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ASSESSING LESBIAN, GAY, AND BISEXUAL AFFIRMATIVE TRAINING IN COUPLE AND FAMILY THERAPY: ESTABLISHING THE VALIDITY OF THE

FACULTY VERSION OF THE AFFIRMATIVE TRAINING INVENTORY

Christi R. McGeorge and Thomas Stone Carlson North Dakota State University

Russell B. Toomey Kent State University

This study established the validity and factor structure of the Faculty Version of the Affirma- tive Training Inventory (ATI-F), which assesses faculty members’ perceptions of the level of lesbian, gay, and bisexual (LGB) affirmative training that occurs in clinical programs. Addi- tionally, this study examined the latent associations among the subscales of the ATI-F and three convergent validity items utilizing a sample of 117 faculty members from accredited family therapy programs. The findings provide empirical support for the relationship between including classroom content on LGB affirmative therapy and faculty members’ beliefs about LGB individuals and relationships. Specifically, faculty members who report more positive beliefs about LGB clients appear to be more likely to include LGB affirmative therapy content in the courses they teach.

Scholars have documented the need for couple and family therapy (CFT) training programs to better prepare students to work with lesbian, gay, and bisexual (LGB)

1 clients (Carlson,

McGeorge, & Toomey, 2013; Doherty & Simmons, 1996; Green, 1996; Henke, Carlson, & McGeorge, 2009; Long & Serovich, 2003; Rock, Carlson, & McGeorge, 2010). For example, Rock et al. (2010) found that 60.5% of the students surveyed from accredited CFT programs had received no training in providing affirmative therapy services to LGB clients. This lack of training is problematic given that research also suggests that the vast majority of CFTs will work with LGB clients during the course of their careers (Green & Bobele, 1994; Henke et al., 2009). Specifically, Green and Bobele (1994) found that 72% of the CFTs they surveyed reported that approximately 10% of their client population identified as LGB and 80% reported that they were currently work- ing with LGB clients. The need for CFTs to be prepared to work with LGB clients is further evidenced by the fact that LGB individuals seek out therapy services at two to four times the rate of heterosexual individuals (Cochran, Sullivan, & Mays, 2003; Liddle, 1997). Thus, it is important to learn more about the training that CFT students are being provided to better understand the extent to which they are prepared to provide competent services to the LGB community.

The existing research exploring the level of training that CFTs receive to competently work with LGB clients has been focused on the perceptions of students and experienced therapists (Carl- son et al., 2013; Doherty & Simmons, 1996; Henke et al., 2009; Rock et al., 2010). For example, Carlson et al. (2013) found that CFT students reported that both the course content they received about working with LGB clients and the overall LGB affirmative environment that training programs foster was associated with their level of self-reported clinical competence working with

Christi R. McGeorge, PhD, and Thomas S. Carlson, PhD, are faculty members in the Human Development

and Family Science Department at North Dakota State University; Russell B. Toomey, PhD, is an assistant professor

in the Human Development and Family Studies Department at Kent State University.

Address correspondence to Christi R. McGeorge, Human Development and Family Science Department at

North Dakota State University, 2615, PO Box 6050, Fargo, North Dakota 58108-6050; E-mail: christine.mcgeorge@

ndsu.edu

January 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 57

Journal of Marital and Family Therapy doi: 10.1111/jmft.12054 January 2015, Vol. 41, No. 1, 57–71

LGB clients. Additionally, Rock et al. (2010) found that the extent to which students had learned about the concept of heterosexism and explored their own heterosexual privileges and biases was associated with self-reported LGB clinical competence. Moreover, Henke et al. (2009) found that the level of knowledge that experienced clinicians reported about LGB topics was directly related to their overall level of skill working with LGB clients. Henke et al. (2009) also found that this relationship was mediated by CFTs’ levels of homophobia, which highlights the importance of encouraging therapists to explore their own negative beliefs about LGB individuals and relation- ships to prepare them to competently work with this population.

Given these findings, it is interesting to note that researchers have yet to explore CFT faculty members’ own reports of what they teach to prepare their students to work with LGB clients. In addition, there is limited information about the stances CFT training programs take with regard to LGB clients. Finally, a mechanism for assessing faculty members’ reports about course content and program environment related to working with LGB clients does not exist. Thus, this study sought to validate a measure of the level of integration of LGB topics into CFT training as reported by faculty members.

LITERATURE REVIEW

LGB Affirmative Training Scholars have long argued for the inclusion of LGB topics in CFT training and, in particular,

have highlighted the importance of preparing students to be LGB affirmative therapists (Bernstein, 2000; Carlson & McGeorge, 2012; Godfrey, Haddock, Fischer, & Lund, 2006; Green, 1996; Green, Murphy, Blumer, & Palmanteer, 2009; Long & Serovich, 2003; McGeorge & Carlson, 2011; Rock et al., 2010). This approach to training involves teaching about topics relevant to working with LGB clients and helping students develop more positive attitudes toward LGB individuals and relationships (Carlson & McGeorge, 2012; Rock et al., 2010). For example, scholars suggest that training programs teach students about such topics as models of sexual orientation identity devel- opment for both LGB and heterosexual individuals (McGeorge & Carlson, 2011; Mohr, 2002; Worthington, Savoy, Dillon, & Vernaglia, 2002), the coming out process (Bernstein, 2000; Godfrey et al., 2006; Green, 1996; Long & Serovich, 2003), LGB couple and family development processes (Nealy, 2008) and the concepts of gay-related stress (Lewis, Derlega, Griffin, & Krowin- ski, 2003; McGeorge & Carlson, 2011; Meyer, 1995), internalized homophobia (Bernstein, 2000; Godfrey et al., 2006; Green, 1996), heterosexism (Godfrey et al., 2006; Long & Serovich, 2003; McGeorge & Carlson, 2011), heterosexual privilege (Carlson & McGeorge, 2012; Godfrey et al., 2006), and heteronormativity (Oswald, Blume, & Marks, 2005).

