Saturday, August 12, 2006
APA president speaks about a client's right to self-determination
Update: I spoke with David Blakeslee who was in the Q&A and asked Dr. Koocher a question about APA guidance regarding clients who have religious conflicts surrounding sexuality. Dave's question went something like this: "Dr. Koocher, I appreciate you participation in constructing and presenting guidelines for ethical behavior and attended your conference in Portland 18 months ago which I found very helpful. As a social and religious conservative I have found myself in a difficult situation about which I think the APA has not provided sufficient ethical guidance. I have been sought out by clients with deeply held religious beliefs who also have unwanted same-sex attractions. For these persons their religious beliefs are even more important to their identity than their same-sex attractions. Because of APA's lack of guidance in this matter, I am forced to seek advice outside APA. What is APA doing to give explicit guidance to psychologists like myself and thereby ensure that treatment of my clients honors their deeply held religious beliefs as they struggle with their same-sex attractions and is consistent with APA values of self-determination and client autonomy?"
In addition to what I reported above, Dr. Koocher reportedly emphasized that the therapeutic relationship is constructed by both the client and the therapist along the goals of the client and that the whole person must be taken into account when considering an intervention.
Dave tells me that Dr. Nicolosi followed up with a comment that his response seemed in conflict with official policy of the APA on homosexuality and that clients sometimes come to therapy wishing to explore their potential for heterosexual attraction; to which Dr. Koocher reemphasized his position of client self-determination and then cautioned about coercion.
I have heard back from Rhea Farberman, of the APA Publication Office this morning that she will soon give a complete response to my request for confirmation. She did add this:
In brief, this is a complex issue and one about which we seek to balance patient choice with the therapist’s obligation to gain informed consent. There are also questions about the efficacy of therapies intended to change sexual orientation and potential harm of such techniques. APA’s position is based on the standing Council of Representatives resolution on the topic.
Hit the link for the APA's official statement. Anything that is said here or is said anywhere must be interpreted in light of that resolution.
My take on this is that the APA has stopped short of banning change therapies but guides psychologists to inform clients of the APA position on homosexuality, to forbid coercion, to oppose therapy that has as its premise homosexuality per se is a mental disorder and to avoid making public statements that cannot be supported.
Now where have I read guidance consistent with that...
Yesterday afternoon, as I pondered my response to Mike's challenges in the previous blog thread, I realized that I don't need homosexuality to be reclassified as a mental illness. What I've been seeking is an end to the bias against people who want to pursue change. If the statements attributed to Gerald Koocher are true, there may come a day when we'll have credible and measureable criteria by which we can evaluate the prospects for change...including who can change, how much can change, what aspects ought to be changed, etc.
Grace, this seems to be in tune with your input from the previous blog. I, for one, believe that you contribute more basic common sense than you give yourself credit for!
Keep on posting!
And the new part would be....?
If you could have been there, you would have felt the surprise at Koocher's standard application of client autonomy and self-determination applied to pursuing heterosexual potential.
If you could have been there afterwards when Koocher was cornered by other APA leaders and "counseled" about his answer, you would know that something big had just happened.
I should add that there will be very little real dispute over what was said, as Koocher's comments were verified with Clinton Anderson (APA CEO and also in attendance) immediately after the session.
We will see how far this goes. But, it seems reasonable that client autonomy and self-direction are the cornerstone of all psychological treatment. To exclude this cornerstone from treatment of those with unwanted Same Sex Attraction seems bigoted; in this case against the religiously motivated client. This would violate ethical guidelines laid down in 1992.
I'm not aware of any "gay activists" who have said the APA "forbids change therapists". Some uninformed gay individuals maybe (but who cares), but all of the groups you would call gay activist have been fairly straight down the line about what the professional bodies say -- PFLAG, GLSEN, HRC, NGLTF etc etc.
They all simply repeat what the APA etc resolutions are: change therapy finds no support, and it has the potential to cause harm.
The "myth" that the APA has banned such efforts comes instead from those who are anti-gay activists. Take the recent Exodus press release: "In 2002, it declared the treatment of homosexuality to be unethical — even if a patient willingly sought help."
No Exodus. Dead wrong.
Now for the guidelines, cannot remember if we mentioned this... page 14 needs a word changed.
The sentence -- refrain from shaming children for openly expressing their distress to parents and the therapist. -- suggests that the young person will be distressed.
Not so. Why not just "expressing themself to" or similar?
