Addressing Existential Issues in Affirmative Therapy

Exploring one’s sexuality or gender identity is, by its very nature, an existential pursuit. In fact, LGBTQ+ clients often seek out therapy to help make sense of their phenomenological experience. Yet clients may be disheartened if their counselor is unfamiliar with existential issues, or continually redirects sessions to a goal-oriented approach. 

Yes, LGBTQ+ clients face many social, political, and occupational obstacles in need of practical, and above all, workable solutions, yet they also need their counselor to be open to the full depth of their being. Sometimes there is no direct answer. Sometimes clients just need their counselor to stand with them at the edge of the unknown.

Fortunately, affirmative therapy is rooted in existential and humanistic psychology. While existentialists emphasized freedom of choice, personal responsibility, and the pursuit of personal meaning, humanists emphasized willpower, humanity’s inherent good, and the pursuit of personal growth. While affirmative therapy is distinct from other existential and humanistic modalities like existential therapy, gestalt therapy, logotherapy, narrative therapy, and person-centered therapy, it adapted many of their key perspectives to specifically help sexual and gender minorities explore and self-actualize their identity.

The Core Principles of Affirmative Therapy

To tackle the internalization of homophobia and transphobia, Proujansky and Pachankis (2014) identified five core principles of affirmative therapy:

  1. Normalize the mental health impact of minority stress
  2. Facilitate emotion awareness, regulation, and acceptance
  3. Decrease avoidance
  4. Restructure minority stress cognitions
  5. Empower through assertive communication

Within the fourth principle, whereby affirmative therapists help their clients restructure minority stress cognitions, many existential questions arise about identity, meaning, isolation, freedom, and death.

Establishing Identity

To be authentic means to live in accordance with oneself, which sounds simple enough until self-doubt comes into play. For LGBTQ+ individuals, identity can be suppressed, repressed, or complicated by socially constructed roles. Not only this, “who I am” and “what I am” can get mashed together and teased apart since sexual identity and sexual orientation are two overlapping concepts with the potential for cognitive dissonance. 

A person may have an identity built around a heteronormative social construct, yet struggle with their same-sex attraction. Hence the phrase: “I’m straight, so I can’t be attracted to men.” Or they may have a clear same-sex attraction, yet feel disconnected from the homonormative culture they’ve encountered. Hence the phrase: “I may have sex with men, but I’m not gay.”

Identity is also a huge question for gender explorative people, which Maril and Mollen’s (2017) address in their article Existential Approaches and Gender. Not only do gender-diverse people question the fundamental relationship between self and self, but they must also contend with how their gender identity impacts the relationship between self and other.  

Furthermore, while sexuality and gender are only facets of a person’s identity, intolerance and social pressure can build them into an identity crisis. Both existential and humanistic modalities respond to this by asking the client to lean into their curiosity—to live in the question. Does their experience align or differ from their expectations, aspirations, or beliefs about themselves? When do they feel natural, and when do they feel performative? This gentle exploration allows the client to question what they know about sexuality, gender identity, who they are, and who they’re becoming.  

However, because sexual and gender identity formation can be destabilized by encounters with intolerance, affirmative therapy goes one step further; affirmative therapists help clients differentiate themselves from their negative self-talk by taking an inventory of the client’s self-description. Instead of judging maladaptive coping mechanisms, affirmative therapists frame their behavior in context, recognizing their survivalism in their social camouflage, anxiety, and depression. 

In this way, affirmative therapists help clients to “thank the guard at the gate,” “lower the shield,” or “remove the mask” to recognize what they have been guarding or concealing, and how precious it is to have been guarded or concealed for so long. By affirming the client’s identity, and validating the emotionality of their emergent process, affirmative therapists help clients cultivate their ability to accept and affirm themselves.

Finding Meaning

Unfortunately, because of the ongoing prejudice towards sexual and gender minorities, many LGBTQ+ youth are conditioned to distrust, judge, conceal, or shame their natural play instinct, curiosity, same-sex attractions, or gender expression. Being told that one is wrong, immoral, sinful, or insane is not only undermining self-esteem, but it is also contributing to a fatalistic sense of meaninglessness. 