In addition to teaching about the above-listed topics, scholars also suggest that CFT students need to explore their own biases and beliefs to develop more positive and affirming beliefs about the LGB community (Godfrey et al., 2006; Green et al., 2009; McGeorge & Carlson, 2011). In particular, the existing literature suggests that faculty members have a responsibility to assist students in exploring their heteronormative assumptions, heterosexual privilege (or internalized homophobia), and heterosexist biases as these appear to be barriers to competent therapy with LGB clients (Carlson & McGeorge, 2012; Rock et al., 2010). This approach to training moves beyond teaching tolerance for LGB individuals and relationships and toward helping students adopt a truly affirmative stance toward the LGB community (Godfrey et al., 2006).

Program Environment and LGB Affirmative Training Another important component of LGB affirmative training involves the importance of devel-

oping an affirmative program environment (Carlson & McGeorge, 2012; Carlson et al., 2013; Long & Serovich, 2003). The literature suggests that the development of an affirmative program environment involves the creation and implementation of program policies that both discourage discrimination and support the rights of LGB students, faculty, and clients (Carlson & McGeorge, 2012; Carlson et al., 2013; Long & Serovich, 2003). For example, Long and Serovich (2003) recom- mend that programs develop a clear anti-discrimination policy that specifically bans the use of anti-gay and homophobic language. Additionally, Carlson et al. (2013) encourage CFT programs to develop an official statement that clearly communicates the program’s identity as LGB

58 JOURNAL OF MARITAL AND FAMILY THERAPY January 2015

affirmative. Another recommendation in the literature is for CFT programs to create remediation policies for students who hold beliefs that would interfere with their abilities to provide competent and affirmative therapy to LGB clients (Carlson et al., 2013; Long & Serovich, 2003). Finally, Long and Serovich (2003) recommend that programs should use the following question as a guid- ing framework in the development of LGB affirmative policies and practices: “Would gay, lesbian, and bisexual trainees feel comfortable disclosing their sexual orientation within the environment of this program?” (p. 65).

Another aspect of developing an LGB affirmative program environment involves the creation of specific practices at the program level that encourage the full inclusion of LGB persons (Carlson & McGeorge, 2012; Carlson et al., 2013; Green, 1996; Long & Serovich, 2003). For example, scholars recommend that programs develop a specific plan to actively recruit and retain LGB students and faculty (Carlson & McGeorge, 2012; Long & Serovich, 2003). The literature also rec- ommends that CFT programs with an on-site training clinic develop relationships with local LGB community organizations to recruit LGB clients (Carlson & McGeorge, 2012; Godfrey et al., 2006; Long & Serovich, 2003). An important part of this process would involve taking steps to ensure that the overall clinic environment (e.g., waiting room, clinic paperwork, etc.) is welcoming to the LGB community (Carlson & McGeorge, 2012; Carlson et al., 2013; Long & Serovich, 2003). Additionally, CFT training programs could develop a practice of requiring their students and faculty to participate in LGB ally trainings that are associated with their university (e.g., ALLIES, Safe on Campus, Safe Harbor, Safe Space, and Safe Zone; Carlson et al., 2013). The literature also suggests that it is important that CFT faculty members support and encourage students to engage in research on LGB topics (Carlson et al., 2013).

The importance of LGB affirmative policies and practices at the program level has been sup- ported by the existing research. In particular, these studies have found that an LGB affirmative program environment is positively associated with students’ self-reported clinical competence to work with LGB clients (Carlson et al., 2013; Rock et al., 2010). Additionally, Carlson et al. (2013) found that the more LGB affirming the program environment, the more students held positive beliefs toward LGB individuals and relationships.

STUDY AIMS

Given the importance of LGB affirmative therapy training and the lack of research exploring CFT faculty members’ efforts to prepare their students to work with LGB clients, a mechanism for assessing faculty members’ reports about course content and program environment related to working with LGB clients is needed. Thus, the purpose of this study was to establish the factor structure of and validate an adapted version of the Affirmative Training Inventory – Student Version (ATI-S; Carlson et al., 2013) for faculty members. The faculty version of this inventory assessed faculty members’ inclusion of affirmative therapy in their courses and work with students when compared with the original student version that assessed students’ receipt of affirmative ther- apy training in couple and family therapy graduate programs. Given the substantial conceptual difference between the focus of these scales (i.e., self-reported training received by students versus self-reported inclusion by faculty), it was imperative to examine the factor structure of the adapted scale to determine if the dimensions of affirmative therapy training remained consistent across the faculty version and the previously established student version. After an acceptable factor structure was established for the faculty version of the ATI (ATI-F), this study also examined the construct validity of this measure using the revised Sexual Orientation Clinical Competency Scale (R-SOCCS; Bidell, 2005; Carlson et al., 2013) and two additional measures that assessed affirming beliefs at the individual and program level.

