How should religious therapists handle gay and lesbian clients?

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Counselors and therapists with strong religious beliefs sometimes refuse to treat gay and lesbian clients. Some even refuse to offer referrals. Can they do that?                                                                                                               

Homosexuality symbolsSo-called “conscience clauses” are common in health care. They allow professionals to refuse to provide a service within their scope when that service would conflict with the professional’s moral or religious values. In reproductive health, for example, this allows gynecologists to refuse to perform abortions, and allows pharmacists to refuse to distribute birth control, if they find these objectionable.

Such provisions are controversial. The Obama administration has moved to (mostly) end them in federally-funded facilities, and there have been several instances where patients have been harmed — and then filed lawsuits — over treatment refusals based on conscience clauses.

The debate is now coming to mental health, as a result of religious therapists and students taking a stand against treating gay and lesbian clients. These cases point to an interesting contradiction in professional ethical codes:

  • Mental health professionals do not discriminate based on sexual orientation.
  • Mental health professionals do not treat clients outside of their scope of competence.

Though the specific wording varies, versions of those statements can be found in the ethical codes of every major mental health association. When a religious therapist, whose beliefs suggest that homosexuality is immoral[*], is asked to treat a gay or lesbian client (or couple), what should the therapist do?

Offering treatment would abide by the non-discrimination sections of professional ethical codes, but could lead to ineffective — or even harmful — treatment. Religious therapists who, perhaps by their own choosing, lack the training and experience to work effectively with gay and lesbian clients then should not ethically be treating those clients. On the other hand, refusing to treat a client based on the client’s sexual orientation seems to be quite clearly discriminatory.

On issues like this where different parts of a code of ethics conflict, the ethical codes generally do not indicate which standards should take precedence over others. (They also do not allow exceptions based on the therapist’s religious beliefs.) The NASW Code even includes a clear statement that it does not prescribe such an ethical hierarchy, as ethical decision-making is centered around process more than outcome. So no one really knows whether it is ethical for a therapist to refuse to treat clients in same-sex relationships.

Again, allowing a health care provider to refuse to treat clients based on the provider’s religious beliefs is common in other fields (Pharmacy | Medicine), but it comes with an important caveat: The provider usually must give the patient a referral to another provider who would offer the treatment in question. In theory, that should resolve the issue; patients get the services they need while providers maintain their religious convictions. In practice, it only works if that other provider is close at hand. Patients refused services based on religious “conscience clauses” in rural areas, as well as those needing to be treated immediately for the treatment to be effective, are left without options when their provider refuses to treat them for religious reasons — which is precisely why many states put exceptions in their “conscience referral” legislation or simply do not allow such referrals.

Some states already have “conscience clause” laws on the books that do not require any referral at all, which has drawn protest from professional associations who worry that they allow a health care provider’s religious beliefs to “run roughshod over the profession’s code of ethics.”
In the Lincoln (Nebraska) Journal-Star, Rev. Christopher Kubat presented the case that religious therapists should be able to turn away same-sex couples without offering referrals:

Since the Catholic Church teaches that sexual relations are meant for one man and one woman in the context of marriage, if a same-sex couple requests therapy to support, validate or enhance their sexual relationship or something akin to marital therapy, it would be inappropriate to provide that specific, narrow service or make a referral for it, as referring for something considered inappropriate or immoral would itself be inappropriate and immoral because of the element of cooperation.

That strikes me as blatantly discriminatory and harmful to those in need of treatment. It also is theologically consistent.

This is the debate I wish had taken place in CAMFT’s rightly-maligned (and eventually disowned) same-sex-marriage issue of The Therapist. I think there is a legitimate concern on both sides. Religious therapists have an ethical obligation not to refuse treatment based on a client’s sexual orientation. But how can that treatment possibly in the client’s best interests when the therapist’s religion precludes them from in any way supporting the client’s romantic relationship? It seems unlikely. Is there a workable middle ground?

Proposed legislation in California would attempt to at least partially resolve this issue by ensuring all mental health professionals receive training in working with LGBT populations. That may be helpful when it comes to establishing competence, but likely will not change anyone’s religious beliefs.

