Out On The Couch

4 Barriers to Affirmative Clinic Change

Posted: 6-9-21 | Melissa Dellens

Collage of images of "I can do it" representing confidence, a pile of books representing knowledge, the phrase "learn, practice, improve" to represent skills, and a scale with "facts" and "bias" on the other side, representing objectivity. These are Caplan's 4 barriers to effective treatment.

Gerald Caplan is seminal in developing some of the early theories of consulting work (Caplan, 1960). Caplan worked in Israel after World War II providing mental health support to 16,000 displaced and orphaned teens in overwhelmed residential and refugee facilities (Mendoza, 1993). Caplan’s resources were limited, and his team had no way of serving the number of traumatized children. In real time, in post-war conditions, Caplan developed many of the core concepts that we understand about mental health consultation today. He identified peers and leaders in the communities he entered, developed systems for intervention, and also observed four basic barriers of care that the field clinicians he was training and supervising on the job experienced.  These barriers are a lack of knowledge, skill, confidence, and objectivity (Caplan, 1960). 

Making Caplan’s Theory Affirmative

In Affirmative Organizational Development Consulting, over seventy years later, we see ourselves in Gerald Caplan’s role. Affirmative therapists in the United States are treating and caring for gender-,sexuality-, and relationship-expansive communities in hostile and inequitable conditions. Caplan saw that he couldn’t help everyone, but he could help the helpers to expand his ability to indirectly help the displaced and orphaned children and adolescents. Similarly, the staff at The Affirmative Couch cannot individually help every LGBTQIA+, CNM, or kinky client. But we can work with organizations to become affirmative!

The need for affirmative therapists is high. LGBTQIA+ youth are more likely to face homelessness due to family rejection (Family Acceptance Project, 2021). In Arkansas, we saw the devastating legislation that will limit medical care to transgender and nonbinary children (BBC, 2021). We already know that this discrimination in childhood carries over into adulthood where adults face lack of access in housing and employment (Urban Institute, 2017). Sexuality-,gender-, and relationship-, expansive communities all face higher rates of mental health challenges and substance use (Medley, et al, 2016). They also seek out mental health services at higher rates than  heterosexual, cisgender, monogamous populations (Bowers & Bieschke, 2005; Jones et al, 2003: Liddle, 1996). These communities need affirming and welcoming spaces to begin to heal, and there are not enough in most parts of  the United States. 

The majority of affirmative providers are in private practice, and that treatment may only financially accessible through health insurance, which in our country is a privilege. Therapists in private practice usually have more resources for training and education than those who are overworked in community mental health settings. Many people in these communities, and particularly youth are reliant on clinics and community mental health to address their needs. There needs to be more affirming spaces. Clinics and community mental health centers provide services to a wide variety of clients and need to be prepared for any client coming into their clinic.

Similarly to Caplan’s work after World War II, we find that the same barriers remain for clinics today to become affirmative. Staff may have a lack of confidence in working with diversity, lack of knowledge of nuances of terminology and clinical concerns that these communities face, lack of skills in being able to address clinical issues, and lack of objectivity in which the clinician’s biases are in the way. 

Building Confidence for Affirmative Therapists & Clinic Staff

Caplan’s first barrier was lack of confidence. Many clinicians we talk to are insecure about saying the wrong thing, stumbling over their words, or offending their clients. Building confidence is more than just feeling confident in what you say. Confidence is not just about your clinical ability to put your skills and knowledge to work. It is about establishing belief in your ability to learn (Fischer & Sliwka, 2018). Learning is a dynamic process, and for those of us who have finished school and training and have been getting continuing education from the same sources for years, our learning skills may be a little rusty. Meanwhile, newer clinicians may experience fatigue from the immense amount of learning they have undertaken to get where they are now, and feel defensive about having to take on yet more.  We may experience some resistance to taking in new information. This information may also be triggering, as a clinician works to un-learn discriminatory ideas they have previously developed. Anti-bias work and un-learning takes  vulnerability, and getting in touch with parts of self that may be less affirming requires humility. These challenges need to be identified and addressed in order to challenge systemic homeostasis. 