METHOD

Participant Recruitment and Description Faculty members from all CFT master’s and doctoral programs accredited by the Commis-

sion on Accreditation for Marriage and Family Therapy Education (COAMFTE) were contacted through an electronic request to participate in this study. In particular, email addresses for faculty

January 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 59

members were obtained from the individual websites of each accredited CFT program. However, ten of the accredited programs did not list faculty email addresses on their website; therefore, we emailed the program directors for those programs and asked them to forward information about the study to their faculty members. Additionally, we posted information about this study on the American Association for Marriage and Family Therapy (AAMFT) Community website and the on-line AAMFT Research Directory. We also sent email announcements about the study to the National Council on Family Relations (NCFR) Family Therapy Section listserv. Finally, we sent two reminder emails in two-week increments.

These recruitment efforts resulted in a sample of 117 participants for this study. The partici- pants ranged in age from 29 to 73 years and had a mean age of 47.17 years (SD = 12.07). On average, these participants had been faculty members for 10.72 years (SD = 9.73) with a range of one to 40 years. The majority of the participants identified were women (60.7%), White (70.1%), and heterosexual (76.1%). Additionally, 54.2% of the participants reported working in a master’s program only, 14.0% reported working in a doctoral program only, and 31.8% reported working in both a master’s and doctoral program. Finally, 88.9% of the participants reported that they had worked with an LGB individual or couple in therapy.

Procedure Potential participants received an email explaining the purpose of the study and providing

them with a link to the online survey. Participants were first presented with the study consent form followed by the ATI-F, the convergent validity scales, and finally, a demographic questionnaire. If participants chose to electronically submit the survey then informed consent was inferred. This study was approved by a university Institutional Review Board.

Measures Affirmative Training Inventory – Faculty Version (ATI-F). The ATI-F comprised 27 items

used to explore the level of LGB affirmative training that occurred in clinical training programs. The ATI-F also measured faculty members’ beliefs about the role of LGB affirmative training in family therapy programs. The ATI-F comprised the following three subscales: (a) the teaching sub- scale included 14 items that measured the type and amount of LGB affirmative content that faculty included in their teaching (a = .90); (b) the program subscale included nine items related to the extent to which faculty report that their programs embraced an LGB affirmative identity at the programmatic level (a = .78); and (c) the faculty experience subscale included four items that assessed faculty members’ experience supervising student research on LGB topics and clinical work with LGB clients, and the extent to which they had sought out continuing education related to LGB affirmative therapy and training (a = .67). See Table 1 for a list of the items comprising the ATI-F. A six-point Likert scale was used for the ATI-F ranging from one (strongly disagree) to six (strongly agree). Four items were reverse coded to mirror the other items in the scale (see Table 1). The overall alpha coefficient for the ATI-F was .91.

Revised-Sexual Orientation Counselor Competence Scale (R-SOCCS). The R-SOCCS was used to measure participants’ self-report LGB clinical competence and attitudes toward LGB indi- viduals and relationships (Bidell, 2005; Carlson et al., 2013). Previous studies had found that the R-SOCCS appeared to demonstrate good reliability and validity (Carlson et al., 2013; McGeorge, Carlson & Toomey, 2015). Specifically, the R-SOCCS had an alpha coefficient of .90 (Carlson et al., 2013). The R-SOCCS comprised two subscales: the knowledge/skill subscale and the aware- ness subscale. The knowledge/skill subscale comprised 16 items measuring the self-reported level of clinical competence and knowledge of LGB topics. In this study, the alpha coefficient for the knowledge/skill subscale was .84. Sample items from the knowledge/skill subscale included: “I have received adequate clinical training and supervision to counsel lesbian, gay, and bisexual clients;” “At this point in my professional development, I feel competent, skilled, and qualified to counsel lesbian, gay, and bisexual clients;” and “I have experience counseling lesbian or gay couples.” The awareness subscale comprised 12 items assessing attitudes and beliefs about LGB individuals and relationships. For this study, the alpha coefficient for the awareness subscale was .93. Sample items from the awareness subscale included: “It would be best if my clients viewed a heterosexual lifestyle as ideal;” “I believe that LGB couples don’t need special rights (domestic partner benefits, or the

