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The Journal for Specialists in Group Work

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Examining the Utility of Group Counseling for LGBTQ+ Young Adults in the Coming Out Process

Shainna Ali & Glenn W. Lambie

To cite this article: Shainna Ali & Glenn W. Lambie (2019) Examining the Utility of Group Counseling for LGBTQ+ Young Adults in the Coming Out Process, The Journal for Specialists in Group Work, 44:1, 46-61, DOI: 10.1080/01933922.2018.1561775

To link to this article: https://doi.org/10.1080/01933922.2018.1561775

Published online: 31 Jan 2019.

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RESEARCH

Examining the Utility of Group Counseling for LGBTQ+ Young Adults in the Coming Out Process Shainna Ali and Glenn W. Lambie

University of Central Florida

ABSTRACT Although the need for counseling specific to LGBTQ+ coming out concerns is recognized, limited empirical evidence exists to substanti- ate such claims. Therefore, the primary purpose of this study was to investigate the relationship between LGBTQ+ young adults’ (ages 18–24) group therapeutic factor scores and their levels of coping, appraisal of social support, and coming out growth following their participation in a strength-based group counseling intervention. Significant relationships were identified between the participants’ group therapeutic factor score and their adaptive coping and coming out growth scores. Implications for group counseling and counselor education are discussed.

ARTICLE HISTORY Received October 26, 2017 Accepted October 10, 2018

KEYWORDS Coming out process; group counseling intervention; group therapeutic factors; LGBTQ+

Coming out, the process in which an LGBTQ+ individual discloses identity, is a stressful, ongoing, and transformative process that encompasses the lifespan (Ali, 2017; Ali & Barden, 2015). During the coming out process, individuals are at-risk for a multitude of concerns such as anxiety, isolation, and depression (e.g., Baams, Grossman, & Russell, 2015; Kosciw, Greytak, Diaz, & Bartkiewicz, 2014; Meyer, 2003; Vaughan & Waehler, 2010). In the lifelong cycle of coming out, continuous intrapersonal and interpersonal pressures may evoke negative emotions such as anxiety, loneliness, isolation, fear, anger, resentment, shame, and guilt (e.g., Ali, 2017; Ali & Barden, 2015; Kosciw et al., 2014; Vaughan & Waehler, 2010). When coming out, individuals require coping, social support, and intrapersonal strength in order to develop resilience, persevere, and progress into healthy adulthood (e.g., Ali, 2017; Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling [ALGBTIC], 2013; Meyer, Schwartz, & Frost, 2008; Needham & Austin, 2010). Group counseling is an effective approach in providing social support (Kiweewa, Gilbride, Luke, & Seward, 2013; Yalom & Leszcz, 2005) and increasing coping strategies (Griffith, 2014; Meaney-Tavares & Hasking, 2013). Additionally, group counsel- ing is an effective intervention strategy for individuals experiencing a range in their progress along the coming out continuum (Dunlap, 2014a). Furthermore, group counsel- ing is suggested as a strengths-based intervention to contribute to well-being of LGBTQ+ individuals (Craig, 2013; Goodrich & Luke, 2015; Fisher et al., 2008; Griffith, 2014; Riggle, Gonzalez, Rostosky, & Black, 2014). Specifically, young adulthood is noted as a pivotal time in development (Dunlap, 2014a; Guittar, 2013) in which internal identity develop- ment processes coincide with stressors from the outside world (e.g., beginning college,

CONTACT Shainna Ali [email protected] University of Central Florida, 4000 Central Florida Blvd., Orlando, FL 32816.

THE JOURNAL FOR SPECIALISTS IN GROUP WORK 2019, VOL. 44, NO. 1, 46–61 https://doi.org/10.1080/01933922.2018.1561775

© 2019 ASGW

starting a career). Although group counseling is acknowledged as an applicable method in providing counseling to LGBTQ+ persons, the efficacy of coming out group counseling interventions has not been investigated with a sample of LGBTQ+ young adults. Therefore, this study contributes to the literature by examining the relationship between LGBTQ+ young adults’ group therapeutic factors scores and their coping, social support, and coming out growth scores following their participation in a strengths-based coming out group counseling intervention

Group Counseling for Coming Out Concerns

Group work scholars assert that group counseling research should give a voice to margin- alized populations (Goodrich & Luke, 2017; Rubel & Atieno Okech, 2017; Vereen & Bohecker, 2017). However, Rubel and Atieno Okech (2017) highlight low motivation amongst group work researchers, particularly in reference to real world groups. Additionally, Byrd, Crockett, and Erford (2012) posit that the academic emphasis within group work literature may cause field experiences to be lacking. Moreover, Vereen and Bohecker (2017) acknowledge that there is limited group work research pertaining to LGBTQ+ issues. In recognizing this gap, we are also aware that therapy is not only a common suggestion without coming out research (Alessi, 2014; Chazin & Klugman, 2014; Hartwell, Serovich, Grafsky, & Kerr, 2012), but group in particular can help individuals in this coming out process (Fisher et al., 2008; Goodrich & Luke, 2015; Muller & Hartman, 1998; Roberts, 2007).

In a qualitative study across five age LGB community cohorts between the ages 18 and 74, Dunlap (2014b) noted that in addition to therapy, relationships, education, and community are helpful in navigating the process of coming out. Peer counseling pro- grams, speaker panels, support groups, and Gay/Straight Alliances have been recognized for their utility in providing safe environments and support to individuals in the coming out process (Dunlap, 2014a; Fisher et al., 2008). Similarly, in a qualitative study examining helpful variables during the coming out process, participants noted that in addition to social support, the ability to reflect, plan, and discuss in a safe environment were catalysts to a positive coming out experience (Ali, 2017).

Therefore, in recognizing the need for LGBTQ+ group work and the potential for clients to benefit from group work research that is applicable to their experiences, we sought to create a strengths-based coming out counseling group and examine the relation- ship between the participants’ group therapeutic factor scores and their levels of coping, appraisal of social support, and coming out growth. We hypothesize that a strengths-based group crafted to address coping, social support, and coming out growth would be related to group therapeutic factors and hence improve the group counseling experience for clients seeking help during the coming out process.

