components" they contain, the more likely clinicians are to be confused about how to deal with unpredictability. No model can capture the truly messy nature of unresolved trauma or grief, let alone offer the perfect solution for healing it. A simpler model allows for flexibility and the ebb and flow that characterizes human healing. As such, the consensus model is a framework. It is common sense to stabilize first—to make sure a person can deal with what may come up in the stage of deeper identification or exploration [36]. Affirmative practices and teaching basic skills for managing affect, feelings, and unpredictability (especially if a coming-out process happens during treatment) are imperative in stage 1 work with bisexual umbrella clients. However, if the exploration stage begins and it is evident that the client is not adequately prepared to engage in deeper work around oppressive cognitions or other traumatic causes of presenting symptoms, the treatment can steer back to a stabilization focus at any time. Even when actively working with clients doing stage 2 processing with any appropriate modality, it is wise to use skills acquired during stabilization (stage 1) to close sessions safely or to remind the client how to use these skills to stay as safe and as regulated as possible between sessions.

As discussed, no single theory or modality is recommended for working with bisexual umbrella clients. Professionals should apply their chosen modality in a trauma-focused and culturally responsive manner; any modality or series of modalities can work well with bisexual clients in the context of the three-stage consensus model. In this section, a sample outline for tasks that could happen in each phase of treatment with bisexual umbrella clients is presented to aid in clinical decision making, with specific commentary on how to carry out these treatment tasks. The case of Client A, a bisexual woman, will be used as an example of how a clinician can work through each stage.

Those struggling with any of the concepts covered in this course may benefit from directly talking to a person who identifies as bisexual or as part of the bisexual umbrella. Many will be happy to discuss their experiences and to answer questions. Reputable organizations and websites (Resources) can be helpful for further exploration, particularly if other options are scarce in your community. It is important not to rely on popular films and television as a sole source of cultural information, as the overall portrayal of bisexuals in popular culture is flawed and potentially damaging.

Seeking supervision or consultation around issues that are clear blind spots in working with LGBT+ clients, specifically with bisexual clients, should be considered. Such supervision may be a necessary requirement if one is blocked from effectively working with a bisexual umbrella or other LGBT+ client because of one's personal beliefs. The ethical guidelines of the major clinical organizations that guide practice in the United States assert that professionals cannot discriminate against clients based on sexual orientation or gender identity [39,40,41]. If referral is not available, the duty falls on the professional to work with the client in as ethical a manner as possible.