In 2009, Julea Ward, a counseling student at Eastern Michigan University, was in her school-assigned practicum when she was assigned a same-sex couple for treatment. She went to her supervisor and said she could not provide treatment to the couple, citing a conflict with her religious beliefs. The couple ultimately was assigned to a different counselor at the same agency, who did not have the same conflict. Ward thought she had handled the issue appropriately, as the clients received the treatment they had sought and she was not put in a position of needing to hide or compromise her beliefs. She understood the issue to have been successfully resolved.
Her graduate program, however, did not. The university began a disciplinary action against Ward, citing the non-discrimination clause of the ACA Code of Ethics. The ACA Code, like the AAMFT Code, contains two clauses that appeared to conflict in Ward’s case:
- Mental health professionals do not discriminate based on sexual orientation or religion, among other factors.
- Mental health professionals do not treat clients outside of the professional’s scope of competence.
Though the specific wording varies, versions of those principles can be found in the ethical codes of every major mental health association. None of the ethical codes offers specific guidance on which principle is supposed to take precedence over the other when they conflict. So when a therapist’s religious beliefs suggest that homosexuality is immoral, and that therapist is asked to treat a gay or lesbian client (or couple), what should the therapist do? Can the therapist simply refuse to treat that client?
This post originally appeared as an article in the September/October issue of Family Therapy Magazine, the bimonthly publication of AAMFT. © Copyright 2011 AAMFT, reprinted here by permission. Originally published here on the blog October 3, 2011; republished with minor updates September 5, 2018.
Ward’s case, like two others with similar themes, has garnered national attention, with the ACLU offering support to the University and the Alliance Defense Fund (a legal group that works on behalf of religious students) supporting Ward. Eastern Michigan argued that they had a right to require students to practice in a non-discriminatory manner, in keeping with the ACA Code of Ethics. Ward’s attorneys argued that requiring Ward to treat gay and lesbian clients would infringe on her religious freedom.
Others on both sides of the Ward case have argued that requiring therapists like Ward to provide service to gay and lesbian clients could lead to clients receiving therapy that is at best ineffective, and at worst harmful. The case has become a focal point of tension between therapists concerned about the ability of gay, lesbian, and bisexual clients to receive competent services, and religious therapists concerned that their own beliefs might ultimately be deemed incompatible with their chosen profession.
“Therapists are often scared that their religious beliefs will be marginalized, condemned, and pathologized,” said Scott R. Woolley, Systemwide Director of Couple and Family Therapy Programs at Alliant International University in San Diego, CA. “The ethical principle of ‘do no harm’ should be an overriding principle. If there is a serious question about being able to provide competent services, the therapist should refer rather than risk harming the client.”
This view is not universally shared, however. Within the field of MFT, no consensus has emerged on how such a dilemma should be handled, and there has been no test case before the AAMFT Ethics Committee. In the absence of such guidance or consensus, MFTs, including supervisors and instructors, are left to implement the existing Code of Ethics as best they can. The result is a variety of positions on whether an MFT can ethically refuse to treat clients based on the therapist’s religious views.
One of the overriding questions in this debate is the role of context. Namely, if a religious therapist refuses to treat a gay or lesbian client, does the therapist’s reasoning matter? Refusing to treat a client based solely on the client’s race, religion, or sexuality is clearly discriminatory. But depending on whom you ask, the same religious therapist refusing to treat the same gay or lesbian client because the therapist is not competent to work with the client’s issues may be deemed appropriate.
“I believe a refusal can be ethical or unethical, depending on the context and the situation,” Woolley said. “A referral based on a therapist’s ability to provide competent services can be ethical. A referral based simply on not liking gay people is not.”
On the other hand, whether the reason for refusal is the therapist’s religious belief or their level of competence, the end result can be that members of an already-oppressed group are told that they can be turned away from care simply because they are part of that group.
“MFTs need to be aware of the message that refusing treatment sends,” said William Northey Jr., a licensed MFT and Managing Partner of N-P Consulting and Therapeutic Services in Wilmington, DE. Regardless of their supposed reasons, refusals to treat any specific demographic group bear the appearance of discrimination, and must be critically examined, Northey added.
In Ward’s case, EMU has maintained that she was applying her espoused religious beliefs selectively. Ward said she said she would willingly counsel murderers or child abusers, for example, just not gay or lesbian clients. To the university, this made her refusal to treat the same-sex couple a much more obvious case of discrimination.