Curative Group Therapeutic Factors and the Coming Out Process

Group counseling is an effective modality for increasing coping and social support (Goodrich & Luke, 2015; Griffith, 2014; Kiweewa et al., 2013). Yalom and Leszcz (2005) noted the 11 therapeutic factors of group therapy: (a) instillation of hope; (b) cohesion; (c) universality; (d) altruism; (e) imparting information; (f) interpersonal learning; (g)

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development of socializing techniques; (h) imitative behavior; (i) catharsis; (j); corrective reenactment of the primary family group; and (k) existential factors. When considering the applicability of a group counseling intervention with LGBTQ+ clients, these 11 therapeutic variables are not only facilitative, but essential. The 11 group therapeutic factors have the potential to enhance LGBTQ+ young adults’ coping, social support, and coming out growth. Specifically, Dunlap (2014b) noted that instillation of hope and universality are key ther- apeutic factors in the coming out process. Additionally, a study of examining group growth factors in master’s level students in experiential groups the most common themes included (a) vicarious modeling, (b) genuineness and authenticity, (c) self-disclosure, (d) validation and acceptance, (e) facilitator interventions, (f) cohesive bonding, and (g) universality (Kiweewa et al., 2013). These themes provided a basis for the utilization of group counseling to meet the needs of individuals within the coming out process.

From a social-constructivist perspective, coming out is contextual and unique to each individual and occurrence (Guittar, 2013; Rust, 1993). Variability does not only occur between identities. Diversity in coming out experiences are likely to vary for any one individual as the context (e.g., recipient, environment) affects the process (Ali, 2017). The coming out process can often be lonely and isolating. Since coming out may not be openly discussed, the group environment provides an opportunity for clients to bond with others who are having shared experiences. Individuals who are questioning coming out can be provided with the opportunity to disclose in a safe environment and receive acceptance (Kiweewa et al., 2013). An individual can experience catharsis from having a safe, com- fortable environment to discuss and process identity (Dentato, Craig, Messinger, Lloyd, & McInroy, 2014). Regardless of the result of disclosure, the group can provide an authentic and accepting environment that can provide a buffer of social support.

An individual can experience catharsis from having a safe, comfortable environment to discuss and process identity (Dentato et al., 2014). A group counseling approach provides an opportunity to normalize the process and to experience cohesiveness and universality. For example, if individuals in the group are in an early phase of identity development and are struggling with disclosing to their parent(s) and witness a peer successfully do so, they have the opportunity to grow from that indirect experience. When group members share experiences, the coming out process is not only normal- ized, but a wider range of perspectives may also be provided, allowing individuals to learn what may be helpful and unhelpful (Alessi, 2014; Chutter, 2007). The group counseling modality allows for flexibility in gaining varying views and insight for individuals who have existential inquiries. Peers can learn from one another’s pro- cesses, whether positive or negative. Additionally, group counseling provides an accept- ing, facilitative environment to release and heal from negative disclosures. Moreover, the group can provide an outlet for individuals to share their experiences, feelings, thoughts, and plans (Fisher et al., 2008).

During young adulthood, LGBTQ+ individuals often lack role models to guide them through the coming out process (Chutter, 2007; Mears, 2004; Riggle, Whitman, Olson, Rostosky, & Strong, 2008). Through a group counseling approach, participants are not only learning from the facilitator and the provided materials, but also experiencing vicarious learning (Bandura, 1995; Kiweewa et al., 2013). Moreover, since coming out is a continuous process, regardless of whether it is the client’s initial disclosure or if the client has been openly sharing with others, clients can still benefit from hearing various

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coming out narratives and informing their own choices (Dunlap, 2014a). Therefore, group counseling can serve as an affirmative counseling method to help clients maintain their well-being during the coming out process (Riggle et al., 2014).

Purpose Statement

Strength-based group counseling has been suggested as an affirmative practice with LGBTQ+ clients. Furthermore, group counseling is noted as a helpful modality for clients affected by coming out concerns. The present study sought to examine the relationship between LGBTQ+ young adults’ group therapeutic factors and their levels of coping, appraisal of social support, and coming out growth.

Methods

Participants

The Institutional Review Board granted permission to conduct this study. Participants were recruited from a large city in the Southeastern United States. Individuals who identified as LGBTQ+, were between the ages of 18 and 24, and were actively considering coming out to at least one person were invited to participate in this study. Acknowledging the benefit of vicarious modeling (Kiweewa et al., 2013; Yalom & Leszcz, 2005) in relation to the coming out continuum (Ali, 2017; Ali & Barden, 2015; Dunlap, 2014a), individuals were not recruited based on stage. Hence, participants ranged from no past disclosure to partial disclosure (i.e., disclosure to some individuals but not all). To recruit potential participants, we utilized local LGBTQ+ organizations to share our promotional materials. Considering the use of a group intervention, individuals were excluded from the study if they were not suitable to group treatment, such as individuals that may monopolize or who have severe mental health concerns that would distract from the group (i.e., psychosis, active illegal substance abuse; Gladding, 2012). Individuals who did not qualify to participate in the study but were interested in receiving group counseling were referred to local resources.

A total of 45 individuals inquired about participating in the investigation. Following the screening process, 32 individuals were eligible for participation. The seven individuals who were deemed unacceptable for this study were either under the age of 18, over the age of 24, or had active suicidal ideation. Since the intervention follows a group counseling format, individuals needed to have availability that matched other participants in order to be assigned to a group. Of the 32 eligible individuals, 28 had suitable availability and were assigned to one of three groups. All 28 participants completed the initial data collection packet, 27 participants completed the second packet (96.43% response rate), and 26 participants completed the third packet (92.86% response rate). Thus, a total of 26 LGBTQ+ individuals between the ages of 18 and 24 (M = 19.96, SD = 1.78, Mdn = 20) provided complete data for our study. Two participants began jobs during the study that conflicted with attendance and needed to drop out of the group. Pallant (2010) asserts that the sample size should be at least more than the number of dependent variables; therefore, the sample utilized is adequate. Additionally, Lipsey (1990) asserts that at an alpha level of .05, the present sample size meets the criterion to achieve adequate effect sizes (.25) and power (.80) for experimental designs.

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Providing LGBTQ+ individuals with pre-selected categories to define gender and orientation can perpetuate stigma and bias. Therefore, aligned with best practice standards to strengthen and empower marginalized clients (Goodrich & Luke, 2017), participants were given fill-in-the-blank prompts pertaining to identity. More participants identified as female (65.4%) than male (26.9%); furthermore, one participant identified as genderqueer (3.8%), and one participant identified as genderfluid (3.8%). In terms of affectional orientation, participants identified as lesbian (n = 8, 30.8%), gay (n = 7, 26.9%), bisexual (n = 7, 26.9%), asexual (n = 2, 7.7%), queer (n = 1, 3.8%), and one participate identified as polysexual/pansexual (n = 1, 3.8%). The majority of participants reported being single (n = 22, 84.6%) whereas four individuals were in a relationship (15.4%).