60 JOURNAL OF MARITAL AND FAMILY THERAPY January 2015

Table 1 Items Comprising the ATI-F Subscales

Teaching Subscale In my family therapy courses, I specifically include content related to the experiences of lesbian, gay, and bisexual (LGB) individuals. In my family therapy courses, I teach my students about the influence of heterosexual bias (i.e., the act of conceptualizing human experiences in heterosexual terms, thereby marginalizing LGB experiences and relationships) on the therapy process. In my family therapy courses, I teach my students about the concept of heterosexism (i.e., a belief system supported by laws and societal customs that legitimizes heterosexuality as the only acceptable way of being which leads to the unequal treatment of LGB individuals). In my family therapy courses, I teach my students how to explore the negative influence that heterosexism (i.e., a belief system supported by laws and societal customs that legitimizes heterosexuality as the only acceptable way of being which leads to the unequal treatment of LGB individuals) may have on the lives of LGB clients. In my family therapy courses, I teach my students about the concept of heterosexual privilege (i.e., the unearned advantages given to heterosexual individuals based solely on their sexual orientation). I encourage my family therapy students to explore their own heterosexual biases (i.e., the act of conceptualizing human experience in heterosexual terms, thereby marginalizing the experiences and relationships of LGB individuals). I encourage my non-LGB family therapy students to explore their heterosexual privilege (i.e., the unearned advantages given to heterosexual individuals based solely on their sexual orientation) as part of their self-of-the-therapist work. In my family therapy courses, I teach my students about models of LGB identity development. In my family therapy courses, I teach my students the skills necessary to support LGB clients in the coming out process. In my family therapy courses, I teach my students to work with lesbian and gay couples in an affirming manner. In my family therapy courses, I teach my students about LGB affirmative therapy (i.e., an approach to therapy that embraces a positive view of LGB identity and relationships and that addresses the negative influences that homophobia and heterosexism have on the lives of LGB clients) through readings, lectures, supervision, etc. In my family therapy courses, I teach my students that it is ethical to refer a client based solely on the client’s sexual orientation. (reverse coded; item removed) In my family therapy courses, I teach my students about how to conduct reparative therapy. (i.e., an approach to therapy intended to change a client’s sexual orientation from LGB to heterosexual) with LGB clients. (reverse coded; item removed) In my family therapy courses, I teach my students about the negative impacts of reparative therapy (i.e., an approach to therapy intended to change a client’s sexual orientation from LGB to heterosexual) on the lives of LGB clients. (item removed)

Program Subscale My training program intentionally recruits LGB students. Our program would be a safe place for a LGB student to come out. The other faculty in my family therapy training program take an affirmative (i.e., a positive view of LGB identity and relationships) stance toward LGB individuals and relationships. My family therapy program takes an affirmative (i.e., a positive view of LGB identity and relationships) stance toward LGB individuals and relationships. My program has specific policies designed to create a LGB affirmative environment.

January 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 61

right to marry) because that would undermine normal and traditional family values;” and “I believe that all LGB clients should be discreet about their sexual orientation around children.” All the items comprising the awareness subscale were reverse coded. The R-SOCCS utilized a six-point Likert scale ranging from one (strongly disagree) to six (strongly agree).

Individual affirmation. The individual affirmation scale comprised one item that assessed the degree to which participants affirm LGB individuals and families. The item stated: “I take an affir- mative (i.e., a positive view of LGB identity and relationships) stance toward LGB individuals and relationships.” This item was measured on a six point Likert scale that ranged from one (strongly disagree) to six (strongly agree).

Program affirmation. The program affirmation scale comprised two items that measured the extent to which participants believed that CFT training programs had an obligation to teach students to be LGB affirmative therapists. The two items that comprised this scale were:

Family therapy training programs have a responsibility to train students to provide affirmative therapy (i.e., an approach to therapy that embraces a positive view of LGB identity and relationships and that addresses the negative influences that homophobia and heterosexism have on the lives of LGB clients) to LGB clients.

Family therapy training programs have a responsibility to train students to develop affir- mative (i.e., a positive view of LGB identity and relationships) beliefs about LGB individ- uals and relationships.

A six-point Likert scale ranging from one (strongly disagree) to six (strongly agree) was used. The alpha coefficient for this scale was .77.

Analytic Strategy A three-step strategy was employed to identify and validate the factor structure of the ATI-F.

First, given that the inventory substantively changed from the student version of the ATI to the

Table 1 Continued

Overall, the family therapy program in which I teach provides students with information on LGB affirmative therapy (i.e., an approach to therapy that embraces a positive view of LGB identity and relationships and that addresses the negative influences that homophobia and heterosexism have on the lives of LGB clients) through readings, lectures, supervision, etc. My program provides students with the opportunity to work with LGB clients. (item removed) Students in my program are allowed to choose not to work with LGB clients based on their own personal and/or religious beliefs about sexual orientation. (reverse coded; item removed) Students in our program are allowed to practice reparative therapy (i.e., an approach to therapy intended to change a client’s sexual orientation from LGB to heterosexual) with LGB clients. (reverse coded; item removed)

Faculty Experience Subscale I have supervised student research (e.g., thesis, dissertation) on topics specifically related to LGB individuals, couples, and/or families. I have sought out continuing education opportunities to further my knowledge of LGB affirmative therapy and training. I have experience supervising students working with LGB clients. I feel competent in my ability to train students to be affirmative in their clinical work with LGB clients.