And even if they are stressing a bit, it's also likely not to be about their feelings per se. More likely to be concern about how others will percieve them and react toward them. ie a commonplace reaction to prejudice. It is distress about prejudice that the young person will need support about, not "values clarification".
Compounding the weakness of this section -- weakness in contrast to the others -- is the fact that a large slab of the GLBT teens bought into a therapist by their parents will have been so because of the distress of the parents. This type of parent is well enough documented to therefore need specific mention in those guidelines.
Hence, the section needs a fair bit more where it actually touches on one area with the greatest potential for abuse and coercion around an unempowered client ie a child at the whim of their parent's religious (and anti-gay) identity.
I'd even go so far as to say that such sexuality/religiosity values clarification would be better directed at the parent, not the child, at that point.
Actually I'd probably prefer to find someone to bully them around for a month or two, just so they could experience what it's like to be trodden all over, but I guess that's a subject probably well outside the ambitions of your draft.
(*** so far hasn't crashed. Now, the big test -- posting... ***)
Another cornerstone is making accurate information available to the client. Without that accurate information the "client choice" occurs in an environment open to gross abuse.
Accurate information does not entail:
> inflating "success rates"
> manipulating a client with "hope" of change
> presenting false information about the lives of gay men and women
> choosing to speculate when solid information is otherwise available
> misrepresenting the opinions, and motivations, of the majority of collegues or the professional bodies
> coaching prejudice
> pretending that what gets said outside the rooms has no impact on the client, or the health of others
Regardless of what a client decides to do, they should at least be clearly aware that the reason the majority of therapists will not attempt, let alone promise a change to sexual orientation is because they think it simply doesn't work, and has the potential for harm.
It's insulting to even speculate that 130,000 therapists (minus the 400 in NARTH) have somehow been hoodwinked by a few hundred souls in div. 44
Passing on that type of "information" to a client -- in the therapy room or by media release -- is also unethical. Regardless.
Saying that reparative therapy is not supported by science and that it may actually be harmful doesn't mean that unhappy gays and their RPT's (religiously prejudiced therapists) can't TRY.
Do you really think that the reason why most therapists will not attempt to change a patient's sexual orientation is because they think this cannot be done? I might have thought the reason was more likely to be that they see no reason why someone should want to change.
A cornerstone alone is a rock on the ground...
So if I am using client self-determination but am biasing my work to move a client toward my goals (either gay affirmative or heterosexual), I am corrupting the cornerstone.
The cornerstone is where you begin and it is what you refer back to throughout treatment. If the cornerstone is faulty because the patient has a basic misunderstanding about the facts of Same Sex Attraction, the therapist has an obligation to inform them of what we know and what we don't know in psychology.
At that point the patient can more fully self-determine the goals of therapy (it is a second, better, cornerstone).
A faulty cornerstone says that no one can change their orientation; that everyone can change their orientation; that trying to change your orientation is always harmful; that trying to change your orientation is never harmful.
So, it is a process which many ethical therapists engage in on a variety of topics other than homosexuality (divorce is a good example).
I think you assume much coercion on one side of this debate. Polarization and demonization provides an emotional release, but doesn't help us deal thoughtfully with the facts.
I don't make this offer often, so take it while it's available: hop on a plane, or pay my airfare, and we'll spend a few hours walking around hand in hand. Go the mall or something and do just that alone.
I think that should be long enough to show that I'm not assuming anything about external coercion.
And afterwards, we'll also have a little discussion about how you were internalizing those few hours.
By the time the client comes to a EXODUS group, the pressure to change is already deeply imbedded.
The "reparative therapist" doesn't need to do much "coercion". The client already knows how the church, family and society feel about gays. The client already despises his or her gayness.
Then, the "reaparative therapist" steps in to "help". How benevolent!
Straight people do not have to worry that they will be beaten or killed if someone finds out they are straight. Straight people do not have to worry that they will be rejected by their church and go hell for being straight. Straight people don't have to worry that their family and friends will abandon them for being straight.
Thats the "coercion".
After 30 years of trying, shouldn't EXODUS already have some "credible and measurable criteria by which we can evaluate the prospects for change"?
What's the problem? Do they need another 30 years?
Thread of logic: If, for the most part, licensed therapists are discouraged or forbidden from administering reparative therapies, where will this scientific support for the possibility of change come from?
Please remember that the big change came way back in 1974! We were living on "Leave It To Beaver" in the 1950's. This leaves a span of less than 20 years where psychology actually gave the homosexual issue any serious look at all.