All participants were college students; however, not all participants were enrolled in the same institution and there was education level variation. Seven participants reported being freshman (26.9%), eight were sophomores (30.8%), six were juniors (23.1%), four were seniors (15.4%), and one student was in graduate school (3.8%). In reference to ethnicity, the participants identified as White (n = 12, 46.2%), Hispanic/Latino (n = 6, 23.1%), Multiracial (n = 4, 15.3%), Black/African-American (n = 1, 3.8%), Asian (n = 1, 3.8%), West-Indian (n = 1, 3.8%), and Persian (n = 1, 3.8%). Therefore, a majority of the sample identified as an ethnic minority (53.8%). The ethnic demographic data for our participants were similar to demographic data for United States in reference to the majority and largest minority group, including representation from diverse ethnic groups (United States Census Bureau, 2014).

Procedure

Participants received an 8-hour group counseling intervention to assist them through the coming out process. The intervention was divided into four 2-hour sessions. The partici- pants met weekly for four consecutive weeks. Incentives were utilized to improve parti- cipation (Dillman, Smyth, & Christian, 2009), including participants receiving $10.00 for their involvement in the study ($5 gift cards provided at sessions one and four). This investigation was part of a larger study (Ali & Lambie, 2016).

The Group Counseling Curriculum A manual was utilized in order to standardize the intervention and to enhance treatment fidelity (Gall, Gall, & Borg, 2006). Since no empirically supported manual was found, the lead author developed a manual that was grounded in affirmative practice.

The materials were based created based on the Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling’s counseling competencies and coming out literature such as the cycle of coming out (Ali & Barden, 2015) and previous client’s experiences in the coming out process (Ali, 2017). The manual consists of facilitator guidelines, an outline of the group curriculum, required handouts, and recommended resources. The group curriculum included interactive and psychoeduca- tional sessions with the aims of (a) encouraging constructive behaviors, (b) promoting healthy ways of coping, (c) utilizing a positive support system, and (d) assisting clients through coming out decision-making processing. The general schedule for each session included a check-in, the topic of the day, an activity, processing, and assigned home- work. The session topics varied to cover both the skills and cycle of coming out in an

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intentional, developmental order. The first session introduced the members to the group goals, rules, and purposes. Members were encouraged to introduce themselves and begin to engage with their peers. The first group counseling session began to lay the foundation for the remaining of the sessions as the cyclical concept of coming out was introduced. The second session focused on coping and the awareness phase of coming out. The third session targeted social support and assessed the decision to disclose identity. The final session included practice of coping and social support skills as well as coming out plans. For more details on the group counseling manual, guide- lines, sessions, or curriculum, please contact the first author.

Data Instrumentation

The data collection packet included four measures: (a) the Therapeutic Factors Inventory Short Form (TFI-S; Joyce, MacNair-Semandis, Tasca, & Ogrodniczuk, 2011), (b) the Brief COPE (Carver, 1997), (c) The Social Support Questionnaire 6 (Sarason, Sarason, Shearin, & Pierce, 1987), and (d) the Coming Out Growth Scale (Vaughan & Waehler, 2010). Additionally, the first data collection packet (first session) also included the demographics questionnaire, tracking the participants’ age, ethnicity, biological sex, gender identity, affectional orientation, and level of disclosure about LGBTQ+ status.

The Brief COPE The COPE was developed to assess a broad range of coping responses. Recognizing the utility of a shortened instrument in assessment, Carver (1997) created the 28-item Brief COPE (Carver, 1997). The Brief COPE is to be analyzed in reference to positive and negative coping strategies rather than total scores (Jacobson, 2005; Moore, Biegel, & McMahon, 2011). Therefore, the Brief COPE was examined in reference to two categories: Adaptive Coping (subscales 1–10: active coping, planning, using instrumental support, using emotional support, venting, self-distraction, positive reframing, humor, acceptance, and religion) and Maladaptive Coping (subscales 11–14: behavioral disengagement, self- blame, denial, and substance use). The Brief COPE has been used to better understand coping for a variety of concerns such as HIV (e.g., Mohanraj et al., 2015), aging (e.g., Lagana & Zarankin, 2010), depression (e.g., Cooper, Katona, Orrell, & Livingston, 2008), and breast cancer (e.g., Culver, Arena, Antoni, & Carver, 2002). The Brief COPE was used in an investigation to examine a group intervention for LGBTQ+ individuals ages 18–20 (Griffith, 2014), having sound international consistency reliability at pretest, midpoint, and posttest points (Adaptive Coping, α = .81, .83, .85; Maladaptive Coping, α = .88, .84, 84). For our data, Adaptive Coping displayed sound internal consistency (α = .71) scores.

The Social Support Questionnaire 6 The Social Support Questionnaire 6 (SSQ6; Sarason et al., 1987) is 6-item measure that assesses perceived social support (SSQ-N) and the satisfaction with perceived social support (SSQ-S). The SSQ6 is an abbreviated version of the original 27-item SSQ (Sarason, Levine, Basham, & Sarason, 1983). Positive associations have been found between both SSQ6 subscales and social aspects such as skill and support, providing support for convergent validity. Multiple measures were used to establish concurrent validity for the SSQ6, including correlates with the Inventory of Social Supportive

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Behaviors (ISSB; Barrera, Sandler, & Ramsay, 1981). The internal consistency reliability for the two SSQ6 subscales ranges from .90–.93 (Sarason et al., 1987). For our data, the SSQ-N (α = .94) and the SSQ-S (α = .87) had high internal consistency reliability.

The Coming Out Growth Scale Vaughan and Waehler’s Coming Out Growth Scale (COGS; 2010) measures the perceived gains from the process and outness. The 34-item version of the COGS was utilized in order to allow for an examination of intrapersonal and interpersonal dimensions of growth. The Individualistic Growth dimension includes perceived gains in authenticity/honesty, biopsy- chosocial well-being, and sexual minority identity. The Collectivistic Growth dimension captures growth in LGBT-affirming views, a sense of belonging, and a collective LG identity. The intrapersonal growth subscale of the COGS (Vaughan & Waehler, 2010) has a reliability of .96 and the collectivistic growth subscale has a reliability of .88. For our data, the COG internal consistency reliability was high for both subscales: individualistic growth (α = .96) and collectivistic growth (α = .91). Although the COGS was normed for lesbian and gay identities, the creator was a part of the research group and supported the application of this form to other identities. Therefore, this is the first study to use the COGS to measure the gained from the coming out process with diverse sexual and gender minorities.