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faculty version and new items were included in this version of the measure, exploratory factor analysis (EFA) in Mplus (Muth�en & Muth�en, 2010) with promax rotation was used to assess the factor structure of each adapted subscale of the original ATI-S. Promax rotation allowed factors to be correlated (i.e., non-orthogonal), which was consistent with the expected interpretability of the associations amongst any factors that may appear in each subscale (DeVellis, 2003). The num- ber of factors for each subscale was retained on the basis of three criteria: examination of the scree plot, number of eigenvalues greater than one, and the interpretability of the solution (DeVellis, 2003). The 14 items that conceptually belonged to the ATI-F teaching subscale (similar to the classroom subscale of the ATI-S) were examined in an EFA, and separately, the 9 items that con- ceptually belonged to the ATI-F program subscale (similar to the program subscale of the ATI-F) were examined in a second EFA. The ATI-F experience subscale, which did not appear in the ATI-S, was directly examined using confirmatory factor analysis (CFA) given that there were only four items. At the EFA stage, items were removed from the subscale that did not load onto the fac- tor with a loading of at least .40 or if they demonstrated substantial cross-loadings across factors (DeVellis, 2003).

Second, after a factor structure was established for each subscale, the entire scale was exam- ined in CFA. Third, if model fit of the ATI-F was acceptable, construct validity of the ATI-F subscales was examined in a latent structural equation model (SEM) with the R-SOCCS and two measures that assessed affirming beliefs at the individual and program level. For CFA models and the final SEM, model fit was evaluated with three fit indices: the chi-square statistic, the compara- tive fit index (CFI), and the root-mean-squared error of approximation statistic (RMSEA). According to Kline (2011), good (acceptable) fit is indicated for the CFI with values equal to or greater than .95 (.90) and for the RMSEA with values less than or equal to .05 (.08). Perfect fit is indicated if the chi-square statistic is not significant; however, research has demonstrated that this statistic is vulnerable to sample size bias (Kline, 2011). Full Information Maximum Likelihood (FIML) was invoked to handle missing data in Mplus (e.g., Schafer & Graham, 2002), given that this strategy maximizes statistical power and minimizes bias due to missing items.

RESULTS

Initial Measurement Assessments with the ATI-F ATI-F teaching subscale. An initial EFA of the 14-item ATI-F teaching subscale revealed that

a single factor was the best solution; however, three items had factor loadings that were less than .40. These items included: “In my family therapy courses, I teach my students that it is ethical to refer a client based solely on the client’s sexual orientation;” “In my family therapy courses, I teach my students about how to conduct reparative therapy (i.e., an approach to therapy intended to change a client’s sexual orientation from LGB to heterosexual) with LGB clients;” and “In my family therapy courses, I teach my students about the negative impacts of reparative therapy (i.e., an approach to therapy intended to change a client’s sexual orientation from LGB to heterosexual) on the lives of LGB clients.” Conceptually, it makes sense that these items had inadequate factor loadings as each of these items represent concepts or practices that participants may view as uneth- ical regardless of their beliefs about LGB affirmative therapy. Thus, these items were dropped from the scale. A second EFA was conducted with the remaining 11 items, and no additional problem items were identified. For use in the final CFA, the item-to-construct balance approach was used to create three parcels for a latent construct with the 11 remaining items (Little, Cunningham, Shahar, & Widaman, 2002). The item-to-construct balance approach created a more structurally stable latent construct when compared with the use of 11 indicators to form a single latent construct.

ATI-F program subscale. The initial EFA of the nine-item program subscale revealed that a single factor was the best solution and three items had factor loadings of less than .40. These items included: “My program provides students with the opportunity to work with LGB clients;” “Stu- dents in my program are allowed to choose not to work with LGB clients based on their own per- sonal and/or religious beliefs about sexual orientation;” and “Students in our program are allowed to practice reparative therapy (i.e., an approach to therapy intended to change a client’s sexual orientation from LGB to heterosexual) with LGB clients.” Conceptually, the inadequate loading

January 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 63

of the first item might be surprising; however, it is possible that few of our participants actually provided their students with the opportunity to work with LGB clients regardless of their beliefs about LGB affirmative therapy, which was consistent with the existing literature (Long & Sero- vich, 2003; Rock et al., 2010). The other two items with inadequate factor loadings might reflect practices that participants deem as unethical regardless of their beliefs about affirmative therapy and thus did not allow their students to practice reparative therapy or refuse to work with LGB clients. Similar to the teaching subscale, these items were dropped from the subscale and a second EFA did not reveal any additional problematic items. Therefore, the item-to-construct balance approach (Little et al., 2002) was used to create three parcels for the remaining six item latent construct.

ATI-F experience subscale. The structure and fit of the four-item experience subscale was ini- tially examined in confirmatory factor analysis, which resulted in excellent model fit (v2

[df = 2] = 0.97, p = 0.62; RMSEA = 0.00 (90% C.I.: 0.00–0.15); CFI = 1.00). Further, all stan- dardized item to factor loadings were greater than .58 and were significant, suggesting that all items significantly contributed to the experience subscale. Thus, the four-item subscale was retained for use in the full ATI-F model.

ATI-F full model. All three subscales of the ATI-F were then examined simultaneously in a CFA, which resulted in good model fit (v2 [df = 32] = 50.51, p < .05, RMSEA = 0.07 [90% C.I.: 0.03–0.11]; CFI = 0.97). There were positive associations between the teaching subscale and pro- gram (r = .49, p < .001) and experience (r = .77, p < .001) subscales. Further, there was a positive association between the program and the experience subscales (r = .48, p < .001).