This is why I want the possibility of change to be explored by the psychological community. I'm not talking an examination of the success rate of para-church ministries. I want credentialled psychologists to have the freedom to approach the issue of homosexuality with an open mind, to explore with each client the uniqueness of their homosexual drives, desires, identity, etc.
Exodus, for the most part, is not staffed by psychological professionals. Many of its counselors are 'lay counselors' and most come from a gay background. Most would admit to being clueless about how to set up test studies, how to collect data, how to measure and report success. They are, to use a Bible definition, paracletes...peer counselors, not professional psychologists.
Some professsional therapists have -- as you well know -- continued to attempt sexual re-orientation every day of every year since 1974. It's been 15 years since Nicolosi first published his ludicrous book, to give but one example.
The reason they have no data is not because they have somehow been prevented from these attempts. They've continued to do this work, and been free to publish. They've certainly done the first, but not the second. That they are regarded as professional lepers by the majority of their collegues is interesting, but also irrelevent.
After 90 years of such attempts, it should beg the obvious conclusions -- that there is no supporting data and/or that they don't care to publish what they find. (We know in Nicolosi's case he's dismissed these calls for data because "he doesn't have the time". Pathetic, frankly.)
It is also simply not true that professionals only made these attempts from 1954 to 1974. Go find the works of Rado, for one. Beiber's mentor. QED Socarides' mentor. QED Nicolosi's mentor. Some psych. professionals have been claiming to have "solved" homosexuality since the very start of the profession. And not a single one has ever stood the test of time, or scrutiny. Beiber. Hatterer. et al.
You also seem to be under the impression -- and let me know if it's not the case -- that but for lack of effort or deliberate obstruction the psych. profession would have long ago found a psych-based explanation and cure for homosexuality.
Your faith in this seems odd, given that the vast majority of psych professional themselves have long ago abandoned such a faith. Their own lack of confidence in this regard is something missing from your "thread of logic".
If they have no faith, why should we?
I realize that, on one level, it feels good to hear them say 'you're okay' but, because I've never seen evidence that psychologists have looked deeply into the various aspects of gay culture, I feel that the gay world is being patronized. It's a gentler form of bigotry but it's bigotry all the same.
While it is fascinating to know you have a wide selection of friends, I'm not sure what any of their proclivities have to do with homosexuality as a sexual attraction. There is only one of those. How they act in accord with that attraction is as varied as you've suggested.
Just like heterosexuals.
I also cannot agree that the profession has abandoned people who do self-destructive things or do things because they've been bent out of shape by something in their past. People appear at therapist's doorsteps every day and deal with such matters. I don't the majority are uncomfortable with gays as a category, or as individuals.
There's also a wealth of literature available - more than ever -- and covering all aspects of the way people live. Including the homosexual ones.
Let me put it another way -- both of us are as homosexual as each other.
How we live, or what our opinions are, have nothing to do with that common element.
Just like two heterosexuals.
You just betrayed your age AGAIN!!!
How groovy 70's man! Peace.
Bet you still know how to make a mean tie-dyed t-shirt too :)
Re: the paragraphs. I swear I put breaks in when I type it and then they disappear before posting.
Re: dated words. Sometimes they really are dated and sometimes it's a matter of region. It seems that around here people still use that word...and I heard it used recently by a guy who had to be 20 years younger than me.
My city is a bit unusual though; the "Gay Country Line Dancers" hold their monthly dance at a VFW!
That's something you'd never see at the VFW post back where I come from.
I was trying to remember that other quaint word that id's the speaker to that same generation almost at once when wrote that. It came 2 minutes afterwards:
I read that word and I know he's going to have a big moustache as well. And an original vinyl copy of Nightbirds. Much played. :)
Actually the fact of opposed positions -- and I disagree with your view of them -- is not the main issue. The main issue is whether people are harmed.
I've yet to see that addressed in any pro-change forums -- the focus is always on presenting individuals that they claim to have changed, with a sub-text that such change could occur for anyone provided they got the "right" therapy and provided they stuck with it. A gross assumption, at best.
And I also assume you are not including the data on previous forms of "change therapy" -- drugging clients, labotomies, castration, ECT, negative reinforcement, criminalization and imprisonment?
All once recommended as suitable, by some. Now a source of deep embarrassment to the profession. Cummings (in the acticle you posted) also mentions a few other areas where abusive therapy has been used, and now not approved. Begs the question: why did the profession require a long list of damaged people before they realised what was occuring?