Therapeutic Factors Inventory Short Form The Therapeutic Factors Inventory Short Form (TFI-S; Joyce et al., 2011) was designed to measure the effectiveness of group counseling (e.g., curative factors and dynamics). The TFI- S was administered at the conclusion of the group counseling experience. The TFI-S is based on Yalom’s 11 therapeutic factors and higher scores demonstrate participants’ positive experiences within group. In this study, the TFI-S was analyzed using subscale scores, including: (a) Instillation of Hope, (b) Secure Emotional Expression, (c) Awareness of Relational Impact, and (d) Social Learning. TFI-S items are formatted on a 7-point Likert- type scale ranging from strongly disagree to strongly agree. Example prompts from the TFI-S include, “I feel a sense of belonging in group” and “this group empowers me to make a difference in my own life.” Each TFI-S factor demonstrates sound internal consistency reliability (Instillation of Hope [r = .90], Secure Emotional Expression [r = .85], Awareness of Interpersonal Impact [r = .79], and Social Learning [r = .66]), which was consistent with previous research with the TFI-S (e.g., Griffith, 2014; Johnson & Lambie, 2013).

Results

A canonical correlation was utilized to analyze the relationship group therapeutic factors and outcome variables (Tabachnick & Fidell, 2013). Additionally, Pearson Product Moment Correlations (two-tailed) were used to calculate whether there was a significant relationship between the group therapeutic factor scores and Adaptive Coping, Maladaptive Coping, Social Support Number, Social Support Satisfaction, Collectivistic Growth, and Individualistic Growth. The first canonical correlation was .88 (77% over- lapping variance), the second canonical correlation was .60 (36% overlapping variance), the third canonical correlation was .49 (24% overlapping variance), and the fourth was effectively zero. When considering the four canonical correlations, the result was statisti- cally significant, F (24, 57.03) = 2.15, p < .01. Therefore, the results identified a strong

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correlation between participants’ TFI-S scores (group therapeutic factors) and their Brief COPE, SSQ6, and COGS scores (outcomes variables).

The Pearson’s Product Moment Correlations identified statistically significant relation- ships between the participants’ group therapeutic factor scores and their adaptive coping, individualistic growth, and collectivistic growth scores. Installation of hope had a strong correlation with adaptive coping (r = .68, p < .001; 46.24% of the variance explained), individualistic growth (r = .71, p < .001; 50.41% of the variance explained), and collecti- vistic growth scores (r = .52, p < .01; 27.04% of the variance explained). Participants’ levels of secure emotional expression correlated with their adaptive coping (r = .47, p < .05; 22.09% of the variance explained), individualistic growth (r = .47, p < .05; 22.09% of the variance explained), and collectivistic growth scores (r = .52, p < .05; 27.04% of the variance explained). The participants’ level of Awareness of Interpersonal Impact (AII) correlated with their adaptive coping (r = .52, p < .01; 27.04% of the variance explained), individualistic growth (r = .47, p < .05; 22.09% of the variance explained) and collectivistic growth scores (r = .47, p < .05; 22.09% of the variance explained). Finally, participants’ level of Social Learning (SL) correlated with their adaptive coping (r = .72, p < .001; 51.84% of the variance explained), collectivistic growth (r = .69, p < .001; 47.61% of the variance explained), and individualistic growth scores (r = .71, p < .001; 50.41% of the variance explained). For descriptive statistics please refer to Table 1.

Discussion

The canonical correlation highlights the relationship between group therapeutic factors and the factors examined in the present study (i.e., coping, social support, and coming out growth). Upon further examination, Pearson Product Moment Correlations help to illuminate the relationships between group therapeutic factors and adaptive coping, individualistic growth, and collectivistic growth. The correlation between coping and group therapeutic factors highlights that the affirmative coming out group may have been successful in facilitating coping through means such as imparting information, modeling, and validation (Kiweewa et al., 2013; Yalom & Leszcz, 2005). Additionally, the relationships between both individual and collectivistic coming out growth and group therapeutic factors highlights that the strength-based coming out curriculum may be beneficial for fostering coming out growth by means such as providing a safe environment to process identity (Dentato et al., 2014) and positive role models (Chutter, 2007; Mears, 2004; Riggle et al., 2008).

Our participants’ group therapeutic factor scores were higher than participants’ scores in previous studies. Specifically, the TFI-S subscale scores were almost double that of Johnson and Lambie’s (2013) participants (Instillation of Hope, M = 3.61;

Table 1. Brief COPE, SSS-6, and COGS descriptive statistics. Descriptive Statistics M Mdn Mode SD Range Min. Max.

Brief COPE – Adaptive 57.88 60.00 65.00 9.09 34.00 39.00 73.00 Brief COPE – Maladaptive 11.92 11.00 8.00 .45 13.00 8.00 21.00 Social Support Questionnaire 6-Number 5.76 5.83 9.00 2.53 8.00 1.00 9.00 Social Support Questionnaire 6-Satisfaction 5.51 5.67 6.00 .65 3.17 4.00 7.17 Coming Out Growth Scale-Individualistic Growth 92.77 98.50 106.00 15.99 67.00 43.00 110.00 Coming Out Growth Scale-Collectivistic Growth 48.58 49.50 56.00 9.71 41.00 19.00 60.00

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Secure Emotional Expression, M = 3.06; Awareness of Relational Impact, M = 2.77; Social Learning, M = 3.22). Although Griffith’s (2014) study utilized a sample from a similar population, scores in the present study were higher across all of the group therapeutic factors: (a) Instillation of Hope (M = 5.78, SD = 1.03), (b) Secure Emotional Expression (M = 5.77, SD = 1.11), (c) Awareness of Relational Impact (M = 5.15, SD = 1.31), and (d) Social Learning (M = 4.98, SD = 1.31). Griffith’s study provides helpful data as it is the only other study that examined group ther- apeutic factors with LGBTQ+ clients. Specifically, Griffith’s study also examined the relationship between TFI-S and coping scores and no correlations were identified. Thus, there is evidence that strength-based group counseling interventions do not decrease unhealthy coping strategies such as denial and self-blame. Due to the strengths-based focus in the curriculum, unhealthy coping was not thoroughly dis- cussed; hence, direct inclusion of unhealthy coping may be required to influence Maladaptive Coping scores. Contrastingly, regarding Adaptive Coping scores with four TFI-S subscales scores for our study and in Griffith’s study, a correlation was identified between Adaptive Coping (r = .51, p < .05) and Secure Emotional Attachment (r = .52, p < .05). Therefore, the present study may have had a strong presence of group therapeutic factors. The difference in group therapeutic factors could be attributed to the difference in (a) group curricula, particularly the emphasis on psychoeducation and coming out in the present study; (b) facilitation; (c) sample; (d) group members, (e) environment, and (f) incentives.