Convergent Validity of the ATI-F Consistent with the final aim of the current study, convergent validity of the ATI-F was

assessed with three constructs in a structural model: the R-SOCCS, affirmation of LGB persons and relationships at the individual level, and the responsibility of programs to provide affirmative

Table 2 Latent Correlations among Construct Validity Scales and the ATI-F Subscales

1 2 3 4 5 6 7

1. ATI-F: Teaching

—

2. ATI-F: Program

.49*** —

3. ATI-F: Experience

.77*** .49*** —

4. R-SOCCS: Knowledge/ Skills

.63*** .53*** .94*** —

5. R-SOCCS: Awareness

.32*** .22* .41*** .27** —

6. Individual Affirmation

.36*** .36*** .50*** .36*** .78*** —

7. Program Affirmation

.56*** .35*** .55*** .42*** .66*** .73*** —

Mean 4.80 4.62 4.69 4.85 5.59 5.58 5.33 Standard Deviation 0.86 0.83 0.96 0.66 0.72 0.87 1.02

Note. ATI-F = Affirmative Training Inventory – Faculty version; R-SOCCS = Revised Sexual Orientation Clinical Competency Scale. *p < .05; **p < .01; ***p < .001.

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training. The structural model had excellent fit (v2 [df = 133] = 182.39, p < .01, RMSEA = 0.06 [90% C.I.: 0.03–0.08]; CFI = 0.96). Latent correlations among constructs are presented in Table 2. As expected, all constructs were positively and significantly related, providing initial evidence for the validity of the ATI-F.

DISCUSSION

The results of this study support the validity and factor structure of the ATI-F as a measure of the level of LGB affirmative training that occurs in clinical programs as well as faculty members’ beliefs about the role of LGB affirmative training in preparing future therapists. Additionally, our results support the validity of the three subscales of the ATI-F (i.e., teaching, program, and experi- ence). The establishment of this measure is important given that no previous scale exists that mea- sures the integration of LGB affirmative therapy training from the perspective of faculty members. Furthermore, the addition of this measure to the literature is also important given that previous research highlights an overall lack of training on LGB affirmative therapy and this measure would allow clinical programs to better assess the level of training they provide their students (Carlson et al., 2013; Doherty & Simmons, 1996; Green, 1996; Green et al., 2009; Henke et al., 2009; Long & Serovich, 2003; Rock et al., 2010).

In addition to establishing the validity and factor structure of the ATI-F, we also explored the relationships between the subscales of the ATI-F and three relevant constructs, namely, LGB clini- cal competence, personal affirmation of LGB persons and relationships, and the responsibility of programs to provide LGB affirmative training. The association between the subscales of the ATI-F and these relevant constructs were all positive and significant. For example, the results of this study indicated a positive relationship between the subscales of the ATI-F and the R-SOCCS, which sug- gested that increased levels of training by faculty members was associated with greater self-reported LGB clinical competence. In particular, we found that increased levels of teaching about LGB affir- mative topics was associated with higher levels of self-reported knowledge and skills related to working with LGB clients among faculty members. We offer two possible interpretations for this finding. The first and most obvious interpretation is that faculty members who possess greater knowledge and skills related to working with LGB clients are more likely to teach about these top- ics in their courses. It is also possible that an increase in the rates of which faculty members teach about LGB affirmative therapy is associated with an increase in their own knowledge and skills. This finding highlights the importance of ensuring that faculty members receive training on LGB affirmative therapy either in their doctoral programs or through continuing education opportuni- ties and supports calls in the literature for an increase in the level of LGB affirmative content in CFT programs as this may have an influence on students and faculty alike (Carlson et al., 2013; Green, 1996; Green et al., 2009; Henke et al., 2009; Long & Serovich, 2003; Rock et al., 2010).

The results also suggest that the level of instruction that faculty members provided on LGB affirmative therapy was positively associated with their own attitudes and beliefs toward LGB clients. There are a couple possible interpretations for this finding, namely, faculty members with more LGB affirmative beliefs appear to be more likely to teach about affirmative therapy in their CFT courses. It is also possible that teaching about LGB affirmative therapy has a positive influ- ence on faculty members’ attitudes and beliefs toward LGB individuals and relationships. This finding may be important because previous studies have found that clinicians’ attitudes and beliefs about the LGB community predict their competence to work with LGB clients (Henke et al., 2009; Rock et al., 2010). Thus, it is possible that simply requiring or encouraging programs to include LGB affirmative content has the potential to positively influence faculty members’ beliefs about LGB individuals and relationships.

There was also a positive association between the program subscale of the ATI-F and the two subscales of the R-SOCCS. In particular, we found that the more faculty members perceived the environment of their training program as LGB affirmative was positively associated with their own knowledge and skill to work with LGB clients as well as their own beliefs about LGB individuals and relationships. There are a number of possible interpretations of these findings. For instance, the more affirmative a program environment is toward LGB individuals and relationships, the more likely it is that faculty members sought to enhance their own knowledge and skills related to

January 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 65

working with LGB clients and developed more positive beliefs about the LGB community. It is also possible that those with greater skills and knowledge to work with LGB clients and who hold more positive beliefs were more likely to seek out a program with an affirmative environment or to create such an environment in their training program.