What is clear is that there is risk for religious therapists who refuse treatment to specific groups of clients. An MFT or student who refuses to treat gay or lesbian clients based on the therapist’s religious beliefs may be acting in accordance with the principle of “do no harm,” as Woolley suggested, and still risk their job or degree program. Three court cases involving mental health professionals – students in two of them – highlight the potential risks.
- In Ward’s case, she was ultimately dismissed from her graduate program. She sued, and in July 2010, a U.S. District Court ruling supported the university. Ward’s attorneys have said they will appeal. In the meantime, state legislators from both major parties have stepped forward to voice their support for her. State senator Tupac Hunter, a Democrat, introduced the “Julea Ward Freedom of Conscience Act,” a bill which would prohibit universities from dismissing students because they declined to counsel clients based on their religious beliefs. EMU maintains that it was discrimination – a violation of the ACA Code of Ethics – that led to her dismissal, not her religious beliefs. At one point during her disciplinary proceedings, Ward even had asked university representatives, “Who is the ACA to tell me what to do?”*
- In a separate case involving a counseling student, Jennifer Keeton made a number of statements in graduate classes at Augusta State University expressing her view that homosexuality was immoral and a choice. Though she had not refused service to clients, she was told she must complete a remediation plan to remain in her program. Like Ward, Keeton sued, arguing that she had a right to express her religious beliefs and that the university could not force her to change those beliefs. According to the Augusta Chronicle, university faculty testified that they were not punishing Keeton for her beliefs, and did not require her to change her beliefs to remain in the program; rather, the remediation plan was intended to help her develop the needed skills to counsel clients without imposing her values on them. A District Court judge ruled in the university’s favor in August 2010, and the case is currently under appeal.*
- Finally, in a 2007 case, Marcia Walden, a counselor employed by a contractor for the Centers for Disease Control, refused to treat a CDC employee’s same-sex relationship. She referred the case to a colleague who did not share Walden’s beliefs and could see the client immediately. However, Walden was quickly suspended over the incident, and was fired just over three weeks later. She sued, claiming wrongful termination. As of March 2011, she was appealing her case to the 11th Circuit Court of Appeals, according to the Associated Press.
For MFTs facing difficult choices about whether to treat a particular client or couple, the choice should be focused on the client, not the therapist, said Claudia Shields, Director of Clinical Training for Antioch University in Los Angeles. “I am not sure how a therapist can be competent if they are discriminatory,” Shields said. “Our rights as therapists are important, but in a clinical context they are generally secondary to what is best for the client.”
“The practice of psychotherapy does not concern itself with the moral, religious, or personal positions of the clinician,” agreed Angela Kahn, an MFT in private practice in Los Angeles. “Those aspects of being are for the clinician’s own therapy. When a clinician allows personal beliefs to drive therapeutic decision-making, we question overall competence, no matter the content of the beliefs.”
Regardless of whether the reasons for the referral were ethically appropriate, Kahn, Woolley, Northey, and Shields all agreed that the couple to whom Ward had refused treatment was ultimately better off with a different therapist. “I am personally not comfortable with MFTs refusing to provide services on religious grounds or any other personal value system,” Northey said. “That said, at some level it would probably be in the client’s best interest not to see someone who has a prejudice against them.”
Woolley identifies himself as Christian, and said he has seen many students struggle with conflict between their religious beliefs and their desire to provide competent service. Those students often have benefited from opportunities to explore their religious beliefs without judgment. Many attitudes and beliefs change during the developmental process of becoming a therapist, and even those that do not change need to be placed appropriately in a professional context. “I think [the Ward and Keene lawsuits] may have been avoided if faculty had sought to create a safe environment in which to explore the issues with the student,” Woolley said. Such a process, he believes, would include having the student read relevant literature and talk with other therapists with similar beliefs, to help them ultimately integrate their faith with the literature and the ethical code of the profession.
Shields is an example of a therapist whose development has included major changes in belief. “I am an African American woman from a Christian background. For a substantial period of my life I believed that same-sex intimacy was a sin,” Shields said. “Over time and after much prayer and soul searching, I found that I was not able to hold those beliefs and feel that I was engaging in the radical unconditional love that I believe Christians are called to.”
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* – Keeton ultimately lost her case. EMU settled with Ward, but did not admit any wrongdoing or change any of their policies as a result of the case.
Ben Caldwell Labs offers a 1 hour continuing education course on Refusals to Treat, drawing from those court cases, current ethical standards, and more. Complete information, including CE approvals, course objectives, and important policies, can be found at the course page here.
To see an earlier post I wrote on the same topic, go to “How should religious therapists treat gay and lesbian clients?“
My humble thanks to the good people at AAMFT for their invitation to write this article, and their permission to reprint it here.