These findings contribute to filling the present gap in group work research with LGBTQ+ clients (Vereen & Bohecker, 2017), and marginalized populations overall (Rubel & Atieno Okech, 2017). As theorized by Vaughan and Waehler (2010), the results clarify that through counseling, LGBTQ+ young adults can grow from the coming out process. Moreover, beyond individual counseling methods, group therapeutic factors can foster positive experiences in counseling for LGBTQ+ clients in the coming out process. Utilizing a strengths-based group not only aligns with best practice standards in empow- ering and strengthening (Goodrich & Luke, 2017) LGBTQ+ individuals in counseling, but also provides evidence for the utility of group work in aiding clients through the coming out process.

Implications for Group Counseling and Counselor Education

Our findings provide implications for the LGBTQ+ community, group counselors, and counselor educators. Prior to our investigation, no studies were identified examining the relationship between coming out growth and group therapeutic factors. Our study pro- vides support for the use of a strengths-based group counseling intervention in fostering group therapeutic factors, coping, and coming out growth. Due to minority stressors, LGBTQ+ persons may lack a strengths-based perspective; nevertheless, our results demon- strate that the group counseling methods utilized may be able to build and activate underutilized strengths. Specifically, group counseling may be a helpful modality to consider in promoting adaptive coping and coming out growth in relation to coming out concerns. Counselors may be able to adapt activities from the group curriculum to meet the needs of the LGBTQ+ clients in individual and family counseling. Moreover, our results contribute to evidence-based methods for assisting LGBTQ+ clients in counseling,

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increasing insight into counseling method with LGBTQ+ clients both in general and with specific emphasis on the coming out process.

As noted, many counselors lack the appropriate knowledge and skills for adequate counseling competence with LGBTQ+ individuals (e.g., Ali, Lambie, & Bloom, 2017; Bidell, 2012; Graham, Carney, & Kluck, 2012). Furthermore, the curriculum developed for our study affirms identity, recognizes that coming out encompasses the lifespan, and utilizes the power of group work to support LGBTQ+ individuals. Thus, counselors who recognize the boundaries of their competence, the need for continuing education and the importance of maintaining practice standards that are current and effective may benefit from this outcome-based research (ACA, 2014; ALGBTIC, 2013).

Our results may be used to inform ethical and effective counselor education (ACA, 2014; ALGBTIC, 2013; CACREP, 2016). Counselor educators are responsible for infusing LGBTQ+ material into courses in order to foster the development of counselor trainees (ACA, 2014). Moreover, curricula should include ethical and culturally relevant methods for designing and facilitating groups (CACREP, 2016). Counselor educators are respon- sible for promoting counseling interventions that are empirically supported; thus, our results may be used to inform counselor education in the realms of (a) ethical practice, (b) LGBTQ+ counseling, (c) group counseling, and (d) research.

Limitations of the Study

Boyle, Whittaker, Eyal, and McCarthy (2017) highlight that group work research encom- passes particular challenges. In our study, we recognized some of these challenges such as sample size, study design, and data analysis. Although our sample size (N = 26) may indicate limited generalizability (Gall et al., 2006), it was consistent with group work studies (Boyle et al., 2017). In terms of ethnicity, our sample did not match the general population of the United States; however, it contributed to the literature by not over- emphasizing White LGBTQ+ experiences (Boyle et al., 2017). Moreover, when considering the population of not only LGBTQ+ clients, but also individuals who are facing coming out concerns, it is important to consider the vulnerability that may pose as an obstacle in recruitment. Further, Shannonhouse, Barden, and McDonald (2017) recognize that while a rigorous design in which a large sample allows for statistical power is ideal for research conditions, the reality of group settings is that services are often provided to a non- random group of participants who belong to a smaller sample size. Although the quasi- experimental research design utilized in this study is consistent with common practices in group work research (Boyle et al., 2017), the design may have posed threats to both internal and external validity. However, due to the ethical consideration to providing services to individuals in need (ACA, 2014), the design is consistent with best practices in group work. Since there were no other coming out groups in the area, individuals who were suitable and available were included in this study. Although a quasi-experimental design is not the gold standard for experimental studies, when implemented carefully, this format has the potential to exhibit rigor (Boyle et al., 2017). Since assumptions were tested and power analyses were considered, the results can still provide meaningful insight to the field of group work (McCarthy, Whittaker, Boyle, & Eyal, 2017).

The detection of change in variables relies heavily on choice of data collection instru- ments. We utilized brief, clear, and empirically tested instruments (Carver, 1997; Sarason

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et al., 1987; Vaughan & Waehler, 2010); however, self-report instruments are vulnerable to bias and social desirability (Gall et al., 2006), which may have influenced our results. Nevertheless, self-report measures are used by 85% of the group work studies in the literature (McCarthy et al., 2017). In order to account for this limitation, best practice standards suggest utilizing a variation of methods in measurement (Boyle et al., 2017). However, coming out is a subjective experience (Ali, 2017). Thus, aligned with the best practice standard of giving a voice and advocating for marginalized populations self-report measures were intentionally utilized

Additionally, final scores were utilized for the coping, social support, and coming out growth data; hence, results may have varied if change scores were utilized or if TFI-S scores were measured throughout the group process. Furthermore, the lack of significant relationships between Group Therapeutic Factors and Social Support Number, Social Support Satisfaction, or Maladaptive Coping may have been attributed to the 8-hour overall group duration; therefore, in order to implement changes in negative coping, more time may be required. Nevertheless, the structured time required in this group intervention may have been attributed to the lack of young adults who were not enrolled in college. When considering the recruitment process feedback, the participants’ status may have been due to the time constraint of a closed group in which students are more likely to have a consistent schedule whereas an individual not presently enrolled in college may have work and life obligations which hinder group attendance (Byrd et al., 2012).