When young people are displaced, disenfranchised, or abused by their family or their community, they may begin to lose hope and see no point in participating in a society that does not recognize, validate, or include them. Beyond this, they may even question whether life is worth living.

Before one can find meaning in their life, one must first acknowledge that their life has value. Or, said another way, if one sees no value in their existence, they will be unlikely to believe their life has any meaning at all. In the therapeutic relationship, existential therapists rely on Epoché, the Hellenistic philosophy of withholding judgment and setting aside bias, to avoid making assumptions about the client, their conceptualization of self, or their meaning-making process. In turn, humanistic therapists rely on unconditional positive regard and the client’s ability to achieve self-actualization.

Affirmative therapy echoes how important it is for therapists to check their own biases to create a safe and judgment-free environment for LGBTQ+ clients to find their own voices.  While implementing existential and humanistic techniques like active listening and Socratic questioning, affirmative therapists may also implement psychoeducation for LGBTQ+ issues. 

Though affirmative therapy cannot provide concrete answers to a client’s existential quandaries about self, identity, and self-satisfaction, it can connect clients with both living and historical role models who have pondered the same questions. 

Since much of the lived experience of LGBTQ+ people has been erased, censored, or whitewashed, affirmative therapists may introduce clients to relevant LGBTQ+ philosophers, poets, and orators like Audre Lorde, Ludwig Wittgenstein, Simone de Beauvoir, David Hull, Jack Halberstam, or Judith Butler, to name a few. In this way, affirmative therapists validate the client’s internal pursuit of meaning while connecting them to a living history of LGBTQ+ thinkers.

Combatting Isolation

When a person’s sexuality or gender falls outside the social norm of their culture, feelings of loneliness, alienation, and isolation often arise—all of which are common existential themes. These feelings are exacerbated by intolerance and social exclusion, but can also arise even if a person belongs to a loving and accepting community. This latter point can be confusing, especially if one feels lonely amongst friends.

Existential loneliness stems from the question, Can one ever truly be known? Since only you will ever know the inner workings of your mind, only you can wholly know yourself. Everyone else knows an interpretation of you, and while this is true for all, sexuality and gender identity are frequently misunderstood, even by well-intentioned friends and family.

The positive relationship between social support and psychological well-being for LGBTQ+ populations is well-documented, yet social support goes beyond self-esteem to shore up a person’s existential well-being

For this reason, affirmative therapists encourage clients to engage their LGBTQ+ community in a highly personal way. Going to a Pride parade isn’t enough, since one can feel even more lost in the crowd. Being gay does not automatically create a kinship with other gay people. Being transgender doesn’t mean one will be implicitly understood by other trans people. 

Recognizing this, affirmative therapists will often help their clients find social groups—either in person or online—that integrate multiple facets of their identity. This may look like connecting a client with people of the same age or cultural background, or even groups with shared interests like art, music, literature, video games, sports, nature, or spirituality. Such positive social interactions can help clients feel connected, recognized, and understood in a far more holistic way. Think of it like a six-sided die: sure, only you can see all six sides of your character, but you’ll feel far more connected with people who can see five than with people who can see only one. 

Achieving Freedom

To grasp freedom, one must first grapple with facticity. Everyone enters the world involuntarily, and there are many facts about your birth you cannot choose. Where you born, the socioeconomic class you were born into, your race or ethnicity, your anatomic sex, your sexual orientation, and your gender identity are all facts of your existence. They’re the cards you were dealt. 

However, although these facts present many power differentials pertaining to privilege and persecution, they do not automatically eradicate willpower or personal agency. Falling into a deterministic mindset not only shirks off one’s freedom, but it also contributes to an inauthentic, socially constructed performance. For more on this, see Milton’s book (2007) Being Sexual: Existential Contributions to Psychotherapy with Gay Male Clients and Acton’s article (2010) “I am what I am? Existentialism and homosexuality.”

That said, freedom must also be understood contextually, recognizing the intersection of classicism, racism, sexism, cissexism, and heterosexism. This often comes to a head when clients contend with issues of self-disclosure, since “staying in the closet” may feel imprisoning yet hypothetically safe from external judgment, whereas “coming out” may feel liberating yet potentially risky. 