Additionally, there was a positive association between the experience subscale of the ATI-F and the two subscales of the R-SOCCS. In particular, we found that the level of experience that faculty members had working with LGB clients was associated with increased levels of knowledge and skills working with LGB clients and more positive attitudes and beliefs toward LGB individu- als and relationships. This finding is not surprising given that scholars have consistently asserted that the best way to improve clinical competence and increase positive beliefs toward the LGB community is through increased contact and experience with LGB individuals, couples, and orga- nizations (Green, 1996; Long & Serovich, 2003; McGeorge & Carlson, 2011). However, this find- ing highlights the importance of faculty members seeking clinical experience with LGB clients to improve their overall clinical competence with this population.

Another finding worth highlighting is the positive association between the individual affirma- tion convergent validity item and each of the subscales of the ATI-F. In particular, it appears that faculty members who take an affirmative (i.e., a positive view of LGB identity and relationships) stance toward LGB individuals and relationships are more likely to teach about LGB affirmative therapy, perceive their program environment to be LGB affirming, and have had professional experiences with LGB clients and topics. This finding seems to suggest that faculty members may need to do self-of-the-faculty work to help them more actively affirm LGB individuals and rela- tionships (Carlson & McGeorge, 2012). This finding also raises questions about the potential dif- ference between taking an affirmative stance toward the LGB community and being tolerant of the LGB community. As existing research highlights the relationship between homophobia and LGB clinical competence (Carlson et al., 2013; Henke et al., 2009; Rock et al., 2010), further explora- tion is needed regarding the potential impact of being affirmative versus tolerant toward the LGB community when it comes to both LGB clinical competence and teaching about competent approaches to therapy with LGB clients.

Finally, there was a positive relationship between the program affirmation convergent validity subscale and each of the subscales of the ATI-F. In particular, faculty members who believed that programs have a responsibility to teach LGB affirmative therapy practices and encourage students to develop positive beliefs about LGB individuals and relationships were: (a) teaching about LGB affirmative therapy; (b) perceiving their program to be affirmative; and (c) have had professional experience with LGB clients and topics. This finding could highlight the importance of taking an LGB affirmative stance at the training program level, which is consistent with recommendations in the existing literature (Carlson & McGeorge, 2012; Carlson et al., 2013; Long & Serovich, 2003).

Limitations While we believe the findings of this study make an important contribution to the literature,

there are limitations to discuss. First, our sample size was relatively small and, thus, future studies should try to replicate our findings with larger samples. Another possible limitation of this study involves self-selection bias in that faculty members with more affirmative LGB beliefs could have been more likely to complete our survey. Additionally, due to the self-report nature of this survey, we were only able to assess faculty members’ perceptions of the training they provided as well as their own perceived LGB clinical competency. Therefore, future studies could seek to assess the actual training being provided through a review of syllabi or by utilizing observational methodology.

Suggestions for Future Research Based on the results of this study, we have several recommendations for future research. For

example, given the relationship we found between program environment and LGB clinical compe- tence, research could further assess CFT program environments by exploring the types of LGB affirmative policies programs have established and the influence of these policies on faculty and students’ LGB clinical competence. Additionally, it would be interesting if future studies compared the reports of faculty members and students from the same program to determine how their

66 JOURNAL OF MARITAL AND FAMILY THERAPY January 2015

perceptions varied. Finally, researchers could use the ATI-F to compare the level of LGB affirma- tive training that faculty members provide across mental health disciplines (e.g., social work, psy- chology, counseling), as such a study would provide insight into the extent to which LGB affirmative training has been integrated across disciplines.

Recommendations for Clinical Training Based on the results of this study, there are several recommendations for CFT training pro-

grams that we would like to highlight. First, given the documented lack of training in the CFT field on LGB affirmative therapy and the relative newness of this topic in the CFT literature (Carlson et al., 2013; Henke et al., 2009; Rock et al., 2010), it is likely that many of the current CFT faculty were never trained on LGB affirmative therapy practices; therefore, it seems impor- tant that CFT faculty members seek out continuing education opportunities specifically related to LGB affirmative therapy and training. To address this deficit, it may be important for the COAMFTE to consider requiring faculty members from accredited programs to participate in continuing education on LGB affirmative therapy as well as topics related to working with other diverse populations.

Second, given the apparent role that faculty members’ beliefs about LGB individuals and relationships had on the level of LGB affirmative content they provided, it seems important for faculty members to engage in self-of-the-faculty work to facilitate an exploration of their beliefs and biases related to LGB individuals and relationships (Carlson & McGeorge, 2012; McGeorge & Carlson, 2011). This self-of-the-faculty work needs to assist faculty members in exploring their conscious and unconscious biases about the LGB community that come with living in a heteros- exist society as well as help faculty members to actively take a more affirming position as LGB allies in their professional lives. Such self-of-the-faculty work may be particularly necessary for many faculty members as it was probably not a part of their own master’s and doctoral training experience.

Finally, the ATI-F could be used as a self-assessment tool for CFT programs to evaluate their course content and program environment. This would provide CFT programs with insight into the degree to which LGB affirmative therapy topics are integrated into their curriculum and the overall program environment. CFT programs could use the ATI-F to assess faculty members’ perceptions as well as use the original ATI (Carlson et al., 2013) to assess students’ perceptions in order to gain a more complete understanding of how their students are being prepared to work with LGB clients.