Although this study is not without limitations, the methods selected align with best practice standards and ethical group work research with vulnerable populations. The limitations highlight the difficulty of conducting rigorous group work research with the reality of group work processes. Byrd et al. (2012) have critiqued that although best methodological practices are in mind, consideration of field-based practice can become muted. In this study, we aimed to align with best practice methods in terms of both research and practice. Additionally, in moments in which decisions were at the intersection of research and client welfare, we opted to consider the vulnerability of the clients (ACA, 2014).

Recommendations for Future Research

This research investigation was noteworthy in examining the power of group therapeutic factors in strengths-based coming out group counseling. First, methods should be taken to replicate the present study to examine if the intervention is effective for other populations. Although an effort was made to provide the group intervention at various locations, the real world concern of scheduling inhibited enrollment from participants at local commu- nity centers. Further investigation is warranted at settings such as inpatient hospitals or private practices. Generalizability could also be enhanced by implementing the interven- tion with samples of varying diversity in reference to age, ethnicity, education, affectional orientation, and gender. A similar age range was chosen to increase cohesiveness and because young adulthood is noted as a pivotal time in development (Dunlap, 2014a; Guittar, 2013) Nevertheless, since coming out concerns encompass the lifespan (Ali & Barden, 2015; Dunlap, 2014b; Guittar, 2013;) it may be worthwhile to replicate this study to understand the usefulness of group counseling for various ages. The recruitment of LGBTQ+ individuals who vary in gender and affectional orientation was an intentional

56 S. ALI AND G. W. LAMBIE

practice to align with common methods in the community. However, it may be beneficial to explore if dividing groups (e.g., orientation, gender) could enhance cohesiveness.

Additionally, future studies should create and examine the merits of group counsel- ing curricula varied in theory, style, and facilitator orientation in order to discover best practices for group counseling with LGBTQ+ clients. It was hypothesized that group therapeutic factors would correlate with social support; however, the lack of significant findings in our study can be informative. Participants informally shared a difference in perception in general support and support for their LGBTQ+ identity. For example, some participants who were not out to their family members still mentioned being supported by their family members. Therefore, future researchers may benefit from utilizing an instrument that specifically measures support for LGBTQ+ identity or the coming out process. Additionally, due to the short time in which the group was implemented, it may not be plausible to increase the number of individuals in a participant’s social support system. Additional studies utilizing the curriculum over a longer period of time are suggested.

Similarly, since the group facilitator may have had influence on participants, future studies may examine the use of multiple facilitators or the presence of co-facilitators. The use of a consistent facilitator and standardized group curriculum were precautions for treatment fidelity. However, each group has unique dynamics that may have influenced participants’ scores. Additionally, since the researcher doubled as the facilitator, it is possible that researcher bias may have influenced participants. Moreover, since multiple counselors were not used, it is difficult to differentiate between the influences of the facilitator versus the group treatment intervention (Shadish, Cook, & Campbell, 2002). Although consistency is provided through the use of one facilitator and adherence to a treatment manual, researcher bias and the influence of one facilitator is difficult to account for in scores. Future researchers may find it beneficial to utilize research teams to account for fidelity bias (Shannonhouse et al., 2017).

Finally, while the present study aligns with a majority of the group work literature in exploring the efficacy of methods, a qualitative approach could expand the literature by providing another layer to the group counseling process (Rubel & Atieno Okech, 2017). Future researchers may benefit from exploring the lived experienced within the group process and their subjective interpretation of what was helpful and unhelpful in the process. Furthermore, future studies may benefit from the merit of mixed-methods studies in order to replicate the present study and reduce limitations by integrating a qualitative approach as well (Shannonhouse et al., 2017).

Conclusion

The results of this study provide support for the utilization of a strengths-based group counseling intervention to assist LGBTQ+ young adults experiencing coming out concerns. Further, the promising results show that when paired with the curriculum utilized LGBTQ+ individuals may be able to combat minority stressors with the curative factors of group. This study is an important contribution to the counseling literature as it shows that it group counseling can foster coming out growth experiences. Moreover, this study contributes to the gap in examining marginalized populations in counseling, and aligns with best practice methods

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Finally, the findings provide empirical support for a strengths-based group curricu- lum that should be used for counselor education and professional development in order to effectively assist LGBTQ+ clients.

Funding

This work was supported by the Association for Specialists in Group Work.

Notes on Contributors

Shainna Ali is an instructor at the University of Central Florida and counselor at Integrated Counseling Solutions.

Glenn W. Lambie is a professor at the University of Central Florida.

References

Alessi, E. J. (2014). A framework for incorporating minority stress theory into treatment with sexual minority clients. Journal of Gay & Lesbian Mental Health, 18(1), 47–66. doi:10.1080/ 19359705.2013.789811

Ali, S. (2017). The coming out journey: A Phenomenological investigation of a lifelong process VISTAS. Retrieved from https://www.counseling.org/knowledge-center/vistas/by-subject2/vistas- client/docs/default-source/vistas/the-coming-out-journey

Ali, S., & Barden, S. M. (2015). Considering the cycle of coming out: Sexual minority identity development. The Professional Counselor, 5(4), 501–515. doi:10.15241/sa.5.4.501

Ali, S., & Lambie, G. W. (2016). The impact of a strengths-based group counseling intervention on LGBTQ+ young adult’s coping, social support, and coming out growth. Orlando, Florida: University of Central Florida.

Ali, S., Lambie, G. W., & Bloom, Z. D. (2017). Exploring the factor structure of the sexual orientation counselor competency scale. The Professional Counselor, 7(3), 223–237. doi:10.15241/sa.7.3.223

American Counseling Association. (2014). ACA code of ethics. Alexandria, VA: Author. Association for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling. (2013). Association

for Lesbian, Gay, Bisexual, and Transgender Issues in Counseling competencies with lesbian, gay, bisexual, queer, questioning, interview, and ally individuals. Alexandria, VA: Author.