Existential and humanistic psychologists take time to explore a client’s sense of being in the world, and what it means for them to identify as a sexual or gender minority. After all, there is a difference between being in danger and believing one is never safe, just as there’s a difference between acknowledging life’s hardships and believing life is nothing but hardship. While exploring the fine line between experience and perception, existential and humanistic psychologists will also draw a client’s attention to their sense of purpose in any given situation, no matter how dire. Some accomplish this by focusing on a client’s intrinsic values, while others favor emotional process.

Since many LGBTQ+ clients experience persecution and trauma, affirmative therapy takes a realistic approach to what is within a client’s power. On one hand, affirmative therapists often work with their clients to increase their community support and upward momentum on a social level. Yet affirmative therapy also centers the client in their process, as the mind is the first prison one must liberate themselves from. Every small step towards self-actualization is recognized and affirmed to validate the client’s effort, empower their sense of agency, and demonstrate their active freedom in any given moment.

Considering Mortality

Presumed longevity is a privilege many LGBTQ+ people do not have. Sexual and gender minorities contending with oppression, exclusion, and both physical and verbal abuse can wrestle with some dark questions of mortality at a very young age. 

Indeed, the Trevor Project found that 45 percent of the 34,000 LGBTQ youth they surveyed had seriously considered suicide in 2021. Not only this but sexual and gender minorities are four times more likely to be the victims of a violent crime than cisgender heterosexuals. Reviewing the literature, Livingston et al. (2020) found that the rates of PTSD in these populations ranged between 1.3 to 47.6 percent, with trans and nonbinary people ranging between 17.8 to 42 percent.

Existential and humanistic psychologists help clients sit with their mortality, and while they do not provide spiritual answers, they do note how one’s relationship with death and inevitability is linked to one’s relationship with life and actuality. In this way, memento mori (remember death), need not be a grim philosophy, but a reminder to appreciate and actively use one’s time to the fullest.

Affirmative therapists consider this through a somewhat different lens, since a client’s perspective of death—albeit something they run from or something they long for—may be shaded by internalized homophobia or transphobia. How much does their anxiety around death correlate to a sense of powerlessness in their life? How often does suicide present itself as a desperate means of reclaiming agency? And how might things change if they were allowed to express themselves in a full and meaningful way, or if they felt truly accepted for who they are?

For those who have experienced violent oppression, the prospect of death cannot be ignored, and clients may have to address issues of grief, survivors’ guilt, residual anger, and internalized self-hatred. Yet even LGBTQ+ people who haven’t experienced violence first-hand can still experience heightened anxiety about their physical safety. 

This awareness of one’s mortality can emerge in various ways, from spiritual crisis to spiritual awakening, from depressive episodes to impulsive carpe diem attitudes. It can also detract from a person’s ability to plan for the future, which is why it’s not uncommon for some clients to say (with earnest surprise) that they “never expected to live this long.” Because of this, affirmative therapists help clients identify how their encounters with prejudice may have shaped their relationship with life and death, to make room for deeper exploration beyond this fatalistic social narrative.


Since LGBTQ+ clients face so many real-world obstacles, counselors frequently develop treatment plans that focus on the client’s behavioral or emotional response, or advocacy plans that focus on improving the client’s environment and overall quality of life. 

Yet some clients may need their counselor to “go deeper” with them, as they actively question who they are, their world, and even their life’s purpose. Affirmative therapy provides a humanistic response to an existential crisis, empowering sexual and gender minorities to grow and self-actualize.

 To this end, counselors are encouraged to take time to sit with their own views of identity, meaning, isolation, freedom, and even death to be mindful of their own biases, and consider how best they can help LGBTQ+ clients navigate these existential questions.

Alex Stitt, LMHC

Alex Stitt, LMHC

Writer & Contributing Expert

Alex Stitt is a nonbinary author, queer theorist, and licensed mental health counselor living in Hawaii. As a proud Queer Counselor, they work to educate professionals in the mental health field interested in working with LGBTQ+ populations. Their textbook, ACT for Gender Identity: The Comprehensive Guide, demonstrates how to apply Acceptance and Commitment Therapy to gender self-actualization.