I do not pretend to have the answer here, though I am optimistic such an answer exists. I wish all clients, regardless of sexuality, could receive competent and accepting treatment anywhere they seek it. I also do not want any of the talented religious therapists I know to feel like they need to betray their religious beliefs to work as mental health professionals. I just wish there were a place for honest, genuine, respectful debate on this issue that could land on some ethics code language on which both sides could agree. Is there a place for that?

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* – For clarity’s sake, of course not all religious therapists believe that homosexuality is immoral, or would refuse to treat gay or lesbian clients. I personally know many strongly religious therapists who see no conflict at all in offering their professional services to clients regardless of sexual orientation.

Study: Marriage stays satisfying over time for many more than previously thought

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Newlywed couples, once thought to consistently experience a quick drop in satisfaction, actually often remain just as happy (or close to it) over time, according to a recent study. For couples who do get worse, the reasons can be evident early on. The study’s author comments.                       

Wedding ringsAccording to a study published late last year in Family Process, the rapid decline in marital satisfaction following a couple’s wedding — generally thought to be quite normal — is actually something many couples manage to avoid. The “average” couple experiences a drop because for some couples, satisfaction declines precipitously. But many couples, including the most satisfied, actually remain fairly stable in their marital happiness.

Justin Lavner and Thomas Bradbury at UCLA monitored the progression of marital satisfaction over time among 232 couples, starting soon after the couples were married. They found that couples’ progressions in happiness clustered into five different groups. For the three groups who started out the most satisfied, they tended to stay at about the same level (or decline only minimally) in the four years after their wedding day. For the two groups who started married life less satisfied, things tended to get significantly worse with time — dragging down the population average. As might be expected, among those five groups, divorce rates varied significantly, with the groups whose satisfaction declined over time far more likely to split up.

I asked Lavner a number of questions via email about the study and its implications. The following has been edited for length and clarity. My questions are in bold, and Lavner’s responses are in plain text.

BC: How would you describe your findings in plain language, and what surprised you the most?

JL: We set out to examine one of the most often-cited “facts” about marriage — that satisfaction declines as marriage goes on. We wondered whether this average pattern obscured different patterns that couples experience, and if so, what factors characterized people who had different patterns and how these patterns related to later divorce rates.

We found that although the average pattern is indeed one of declining satisfaction, there are a few different patterns that better characterize newlyweds’ marriages over the first four years, including very high, stable trajectories, as well as marriages that start off low in satisfaction and experience large declines very quickly.

Spouses with negative patterns could be distinguished by a range of factors as early as six months into marriage. These included their personality characteristics, how they interacted with their partners during a 10-minute problem-solving discussion, how much aggression they reported, and how much stress they had in their lives. Importantly, these early patterns related to ten-year divorce rates: couples with the worst trajectories had rates of divorce that were more than four times as high as those couples with the best trajectories!

I think the finding that surprised me the most was how early these differences emerged. All of the factors that distinguished between patterns were found at six months into marriage, and some couples were already dissatisfied by then. To me, this suggests that there is a lot more variability in couples early in their relationships than we had previously thought.

BC: I was amazed at the wide disparity in divorce rates for couples based on their marital satisfaction trajectories. How do you think this data can be used to inform and improve treatment for couples at risk of divorce?

JL: We often hear that satisfaction declines as marriage goes on. While that may be true on average, what’s really powerful about this data is that they highlight how couples vary widely in the likelihood their relationships will deteriorate, and also give us a better idea of what types of characteristics make couples more likely to experience negative marital trajectories. Using this kind of data, we can be more targeted in our relationship education interventions and direct services toward those couples who need them most.

BC: One of your key findings is that for both husbands and wives, Personality, Stress, Aggression, and Positive Affect distinguished trajectory groups. What does this suggest for identification and treatment of at-risk couples? Do we need multiple forms of therapy geared toward couples with different traits?

JL: These findings indicate that those couples with the greatest distress (and at highest risk of divorce) are characterized by a full range of negative personality traits, experience more stress, report more aggression, and demonstrate lower levels of positive affect. This suggests that focusing on any one factor in treatment will not be sufficient: for example, we cannot focus on negative communication without recognizing how couples’ personalities and stressful environments will limit the benefits they can achieve from communication training.