Baams, L., Grossman, A. H., & Russell, S. T. (2015). Minority stress and mechanisms of risk for depression and suicidal ideation among lesbian, gay, and bisexual youth. Developmental Psychology, 51(5), 688–696. doi:10.1037/a0038994

Bandura, A. (1995). Self-efficacy in changing societies. In A. Bandura (Ed.), Exercise of personal and collective efficacy in changing societies (pp. 1–45). New York, NY: Cambridge University Press.

Barrera, M., Sandler, I. M., & Ramsay, T. B. (1981). Preliminary development of a scale of social support: Studies on college students. American Journal of Community Psychology, 9, 435–446. doi:10.1007/BF00918174

Bidell, M. P. (2012). Examining school counseling students’ multicultural and sexual orientation competencies through a cross-specialization comparison. Journal of Counseling & Development, 90(2), 200–207. doi:10.1111/j.1556-6676.2012.00025.x

Boyle, L. H., Whittaker, T. A., Eyal, M., & McCarthy, C. J. (2017). What really happens in quantitative group research? Results of a content analysis of recent quantitative research in JSGW. The. Journal for Specialists in Group Work, 42(3), 243–252. doi:10.1080/ 01933922.2017.1338812

58 S. ALI AND G. W. LAMBIE

Byrd, R., Crockett, S. A., & Erford, B. T. (2012). Journal for Specialists in Group Work (JSGW) publication pattern review: A meta-study of author and article characteristics from 1981-2010. The Journal for Specialists in Group Work, 37(1), 56–70. doi:10.1080/01933922.2011.632812

Carver, C. S. (1997). You want to measure coping but your protocol’s too long: Consider the Brief COPE. International Journal of Behavioral Medicine, 4, 92–100. doi:10.1207/ s15327558ijbm0401_6

Chazin, D., & Klugman, S. (2014). Clinical considerations in working with clients in the coming out process. PCSP: Pragmatic Case Studies in Psychotherapy, 10(2), 132–146.

Chutter, K. (2007). Opening our awareness to heterosexist and homophobic attitudes in society. Relational Child and Youth Care Practice, 20(3), 22–27.

Cooper, C., Katona, C., Orrell, M., & Livingston, G. (2008). Coping strategies, anxiety and depres- sion in caregivers of people with Alzheimer’s disease. International Journal of Geriatric Psychiatry, 23(9), 929–936. doi:10.1002/gps.2007

Council for Accreditation of Counseling and Related Educational Programs [CACREP]. (2016). 2016 standards for accreditation. Alexandria, VA: Author.

Craig, S. L. (2013). Affirmative supportive safe and empowering talk (ASSET): Leveraging the strengths and resiliencies of sexual minority youth in school-based groups. Journal of LGBT Issues in Counseling, 7(4), 372. doi:10.1080/15538605.2013.839342

Culver, J. L., Arena, P. L., Antoni, M. H., & Carver, C. S. (2002). Coping and distress among women under treatment for early stage breast cancer: Comparing African Americans, Hispanics and non-Hispanic Whites. Psycho-Oncology, 11(6), 495–504. doi:10.1002/pon.615

Dentato, M. P., Craig, S. L., Messinger, L., Lloyd, M., & McInroy, L. B. (2014). Outness among LGBTQ social work students in North America: The contribution of environmental supports and perceptions of comfort. Social Work Education, 33(4), 485–501. doi:10.1080/ 02615479.2013.855193

Dillman, D. A., Smyth, J. D., & Christian, L. M. (2009). Internet, mail, and mixed-mode surveys: The tailored design method. Hoboken, NJ: Wiley.

Dunlap, A. (2014a). Supporting youth in the coming out process: Theory-based programming. Smith College Studies in Social Work, 84(1), 107–129. doi:10.1080/00377317.2014.861173

Dunlap, A. (2014b). Coming out narratives across generations. Journal of Gay & Lesbian Social Services, 26(3), 318–335. doi:10.1080/10538720.2014.924460

Fisher, E. S., Komosa-Hawkins, K., Saldana, E., Thomas, G. M., Hsiao, C., Rauld, M., & Miller, D. (2008). Promoting school success for lesbian, gay, bisexual, transgendered, and questioning students: Primary, secondary, and tertiary prevention and intervention strategies. The California School Psychologist, 13, 79–91. doi:10.1007/BF03340944

Gall, M. D., Gall, J. P., & Borg, W. R. (2006). Educational research: An introduction (8th ed.). Boston, MA: Allyn & Bacon.

Gladding, S. (2012). Groups: A counseling specialty (6th ed.). Upper Saddle River, New Jersey: Pearson Education, Inc.

Goodrich, K., & Luke, M. (2015). Group counseling with LGBTQI persons. Alexandria, VA: American Counseling Association.

Goodrich, K., & Luke, M. (2017). Ethical issues in the research of group work. The Journal for Specialists in Group Work, 42(1), 108–129. doi:10.1080/01933922.2016.1267826

Graham, S. R., Carney, J. S., & Kluck, A. S. (2012). Perceived competency in working with LGB clients: Where are we now? Counselor Education & Supervision, 51(1), 2–16. doi:10.1002/ ceas.2012.51.issue-1

Griffith, C. (2014). The impact of a group counseling intervention on lesbian, gay, bisexual, trans- gender, and queer older adolescents’ levels of hope, coping, and suicidality (Doctoral Dissertation). The University of Central Florida. Retrieved from https://ucf.catalog.fcla.edu

Guittar, N. A. (2013). The queer apologetic: Explaining the use of bisexuality as a transitional identity. Journal of Bisexuality, 13(2), 166–190. doi:10.1080/15299716.2013.781975

Hartwell, E. E., Serovich, J. M., Grafsky, E. L., & Kerr, Z. Y. (2012). Coming out of the dark: Content analysis of articles pertaining to gay, lesbian, and bisexual issues in couple and family therapy

THE JOURNAL FOR SPECIALISTS IN GROUP WORK 59

journals. Journal of Marital and Family Therapy, 38(1), 227–243. doi:10.1111/j.1752- 0606.2011.00274.x

Jacobson, J. M. (2005, January). The Brief COPE: Emerging subscales within a popular standar- dized measure of coping. Society for Social Work Research (SSWR), Annual Conference, Miami, FL.