People who are confident in their ability to learn are more likely to independently pursue learning opportunities independently (Fischer & Sliwka, 2018).  This is important because affirmative theory is a dynamic and evolving field of research. As more people in LGBTQIA+, consensually non monogamous, and kink communities feel safer to live authentically and speak about their experiences, the research, literature, and language will continue to evolve. 

Additionally, mistakes are going to happen. You are going to mis-speak. You are going to fumble. But rest assured that you will have the opportunity to repair a difficult moment with a client. Maya Angelou taught us, “When you know better, you do better.”  When you see each of these moments as an opportunity to learn, you can increase your confidence in sitting across from someone with very different experiences than you. 

Colorful pile of books with the quote "When you know better you can do better" by Maya Angelou. This represents the need for clinics to educate their staff and build their confidence in LGBTQIA+ affirmative therapy.

Knowledge is Power

Sexuality-, gender-, and relationship-expansive communities often get lumped in with each other under the umbrella terms “LGBT” or “queer.” However, many communities with unique needs co-exist. Helping your team get really clear about your level of competence with lesbian, gay, bisexual, pansexual,  transgender, queer, intersex, asexual, polyamorous, and kink communities is essential. We believe that in order to truly be a leader in the community, it is essential that you are able to serve members of all these communities. This means learning to understand the distinct and unique mental health needs among these diverse identities. 

Caplan’s writing on this area was concise. We do not always know what we do not know, but working with a consultant who has committed to staying on top of community research, trends, and new ways of understanding can offer light to areas of growth. 

Increasing Professional Skills

Confidence and increased knowledge are the beginning steps in providing affirmative health care! Putting knowledge into action and developing affirmative skills to serve members of diverse communities requires further education, training, and ongoing commitment to lifelong learning. Some clinics rely on their clinicians with lived experiences to counsel members of their own community. While lived experience is a great start, counseling skills and best practices are also essential to applying techniques and interventions to address clinical issues like minority stress and internalized homo-, bi-, and trans-phobia. Your clinicians with lived experience in sexuality-, gender-, or relationship- expansive communities may also experience additional stress in taking responsibility for the skill building for your entire clinic. Organizational affirmative consulting can help identify these barriers and start offering solutions! 

Reducing Bias and Prejudice

Caplan believed that addressing skills, knowledge, and confidence are relatively straightforward, and spent a lot more time exploring the idea of objectivity (and lack thereof) as a barrier to effective treatment (Caplan, 1970: Mendoza, 1993). Objectivity is a really loaded word, and there are some big reactions to it in current mental health conversations. It can be helpful to break down what Caplan was looking at when he talked about lack of objectivity, and think about what these ideas mean when working with gender-,sexuality-, and relationship-expansive communities. 

Caplan (1970)  describes four common challenges in objectivity: 

  • Direct personal involvement

Direct personal involvement is when the therapist gets overly involved in the client’s conflicts. This can get in the way of their capacity to heal. This loss of objectivity is common in the welcoming, accepting therapist that really wants to hold the position of ally or advocate.  When the therapist gets overly involved in needing to be a champion for the client, there are missed opportunities in treatment to explore the client’s inner conflicts about their own identity formation. This can get in the way of the client’s agency and power in their own healing. 


  • Simple identification

Simple identification happens when the therapist’s inner conflicts look a lot like the clients. This form of objectivity is most common in dyads where the client and therapist share a common identity. This work can be powerfully mirroring for the client, but the therapist has work to do to separate their lived experience from the clients’. The therapist has work to do to explore their own wounds of marginalization and develop resilience in their own coming out and community experiences to differentiate their perspectives from their clients’.


  • Transference

Transference provides important information in therapy, and not all theories or modalities spend a lot of time considering this in the working relationship. Unconscious forces from the client’s early relationship conflicts are projected into the therapeutic relationship and onto the clinician. This can draw closer attention to conflicts the client is struggling with in the present day. If a therapist does not attend to their own countertransference this can turn into an enactment that may not be productive to the treatment.  It is important to look at how the client is recruiting the therapist to engage in conflicts in the treatment, especially when issues of marginalized gender, sexuality, and relationship styles are present. This is a big topic, and requires training, supervision, and ongoing education to consider how specific issues may be playing out between the client and therapist. Examples of this are explored in one of our previous articles about what can happen when a client is misgendered in treatment.

