How to help create safety for LGBTQ+ clients and why it’s essential to therapy

By Unyte Editorial Team Reviewed by Unyte Clinical Team

Fostering a safe environment for clients is essential to building trust in the therapeutic process. This is especially crucial when supporting individuals identifying as LGBTQ+, a population that often faces systemic challenges to receiving adequate healthcare access.

In a 2024 survey conducted by The Trevor Project, a non-profit suicide prevention organization dedicated to advocating for LGBTQ+ youth, 42% of respondents who sought mental health support said they did not receive it because they were afraid to discuss their concerns. Additionally, 34% believed they wouldn’t be taken seriously, 31% feared police involvement or involuntary hospitalization, and 20% wanted to avoid repeating negative experiences.

What can providers do? In this blog, we’ll explore why it’s important for healthcare professionals to establish a safe and affirming space for LGBTQ+ clients, how an approach informed by Polyvagal Theory can support this goal, and strategies that can be implemented to help clients feel accepted and understood in the therapeutic relationship.

“Authenticity is a Privilege Only Some Can Experience”

Queer people don't grow up as ourselves, we grow up playing a version of ourselves that sacrifices authenticity to minimise humiliation & prejudice. The massive task of our adult lives is to unpick which parts of ourselves are truly us & which parts we've created to protect us.

— Alexander Leon (@alexand_erleon) January 7, 2020

The inability to live authentically and present one’s true self to the world can have a profound impact on an individual’s mental, emotional and physical health.

“Authenticity means that we are not putting on masks or filters of ourselves and we are truly embracing who we are as a person and all of our identities and intersections,” says Aden Cosgrove, a registered social worker in Ontario, Canada. Aden, who identifies as queer and non-binary, leads Healing Journey, a trauma-informed online counseling and therapy service supporting BIPOC (Black, Indigenous, and people of color), 2SLGBTQIAP (Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer and/or Questioning, Intersex, Asexual, plus any other sexual orientations and gender identities), neurodivergent, non-monogamous and Indigenous communities.

“Authenticity is a privilege that only some can experience,” they emphasize. “A lot of Queer people have to lie to themselves and others (pretending to be straight) to get through unsafe situations.”

Many external factors prevent LGBTQ+ individuals from living authentically, including workplace discrimination, lack of legal protections and economic disparities resulting from homophobic or transphobic policies or attitudes.

Even well-intentioned providers may not realize when they engage in behaviors that communicate to clients that they may not be a safe person to confide in, such as using exclusionary language that perpetuates heteronormativity or referring to someone using pronouns that don’t reflect their gender identity (misgendering). This can prevent clients from fully expressing their feelings, emotions and thoughts, ultimately impeding progress in therapy as they cannot engage with the provider or the healing process enough. Creating a space where clients can be their authentic selves in therapy without fear of judgment or repercussions is fundamental to the healing process.

Integrating Polyvagal Theory into the Therapeutic Approach

Polyvagal Theory gives providers a lens for understanding how safety and connection are experienced through the autonomic nervous system. Neuroception, coined by Dr. Stephen Porges, explains how we subconsciously search for cues in our environment to inform us whether a person or situation is safe, dangerous or a threat — without involving the thinking parts of our brain.

When a person feels safe, they have greater access to the parasympathetic, ventral vagal state. This is described as the centered, “true self” state, where safe social engagement, connection and creativity occur. When danger is detected, the nervous system moves into a sympathetic state (hyperarousal), commonly referred to as “fight-or-flight,” and mobilizes to survive. When a severe threat to safety is detected or the body needs to shut down to heal or recover, it moves into a dorsal vagal state (hypoarousal), where immobilization occurs.

It is typical to move between states throughout the day and experience hybrid states. But when a person’s nervous system is stuck in a chronic state of defense, the ability to socially connect suffers, affecting not only how a client engages with therapy but also with the world around them.

Understanding a client’s autonomic nervous system can help providers decide how to proceed with treatment, and whether it may be beneficial to first aim to help clients better regulate their nervous system before engaging in other therapeutic work.

“Polyvagal Theory is a big foundation of my work with Queer people and this starts with understanding how they take care of themselves, what the barriers are in their life and the responsibilities that they have, and looking at their balance in life,” Aden says. “From the beginning, I am assessing how often they are in hyperarousal or hypoarousal and in what circumstances they might be in these states.”

To do this, Aden “maps” out their clients’ autonomic nervous systems. Autonomic mapping is a model designed by clinician Deb Dana, LCSW, that helps familiarize clients with their own nervous system by increasing their understanding of nervous system signs, patterns and tendencies.

“Through the mapping, I get a sense of how these [states] show up for them and what would be helpful for them to have as strategies during those times,” Aden says. “Understanding these states is a strengths-based process, as having a good and positive relationship with them helps people not feel stuck when they come on and they can look at them in a positive way. These states have helped them survive, and befriending them allows for more compassion rather than self-judgment or criticism when they come on.”

Strategies for Creating a Safe Environment

Here are key strategies that providers can implement to ensure a safe and supportive environment for LGBTQ+ clients.

Be Clearly Affirming

Ensure the office, clinic or website is welcoming by using inclusive language.

“For in-person work, there are ways to signal to a client who is part of the 2SLGBTQIAP+ community that you are an ally or a member of that community and that can be shared verbally with the client, which is most ideal,” Aden says. “You can put posters, stickers, or a flag in your office that shows that this is a safe space for the community.”

Stay Educated on LGBTQ+ Issues

Understanding the challenges faced by LGBTQ+ individuals can help providers offer more empathetic and trauma-informed care. Knowing the community’s history and present-day issues can make a significant difference in the client relationship.