Joyce, A., MacNair-Semands, R., Tasca, G., & Ogrodniczuk, J. (2011). Factor structure and validity of the Therapeutic Factors Inventory-Short Form. Group Dynamics: Theory, Research, and Practice, 15(3), 201–219. doi:10.1037/a0024677

Johnson, J. M., & Lambie, G. W. (2013). Ethnic identity and social-cognitive maturity in a multicultural group experience. Counselor Education and Supervision, 52(3), 193–206. doi:10.1002/j.1556-6978.2013.00037.x

Kiweewa, J., Gilbride, D., Luke, M., & Seward, D. (2013). Endorsement of growth factors in experiential training groups. The Journal for Specialists in Group Work, 38(1), 68–93. doi:10.1080/01933922.2012.745914

Kosciw, J. G., Greytak, E. A., Diaz, E. M., & Bartkiewicz, M. J. (2014). The 2013 national school climate survey: Experiences of lesbian, gay, bisexual, and transgender youth in our nation’s schools. New York, NY: Gay, Lesbian, and Straight Educational Network.

Lagana, L., & Zarankin, K. (2010). A cross-sectional study on health and physical functioning in relation to coping strategies among community-dwelling, ethnically diverse older women. BMC Womens Health, 10, 1–10. doi:10.1186/1472-6874-10-1

Lipsey, M. W. (1990). Design sensitivity: Statistical power for experimental research. Newbury Park, CA: Sage.

McCarthy, C. J., Whittaker, T. A., Boyle, L. H., & Eyal, M. (2017). Quantitative approaches to group research: Suggestions for best practices. The Journal for Specialists in Group Work, 42(1), 3–16. doi:10.1080/01933922.2016.1264520

Meaney-Tavares, R., & Hasking, P. (2013). Coping and regulating emotions: A pilot study of a modified dialectical behavior therapy group delivered in a college counseling service. Journal of American College Health, 61(5), 303–309. doi:10.1080/07448481.2013.791827

Mears, A. (2004). A therapeutic intervention for increasing young lesbian and bisexual women’s self- esteem through goal setting and visualization in group therapy (Doctoral Dissertation). The California School of Professional Psychology. Retrieved from https://login.ezproxy.net.ucf.edu/ login?url=http://search.proquest.com/docview/305051308?accountid=10003

Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychological Bulletin, 129(5), 674–697. doi:10.1037/0033-2909.129.5.674

Meyer, I. H., Schwartz, S., & Frost, D. M. (2008). Social patterning of stress and coping: Does disadvantaged social statuses confer more stress and fewer coping resources? Social Science & Medicine, 67(3), 368–379. doi:10.1016/j.socscimed.2008.03.012

Mohanraj, R., Jeyaseelan, V., Kumar, S., Mani, T., Rao, D., Murray, K. R., & Manhart, L. E. (2015). Cultural Adaptation of the Brief COPE for Persons Living with HIV/AIDS in Southern India. AIDS & Behavior, 19(2), 341–351. doi:10.1007/s10461-014-0872-2

Moore, B., Biegel, D., & McMahon, T. (2011). Maladaptive coping as a mediator of family stress. Journal of Social Work Practice in the Addictions, 11(1), 17–39. doi:10.1080/ 1533256X.2011.544600

Muller, L. E., & Hartman, J. (1998). Group counseling for sexual minority youth. Professional School Counseling, 1, 38–41.

Needham, B. L., & Austin, E. L. (2010). Sexual orientation, parental support, and health during the transition to young adulthood. Journal of Youth and Adolescence, 39(10), 1189–1198. doi:10.1007/ s10964-010-9533-6

Pallant, J. (2010). SPSS survival guide (4th ed.). Crow’s Nest, Australia: Allen & Unwin. Riggle, E. D. B., Gonzalez, K. A., Rostosky, S. S., & Black, W. W. (2014). Cultivating positive

LGBTQA identities: An intervention study with college students. Journal of LGBT Issues in Counseling, 8(3), 264–281. doi:10.1080/15538605.2014.933468

60 S. ALI AND G. W. LAMBIE

Riggle, E. D. B., Whitman, J. S., Olson, A., Rostosky, S. S., & Strong, S. (2008). The positive aspects of being a lesbian or gay man. Professional Psychology, Research and Practice, 39(2), 210–217. doi:10.1037/0735-7028.39.2.210

Roberts, W. H. (2007). An exploration of the issue of ‘coming out’ and possible counselling interventions in relation to young people. International Schools Journal, 26(2), 29–41.

Rubel, D., & Atieno Okech, J. E. (2017). Qualitative research in group work: Status, synergies, and implementation. The Journal for Specialists in Group Work, 42(1), 54–86. doi:10.1080/ 01933922.2016.1264522

Rust, P. C. (1993). ‘Coming out’ in the age of social constructionism: Sexual identity formation among lesbian and bisexual Women. Gender and Society, 7(1), 50–77. doi:10.1177/ 089124393007001004

Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R. (1983). Assessing social support: The Social Support Questionnaire. Journal of Personality and Social Psychology, 44, 127–139.

Sarason, I. G., Sarason, B. R., Shearin, E. N., & Pierce, G. R. (1987). A brief measure of social support: Practical and theoretical implications. Journal of Social and Personal Relationships, 4, 497–510. doi:10.1177/0265407587044007

Shadish, W. R., Cook, T. D., & Campbell, C. T. (2002). Experimental and quasi-experimental designs for generalized causal inference (2nd ed.). Ann Arbor, MI: Wadsworth.

Shannonhouse, L. R., Barden, S. M., & McDonald, C. P. (2017). Mixed methodology in group research: Lessons learned. The Journal for Specialists in Group Work, 42(1), 87–107. doi:10.1080/ 01933922.2016.1264521

Tabachnick, B., & Fidell, L. (2013). Using multivariate statistics (6th ed.). Boston, MA: Pearson. United States Census Bureau. (2014). State and county quickfacts. Retrieved from http://www.

census.gov/hhes/www/income/statemedfaminc.html Vaughan, M., & Waehler, C. (2010). Coming out growth: Conceptualizing and measuring stress-

related growth associated with coming out to others as a sexual minority. Journal of Adult Development, 17(2), 94–109. doi:10.1007/s10804-009-9084-9

Vereen, L. G., & Bohecker, L. (2017). Research and scholarship in group work: Scope and emergent themes over 20 years. The Journal for Specialists in Group Work, 42(3), 253–269. doi:10.1080/ 01933922.2017.1338810

Yalom, I., & Leszcz, M. (2005). The theory and practice of group psychotherapy (5th ed.). New York, NY: Basic Books.

THE JOURNAL FOR SPECIALISTS IN GROUP WORK 61