I see this not as evidence that we need multiple forms of therapy geared toward couples with different traits, but more that our interventions need to continue recognizing and addressing the multiple factors that affect couples’ lives. My guess is that it is likely to be quite difficult to fully “match” traits with specific forms of therapy to increase success when there are multiple factors at play.

BC: You mention that the data holds some promise for early identification of at-risk couples, but temper this pretty heavily, saying that “it is nonetheless discouraging because it suggests that the task of strengthening these relationships must address a wide range of possible causes for the distress, some of which may be difficult to modify.” Could you expand on this?

JL: Not only are the couples who go on to experience distress those with multiple risk factors, but some of these risk factors are likely to be quite stable, particularly their personalities and the stress they encounter. We also identify this risk very early in the relationship, which means that by the time couples present for therapy (which they are notoriously slow to do), these distressing circumstances have likely plagued them for several years.

That said, I’m still optimistic about therapy possibly changing these trajectories and ultimately reducing divorce risk for these couples, particularly if intervention occurs early and addresses multiple factors of couples’ lives (as integrative behavioral couple therapy and enhanced models of cognitive behavior therapy now do, among others).

BC: You briefly talk about public policy, suggesting that broad-based marriage promotion programs are not likely to be as successful as programs targeting “the challenging circumstances and chronic stresses likely to impede relationship maintenance.” In your ideal world, what would a program designed to reduce divorce look like?

JL: Ideally relationship education programs need to do more to address the complete gestalt of couples’ circumstances — their particular ways of interacting, their personal histories, and how the contexts they live and work in affect their relationships. How this would play out is still an open question, but could include modules such as personality characteristics and emotion regulation strategies, or work stress and how that affects home life, along with stress management techniques. Special attention needs to be given to recruiting and retaining high-risk couples, as this presents the best opportunity to prevent distress and divorce.

I would also like to see more attention given to factors that can promote relationship stability. These findings indicate that many couples have stable levels of satisfaction over time, so how can we help them maintain and even enhance their relationships? For example, Art Aron and his colleagues (Aron, Normon, Aron, McKenna, & Heyman, 2000) have suggested that participating in novel activities can enhance couples’ relationship quality. Our programs must do more to promote relationship functioning, in addition to helping prevent deterioration in relationships.

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Comments are welcome below. In addition, you can email me at ben[at]bencaldwell.com, or help prevent deterioration in my Twitter feed.

To ease stress, and maybe save your marriage, try doing nothing

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When it comes to making a healthier self and a happier family, doing nothing may be the next big thing.                                                                                                                                                                                     

TratakaOne of the hardest things for many of us (myself included) to fathom when we dedicate our careers to solving problems is that sometimes the best solution is no solution at all — just do nothing. Refraining from action can be just as vital a problem-solving strategy as taking action.

Michele Weiner-Davis, the author of Divorce Busting, offers a touching blog entry about how doing nothing helped her own marriage. And there’s the website that challenges you to do nothing for two minutes, which is harder than it sounds if you’re used to moving at a fast pace.

Best of all: Doing nothing can be surprisingly effective.

“Taking a moment to do nothing can be very centering and calming. It allows you to slow the entire experience down and get back to a place of rational thought,” says my good friend and Caldwell-Clark cofounder Aimee Clark. Indeed, doing nothing can be a surprisingly useful treatment for depression, which fairly quickly improves on its own in as many as 1 in 5 untreated cases. (Naturally, if you’re experiencing depression, talk it over with a doctor or mental health professional — just keep “no treatment” on the table as an option.) And doing nothing can improve family life; the tendency for kids to be over-scheduled has been widely covered. The impact of that hyperscheduling may actually be good for kids, but at the same time, studies routinely show that families do better when they simply spend time together… even if they aren’t actually doing anything in that time.

How does one go from doing a lot to doing nothing, even if for just a few minutes a day?

