Coming Out and Facing Rejection: An ACT Case Study

The following is an example of how [Matthew Skinta, PhD, ABPP] used ACT principles to reduce suffering and promote resilience when working clinically with Neil, a twenty-one-year-old gay Indian-American college student who presented with symptoms consistent with major depressive disorder. His struggle with these symptoms began in early adolescence when he first realized he was gay. He developed a negative attitude toward his sexual orientation because he felt different from his peers and struggled to fit in. Although he didn’t experience overt victimization, Neil’s social interactions were limited, and he was afraid people would reject him if they found out he was gay. He didn’t disclose his sexual orientation at the time but sought help for his depression and received cognitive behavioral therapy. He learned skills to manage his symptoms but continued to struggle with accepting his sexuality.

Neil decided to seek treatment again at the age of twenty-one because his symptoms had become increasingly difficult to manage after he finally disclosed his sexual orientation to his parents. His parents weren’t supportive, as being gay conflicted with their traditional and religious values. They encouraged him to pray for absolution and commit to academic and professional pursuits until he met a woman with whom he could settle down. Their frequent attempts to change his sexual orientation caused him a great deal of distress and exacerbated the shame he already struggled with. He responded by avoiding situations that might raise questions about his sexual orientation and engaging in substance use to avoid his pain.

Several ACT principles and exercises were particularly helpful in this case, including clarifying values and engaging in values-based action; cognitive diffusion; and reducing experiential avoidance. A major focus of ACT is identifying one’s values and living a life that is consistent with them. Neil had lost sight of his values, because he was so focused on the fact that his parents didn’t accept him for being gay. In session, we had several discussions about what values are, how they’re different from goals, and how to engage in behaviors that are consistent with values in an effort to lead a satisfying life.

One exercise Neil found particularly helpful was Attending Your Own Funeral, which involves writing two versions of a eulogy to be read at one’s funeral: one focused on what might be said if the person continues to live life in the same way, and one focused on what might be said if the person lives in a way more consistent with individual values. This exercise resonated with him, because the first version of the eulogy that he wrote described the life his parents wanted for him, rather than the life he wanted for himself. He imagined someone recounting a version of his life in which he’d told his parents that he was wrong about being gay and had married and had children, despite his lack of interest in doing so. In this version, he imagined being described as an unhappy man who lost himself in work and kept to himself. His parents were happy with his choices, but he lived a lie and his depression never lifted.

The second version of the eulogy described the life Neil wanted for himself. He imagined someone recounting a version of his life that involved living in a big city and exploring his passions for art and entertainment. He was remembered for having a vibrant personality, being able to make people laugh, and having a long-lasting romantic relationship that endured the challenges of life. When he considered these two versions of his eulogy, it became apparent to him that he valued close relationships, personal growth, and leisure more than he valued education, career, and his relationship with his parents. Although he acknowledged that this might change over time, he realized that he wanted to take some time to develop his relationships with people, explore his interests in arts and culture, and become more independent.

After this exercise, we engaged in a more structured exercise that focused on clarifying what Neil valued in various life domains, such as intimate relationships, family relationships, friendships, career, and leisure pursuits. For each domain, he wrote about what he valued and identified one key value. Then he rated how important each value was to him and how closely he had been living in alignment with each value on a scale of 1 to 10. By examining the differences between these ratings for each domain, Neil could see how much his life needed to change in each area in order to be in line with what really mattered to him. Then we identified goals he might pursue relevant to each value, along with actions he could take to accomplish each goal, potential barriers, and strategies for overcoming those barriers.

This passage is excerpted from Mindfulness and Acceptance for Gender and Sexual Minorities, a book edited by Matthew Skinta, PhD, ABPP, and Aisling Curtin, MsC.





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