“I acknowledge that our community faces a great deal of prejudice, discrimination and oppression, especially right now in North America, and validate that they are not alone in that experience and that this is incredibly hard,” Aden says.

Prioritize a Client-centered Approach

According to the American Psychological Association’s 2024 trend report, policies enacted in recent years targeting “bodily autonomy and individuals’ right to make their own decisions” have had a severe impact on LGBTQ+ individuals. Respect clients’ autonomy and empower them by involving them in their treatment plans, so they know that they are safe and in control of their healing journey.

Providers who offer remote therapy sessions should also consider the client’s physical safety.

“For virtual work, [creating a safe space] is a bit trickier as you can have members at home where violence is occurring as a result of their identities,” Aden says. “Flexibility is important here and the client’s safety is a number-one priority. If the client is at home and violence is occurring there, this is not a safe place to engage in therapy.”

Aden recommends the following strategies for accommodating clients’ needs:

• Ask the client whether there is a safe space where they can engage in virtual therapy, such as a community center that may be queer-focused or a chosen family member’s space.
• Be flexible with scheduling sessions, especially if a client has to wait for privacy in the home to safely engage in therapy.
• For privacy, have the client place a white noise machine outside of the room during the session.
• Conduct text-based counseling (the practitioner should consult their regulatory body to ensure this is done ethically).

Help Expand Clients’ Support Networks

According to Dr. Stephen Porges, “Polyvagal Theory proposes that social connectedness is tantamount to stating that our body feels safe in proximity with another.” If possible, try connecting clients with other LGBTQ+ support networks and resources to provide additional layers of community support.

Creating a safe environment allows clients to feel comfortable enough to share their true feelings and experiences with their providers, engage fully in therapy sessions, and have confidence in the therapeutic journey, leading to better outcomes.

Safe Communication: How to Stay Current and What Behaviors to Avoid

According to the Agency for Healthcare Research and Quality’s Patient Safety Network, a lack of psychological safety can prevent LGBTQ+ clients from trusting healthcare professionals, leading to inadequate outcomes. This can be alleviated by “effective communication and culturally and linguistically appropriate dialogue between LGBTQ+ patients and healthcare workers.”

To remain inclusive and affirming, Aden says they continuously undergo training to understand the language, culture and experience of LGBTQ+ individuals.

“Having lived experience is very helpful in working with the Queer community but language changes and shifts all the time,” they say. “I am finding that I need to constantly keep on top of the language changes as well as training around working with this community.”

They also emphasized the importance of providers conducting the necessary research outside of sessions rather than relying on the client to keep them informed.

“Asking about it distracts from the client’s story,” they said. “Queer people do not want to spend their sessions psychoeducating their helpers and this can be a painful experience as they do not feel understood. Being transparent at the beginning of the relationship about what you are not knowledgeable about and getting a sense of a client’s identities, communities, and the language that they prefer early on in the therapeutic relationship can mitigate this issue.”

Aden recommends the following strategies to communicate safety to clients:

• Providers should write down what they need to learn about and consult a supervisor, available resources, or someone from the community who is also a helping professional.
• Learn and use appropriate terminology. Understanding generational differences in language and terms used within the LGBTQ+ community is crucial. For example, terms like “Queer” might be preferable to younger generations while, for older generations, this term can be viewed as offensive.
• Be aware that someone who is LGBTQ+ may also experience other forms of discrimination in addition to homophobia and transphobia, such as racism, ableism and misogyny.

“The more identities and intersections the person holds, the more barriers that the world has put up for them,” Aden says. “There may be identities that they have to hide when engaging in some of their communities. This may result in some individuals lacking community at all. Being aware of the stressors and systemic barriers that they face is important to look at as an anti-oppressive practitioner.”

Retuning the Nervous System with the Safe and Sound Protocol

The Safe and Sound Protocol (SSP), developed by Dr. Porges, is an evidence-based intervention designed to enhance social engagement and resilience by improving autonomic regulation. It uses specially filtered music to retune the nervous system to orient toward safety and connection, making it a potentially transformative tool for LGBTQ+ clients.

Benefits of the SSP

• Enhances safety and complements a wide range of therapeutic modalities: The SSP is designed to regulate the autonomic nervous system, helping clients feel safer and more grounded, so they can better engage with other therapies.
• Supports emotional regulation: Real-world evidence shows that the SSP is effective in reducing symptoms of anxiety and depression, which affect 66% and 53% of LGBTQ+ youth, respectively, according to The Trevor Project.
• Fosters social connection and more meaningful relationships: The SSP helps clients feel more connected and engaged, both in and out of therapy.

Continuous Learning and Advocacy

Pride Month is an ideal time for providers to highlight the importance of safety and support for LGBTQ+ clients, but the work to create a safe space for LGBTQ+ clients goes beyond June.

“[Collect] resources and articles about the community and its intersections, and [collaborate] with other providers who have lived experience and/or professional experience working with the community,” Aden suggests. “One of the main things that I do to remain inclusive and affirming of my community is to continuously do trainings. The Queer community is always evolving so continuing your education around it is very important.”

Engaging with community resources, supporting fellow providers, asking questions, advocating against discriminatory policies, and speaking up are other vital ways providers can contribute to the well-being of LGBTQ+ communities beyond therapy sessions.

Creating a safe and affirming environment for LGBTQ+ clients in therapy is not just about meeting professional standards; it’s about nurturing a space where individuals can truly be and thrive as their authentic selves. By understanding and addressing the unique needs of LGBTQ+ clients, and using tools like the SSP, providers can make a profound impact on the well-being and lives of those they serve.