  • Theme interference

Theme interference is a “continuing representation of an unsolved problem or of an experienced defeat that is carried over into the client’s treatment” (Mendoza, 1993).  In short, this is any bias that the therapist holds that keeps them from believing their client can accomplish what they set out to do in therapy. When thinking about gender-,relationship-, and sexuality-expansive communities this can be as stark as holding old clinical ideas about homosexuality and gender identity being a mental illness. It can be more nuanced ideas, stereotypes or misbeliefs about what it means to be gay, lesbian, bisexual, pansexual, transgender, nonbinary, intersex, asexual, polyamorous, consensually non monogamous, or kinky. This is why it is important to explore bias around all these communities in your work to resolve theme interferences that may be at play in the treatment. 

Affirmative therapy is rooted in a commitment to your personal work. This includes getting in touch with your biases and having a place to work through them with a supportive consultant who can see misconceptions, prejudices, and experiences that may color your clinical work. 

Next Steps

Identifying these obstacles on your own can create a sense of imbalance and urgency to address unmet needs. It can be especially hard when you are supervising multiple clinicians in a clinical setting. Working with an affirmative organizational development consultant can help you address your knowledge, skills, and confidence in a collective setting, and develop an action plan to begin addressing your clinic’s needs in a collaborative way. While addressing objectivity in an ongoing way is a clinical concern, your clinic’s collective theme interference can be addressed and begin to work with these communities in more effective ways. 

Engaging in clinical consultation for one case may help in the short term, but working to TRANSform your clinic to be a safe and affirming space for members of multiple marginalized communities puts you in the position to do the most good. That work is not easy though, and relying on Caplan’s lived experience, field research, and lengthy body of work we look at the four most common barriers to learning to work in new ways with new populations. 

Learn More from Melissa Dellens, MA, AMFT

Text: “Autistic Affirmative Therapy for Allistic Providers Presenter: Melissa Dellens, MA, AMFT, 3 CE Course” under an image of infinity symbol in rainbow colors on rainbow background depicting Autistic affirmative therapy


Bowers, A., Bieschke, K. (2005). Psychologists’ clinical evaluations and attitudes: An examination of the influence of gender and sexual orientation. Professional Psychology: Research and Practice, 36(1), 97-103.

British Broadcasting Corporation (2021). Transgender youth treatment banned by Arkansas. Retrieved from: https://www.bbc.com/news/world-us-canada-56657625

Caldwell, B. E. (2019). Basics of California law for LMFTs, LPCCs, and LCSWs. Ben Caldwell Labs. Los Angeles, CA.

Caplan, G. (1970). The theory and practice of mental health consultation. Basic Books.

Family Acceptance Project (2021). San Francisco State University. Retrieved from: https://familyproject.sfsu.edu/

Fischer, M., & Sliwka, D. (2018). Confidence in knowledge or confidence in the ability to learn: An experiment on the causal effects of beliefs on motivation. Games and Economic Behavior, 111, 122-142.

Jones, E., Krupnick, J., & Kerig, P. (1987). Some gender effects in a brief psychotherapy. Psychotherapy: Theory, Research,  Practice, Training, 24(3), 336-352. 

Levy, D (2017). Discrimination is limiting LGBTQ people’s access to rental housing. Urban Institute. https://www.urban.org/urban-wire/discrimination-limiting-lgbtq-peoples-access-rental-housing

Liddle, B. (1996). Gay and lesbian clients? Selection of therapists and utilization of therapy. Psychotherapy, 34(1), 11-18. 

Medley G, Lipari R, Bose J, Cribb D, Kroutil L, McHenry G. (2016). Sexual Orientation and Estimates of Adult Substance Use and Mental Health: Results from the 2015 National Survey on Drug Use and Health. NSDUH Data Review. Retrieved from: https://www.samhsa.gov/data/sites/default/files/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015/NSDUH-SexualOrientation-2015.htm

Mendoza, D. W. (1993). A Review of Gerald Caplan’s Theory and Practice of Mental Health Consultation. Journal of Counseling & Development, 71(6), 629–635. 



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