“Commit to one 5-minute practice per day that invokes the nothingness. You can do a simple exercise I call Choosing Your Thoughts, which engages the breath and mind to help you do just that. As you inhale and exhale through your nose, say to yourself, ‘I am aware that I’m doing nothing,'” says Clark. “You can even add a smile, which will help you to enjoy the exercise.”

Call for Change group offers non-rebuttal rebuttal

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MFT Call for Change group responds to my previous post, where I highlighted several of their erroneous statements about California.                                                                                                                                                                                     

The group calling themselves “MFTs Call for Change” (CFC) has posted a lengthy rebuttal to my earlier post criticizing CFC misstatements about California, specifically in areas related to the LPCC license and its development here.

Notably, they rarely, if ever, challenge my statements of fact. They claim that my post included “misinformation,” but their arguments are more often of the moving-the-target (“yes, but”) variety than they are factual disagreement. And they add at least one to the list of factual errors of their own.

  • CFC criticizes my statement that “When CAMFT was negotiating changes to various versions of the LPCC bill, they sought to make MFTs and LPCCs as indistinguishable as possible.” They would prefer I label this as my own belief, or an opinion of AAMFT-CA. But there’s no need. I saw, firsthand, CAMFT’s opposition to language supporting distinctiveness of professions during the negotiation process. Remember, CAMFT wanted grandparenting to be automatic for licensed MFTs based just on coursework (this version of the bill allowed exactly that), and indeed, CAMFT has continued to argue there are no meaningful differences in practice between the MFT and LPCC professions (as CAMFT themselves said, they believe “LMFTs and LCSWs may do in practice everything LPCCs may do“) — which would make the licenses effectively indistinguishable. That’s not my belief, that’s an argument CAMFT itself is continuing to make and act upon.
  • Along similar lines, CFC calls my discussion of CAMFT’s lawsuit against the BBS “patently irresponsible” because… well, I can’t tell why, exactly. I’m not even sure which part they’re taking issue with. CAMFT sued the BBS to try to make the “gap exam” for MFT grandparenting go away, based on their belief that the practices of the professions are indistinguishable. They have very clearly said so. That the lawsuit attempted to use technical means (like the BBS’s failure to consult with a state agency on exams, the one point of three in the lawsuit on which CAMFT won) to reach their desired ends (no gap exam) does not change those desired ends or the publicly-stated rationale behind them.
  • AAMFT-CA and AAMFT have not been “against the LPCC bill since its inception,” as CFC newly and falsely claims. Primary sources here tell the tale. California counselor legislation was first introduced in February 2005. In November 2005, nine months later, I first spoke to a legislative committee about AAMFT-CA’s concerns with bill language. Even then, AAMFT-CA took no formal position, as we understood the bill would be further amended. AAMFT-CA only formally opposed LPCC legislation in 2007 (this legislative committee analysis is the first mention of AAMFT-CA opposition), after it became clear that the legislation was moving in a direction that would hurt the MFT profession. Furthermore, in 2009, once we worked out the compromise language that became the LPCC law, AAMFT-CA’s opposition was removed [page 2], helping the bill pass. The larger AAMFT never took any formal position at all on the bill.
  • In discussing Kim Madsen, the BBS Executive Director, the CFC rebuttal suggests that in my post, “The reader has been lead [sic] to believe Ms. Madsen would be less than forthcoming” when discussing licensure issues. Nonsense. Ms. Madsen has been, in my experience, extremely professional, highly ethical, and very forthcoming, even when we have disagreed on policy. In my earlier post, what I suggested was that CFC, not Ms. Madsen, was being less than forthcoming by leaving out important details. This should have been evident in my preface “I suspect what Ms. Madsen said was…” Given my experiences with each of them, I trust her to be complete and forthcoming much more than I presently trust CFC to do so.

As I said previously, the CFC group seems to be well-meaning. I just don’t understand their dogged pursuit of this line of criticism. It is not supported by facts, and makes CFC look more interested in finding fault with AAMFT than actually supporting or developing the profession.

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If I did make any errors of fact — there or here — I would like to correct them. Email me at ben[at]bencaldwell.com, post a comment, or call for a change to my Twitter feed.