CONCLUSION

This study established the validity and factor structure of the ATI-F as a measure of faculty members’ perceptions of LGB affirmative clinical training. Additionally, this study examined the latent associations among the subscales of the ATI-F, the R-SOCCS (i.e., a measure of LGB clinical competence), and two additional convergent validity scales (i.e., an item assessing personal affirmation of LGB individuals and relationships, and a measure of the responsibility of programs to provide affirmative training). The findings from this study provide empirical support for the relationship between including specific classroom related content on LGB affir- mative therapy and faculty members’ beliefs about LGB individuals and relationships. In partic- ular, faculty members who report more positive beliefs about LGB clients appear to be more likely to include LGB affirmative therapy content in the courses that they teach. This study also found a positive association between faculty members’ professional experience with LGB clients and topics as well as their own beliefs about LGB individuals and relationships, which highlights the importance of faculty members seeking opportunities to educate themselves about LGB top- ics and gain professional experiences with the LGB community. Our hope is that this study encourages CFT faculty members to examine their own biases and beliefs about the LGB com- munity and to evaluate their own course content in an effort to fulfill their responsibility to bet- ter prepare future family therapists to provide competent and affirmative therapy to the LGB community.

January 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 67

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NOTE

1 While literature often refers to the lesbian, gay, bisexual, and transgender community, this

study focuses on sexual orientation rather than gender identity. We recognize that topics related to working with transgender clients have been traditionally marginalized in the literature (Blumer, Green, Knowles, & Williams, 2012; Coolhart, Baker, Farmer, Malaney, & Shipman, 2013), and it is not our intent to add to this marginalization. We believe it is important to acknowledge that sex- ual orientation and gender identity are distinct constructs. There is a clear need for future research to focus on affirmative therapy training with transgender clients.

APPENDIX A: FINAL VERSION OF THE ATI-F

AFFIRMATIVE THERAPY INVENTORY (ATI) – FACULTY VERSION

Instructions: Please select the number that best represents your level of agreement with each state- ment on a scale of 1 (Strongly Disagree) to 6 (Strongly Agree).

1. In my family therapy courses, I specifically include content related to the experiences of lesbian, gay, and bisexual (LGB) individuals. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

2. In my family therapy courses, I teach my students about the influence of heterosexual bias (i.e., the act of conceptualizing human experiences in heterosexual terms, thereby marginalizing LGB experiences and relationships) on the therapy process. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

3. In my family therapy courses, I teach my students about the concept of heterosexism (i.e., a belief system supported by laws and societal customs that legitimizes heterosexuality as the only acceptable way of being which leads to the unequal treatment of LGB individuals). 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

4. In my family therapy courses, I teach my students how to explore the negative influence that heterosexism (i.e., a belief system supported by laws and societal customs that legitimizes heterosexuality as the only acceptable way of being which leads to the unequal treatment of LGB individuals) may have on the lives of LGB clients 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

January 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 69

5. In my family therapy courses, I teach my students about the concept of heterosexual privilege (i.e., the unearned advantages given to heterosexual individuals based solely on their sexual orientation). 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

6. I encourage my family therapy students to explore their own heterosexual biases (i.e., the act of conceptualizing human experience in heterosexual terms, thereby marginalizing the experiences and relationships of LGB individuals). 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

7. I encourage my non-LGB family therapy students to explore their heterosexual privilege (i.e., the unearned advantages given to heterosexual individuals based solely on their sexual orientation) as part of their self-of-the-therapist work. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

8. In my family therapy courses, I teach my students about models of LGB identity development. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

9. In my family therapy courses, I teach my students the skills necessary to support LGB clients in the coming out process. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

10. In my family therapy courses, I teach my students to work with lesbian and gay couples in an affirming manner. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

11. I have supervised student research (e.g., thesis, dissertation) on topics specifically related to LGB individuals, couples, and/or families. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

12. My training program intentionally recruits LGB students. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

13. Our program would be a safe place for a LGB student to come out. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

14. The other faculty in my family therapy training program take an affirmative (i.e., a positive view of LGB identity and relationships) stance toward LGB individuals and relationships. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

70 JOURNAL OF MARITAL AND FAMILY THERAPY January 2015

15. My family therapy program takes an affirmative (i.e., a positive view of LGB identity and relationships) stance toward LGB individuals and relationships. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

16. My program has specific policies designed to create a LGB affirmative environment. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

17. In my family therapy courses, I teach my students about LGB affirmative therapy (i.e., an approach to therapy that embraces a positive view of LGB identity and relationships and that addresses the negative influences that homophobia and heterosexism have on the lives of LGB clients) through readings, lectures, supervision, etc. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

18. Overall, the family therapy program in which I teach provides students with information on LGB affirmative therapy (i.e., an approach to therapy that embraces a positive view of LGB identity and relationships and that addresses the negative influences that homophobia and heterosexism have on the lives of LGB clients) through readings, lectures, supervision, etc. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

19. I have sought out continuing education opportunities to further my knowledge of LGB affirmative therapy and training. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

20. I have experience supervising students working with LGB clients. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

21. I feel competent in my ability to train students to be affirmative in their clinical work with LGB clients. 1 2 3 4 5 6 Strongly Disagree

Disagree Somewhat Disagree

Somewhat Agree

Agree Strongly Agree

January 2015 JOURNAL OF MARITAL AND FAMILY THERAPY 71

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