But, at least on the current type of change therapy promoted, some did decide to project the outcome based on well-tested models. As you well know, this modelling came together long before the APA took it's position. Hence:
Although there is little scientific data about the patients who have undergone these treatments, it is still possible to evaluate the theories
Recent publicized efforts to repathologize homosexuality by claiming that it can be cured are often guided not by rigorous scientific or psychiatric research, but sometimes by religious and political forces opposed to full civil rights for gay men and lesbians.
The "reparative" therapy literature ... not only ignores the impact of social stigma in motivating efforts to cure homosexuality; it is a literature that actively stigmatizes homosexuality as well.
The potential risks of reparative therapy are great, including depression, anxiety and self-destructive behavior, since therapist alignment with societal prejudices against homosexuality may reinforce self-hatred already experienced by the patient.
The reason for the APA caution seems fairly clear. And they should be commended for thinking through what can occur, rather than waiting for scores of people to be harmed. Modelling is something that all other professions are expected to do long before they place people in harms way.
I'm surprised you would want it to be otherwise, and it does you no credit to mischaracterize the genuine concerns that others have about change therapy.
(And I guess this "Research is coming" is the research that Exodus promised would be completed 12 months ago? Yes, we do read their Form 990's...)
By the way, If homosexuality is an illness, what are its symptoms?
You just betrayed your age AGAIN!!!
How groovy 70's man! Peace."
Nah, maybe it's an ocean thing, not a decade thing. "Top" and "bottom" are currently live and well and probably the only commonly used words in Los Angeles to differentiate that distinction. And while "boyfriend" and "husband" are probably most common (legality notwithstanding) you still occasionally hear the term "lover".
At 42, I may be middle-aged (though I hate admitting it) but I have a wide variety of friends so I think I'm pretty much aware of the current slang.
Being the same age (and frankly am indifferent to that fact) we do remember it being used. It still pops up. But it's dropped off. Along with those tedious femme v butch lesbianisms (and then, peace fell upon the World...)
Where did you get the idea that imprisoning people for homosexuality has ever been considered a form of therapy?
And the fact gaol is often viewed as both punishment and opportunity for "reform".
You might like to read Socarides as example -- Socarides from before his NARTH project. He has argued that placing homosexuals in the hands of therapists like him would deliver "change" far better than imprisonment would.
I'm not sure if you have access to a legal case database, but many "first time offenders" were also offered a choice of a course of therapy or gaol at sentencing; particularly if younger.
Predictably, most chose therapy. And most made sure their therapist believed they had been "cured", often a condition of the suspection of a gaol sentence.
And a few years later... these "successful changes" would be written up in the psych. literature as proof that the therapy worked.
If you want a good parallel: compare this to those compelled to attend an exgay group as a condition of being accepted back into a church. The outcomes are as equally predictable, and probably as equally false.
While some exgay seek to change for their own private reasons, the testimonies offered by exgay groups are full of such situations. While you cannot guess from a testimony if any individual was motivated by this reason; you can be certain that at least some will have, overall.
Try the evergreen.org site for some of the "best" examples of such arguably questionable testimonies. Consider them with the understanding that these individuals have been effectively offered a "choice" of actually changing, lying or losing everything.
So was only one of the boys incarcerated or were both boys jailed? How long did they spend in jail? Were they caught doing this in a park by the police or were they turned in by one of the boys' parents? Over the course of your time there, how many boys were jailed for this offense?
I never heard of this in my community (Thank God!). Could this have been an early hysterical reaction to Aids?
Although it is possible that some people might have had the idea that sending gay men to prison would turn them straight, I don't believe that this has ever been regarded as 'therapy' as such. It's just confusing to use that word.
Anon # 23,457
Perhaps the idea of gaol as a cure is confusing, but so? (I think I called it "change therapy" or something -- and only half in jest)
I think if you read some of Szasz and the (at times ugly, brutal) history of the "therapy" profession you'd be less confused.
Szasz was, of course, halfway to crazy half of the time -- but only half way and only half the time. The rest of the time he was a much needed blast of pure fresh air into a profession that was rapidly vanishing up it's own fundament.
If you appreciate what Szasz was concerned about in 1960+, you'll understand where I'm coming from.
Yes, about the anons, I have lost track. I think some of them are talking to each other but I am having trouble keeping up. At least, it is all civil.
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