On Legislating around the Complexities of Clinical Practice

There has been a lot in the news recently about whether California will ban the practice of reorientation therapy with teens and have specific wording as part of informed consent for adults who seek such services. The California senate committee has passed Bill 1172 to the full senate for a vote. I was interviewed about this today for a story that may run over the weekend, and let me share a few thoughts.

In terms of practicing cognitive complexity, let’s take a look at this from the perspective of those who are advancing Bill 1172. It appears to be out of a genuine regard to protect young people who are believed to be at risk for a type of therapy that proponents of the Bill believe is ineffective and inherently harmful.

On the other side are those who disagree with the Bill for several reasons. The main concerns that come to my mind are these:

1. Venue. I tend to agree with the various CA mental health organizations that have either opposed the Bill or expressed concern that legislating around the complexities of clinical practice in this area is not a good idea. Although it isn’t the first case of making a technique or practice illegal, it is not a common practice at all. Opponents also point out that mental health professionals have regulating bodies that oversee clinical practice, license practitioners, and follow up on ethical complaints. Further, several mental health professions also convene working groups and task forces to review the extant literature and provide updates on research in this area, trying to make that information available to practitioners and the public alike.

2. Science around SOCE for teens. There is not much by way of well-designed research on adolescents who pursue sexual orientation change efforts (SOCE). I don’t think the 2009 APA task force report on appropriate therapeutic responses to sexual orientation was able to identify one such study (if memory serves); instead, the task force cited published articles with case examples of clinicians who worked with adolescents navigating sexual and religious identity conflicts. The science that seems to be cited is that of adults who participated in SOCE and then extrapolated to the adolescent.

3. Science around SOCE for adults. This brings up the research on SOCE for adults that has been reviewed by a number of professionals and organizations. The Bill references a number of mental health organizations. One concern is that the Bill uses stronger language than the organizations, in at least a few cases. For example, the Bill indicates that SOCE are ineffectual, while the APA task force tends to talk about not have sufficient evidence to support claims of change, that change is “uncommon”, and that newer studies are not sufficient in quality to answer whether or not SOCE does or does not change orientation. I would note that there are those who disagree with these conclusions, but even if you agreed with these conclusions, this language and these nuances are simply not seen in the Bill.

4. Beyond attractions/desires. The other issue that has been brought up by some of the CA mental health organizations that oppose the Bill in its present form has to do with how broad it is. I believe their concern had to do with a possible unintended consequence if clinicians were not to work with teens to explore a range of sexual and gender identity issues for fear of legal ramifications associated with Bill 1172. I would also note that the Bill covers therapies to change attractions, desires, and behavior. That is rather remarkable and extends far beyond therapies that purport to change orientation. Is anyone really wanting to get behind a legal measure that restricts a clinician from helping someone change their behavior?

5. Issues with informed consent. I wrote an article published in 1998 that argued that those who provide reorientation therapy should obtain advanced informed consent for their services. Informed consent refers to the kind of information the average person would need in order to make a meaningful, informed decision about services. Advanced or expanded informed consent provides even more details about services, potential benefits, risk of harm, and so on. What I did not like about the Bill is that the language overreaches in it’s claim of SOCE being ineffective and the extent of potential harms associated with it. These seem to me to be important considerations that need to be tied to well-designed research studies. The existing research (with the use of convenience samples and seeking out those who were not pleased with services) is fraught with too many methodological problems to be the last word on risks associated with this type of therapy. I am not saying that there are not risks. But I am saying that important questions about the interventions, expectations, and competence of the clinician should also be better understood.

I would also like to see an advanced inform consent form co-authored by people who represent the different stakeholders in these discussions. Is the research far enough along that we could see an informed consent form where people who might otherwise disagree on a number of issues can at least agree on what the public needs to know to make truly informed decisions about services?

6. Trends in providing services to minors. One last thought is that Bill 1172 appears to run contrary to current trends in terms of access to services by minors. I do not want to make too much of this because there are legitimate concerns here about potential harm to minors through misinformation about unrealistic expectations, stigma, and so on. But the trend is toward putting mental health and related health care decisions into the hands of adolescents rather than restricting access (think reproductive health, parental notification laws, issues with consent, etc.). This discussion moves in the other direction – toward restricting access even if an adolescent where to assent to treatment.

I want to reiterate that I recognize the concern that minors may be at greater risk in some ways. Of course a competent clinician knows that he or she has to obtain assent from any minor who seeks any kind of mental health services, even in cases where the parent have provided consent. If the minor does not assent to services, the services should not be provided. I also recognize that some minors may give assent because of pressure they feel from their parents – and this is a genuine concern.

Although I do not provide reorientation therapy, I would say that in my experience not that many teens request reorientation therapy. The interest in it tends to come more from the parents, so the idea that there could be  pressure from parents is definitely something that should be addressed with all involved.  I think the best way to handle the potential for undue pressure is to do a good and thorough assessment of goals, expectations, motivations, and so on. I am really open to ideas on this one, but it is worth more reflection.

I am sure that there are other arguments both for and against the Bill. These are just a few thoughts. And I don’t intend to come across as a defender of reorientation therapy for minors. I have mixed feelings about reorientation therapy. It is not something I provide. My preference is to explore sexual identity questions and to navigate conflicts between religious and sexual identity concerns (following the SIT Framework). But I have defended the rights of clients to pursue such therapy if they are given sufficient advanced informed consent. I hadn’t thought about it that much for teens in part because I have not seen that many teens asking for it.

In any case, I hope these reflections show that this is at least a  complicated issue. My main concern is that legal answers such as the one proposed rarely reflect the complexity inherent in providing clinical services.

UPDATE: CBN News ran a story on the CA Bill.

UPDATE: The CA Senate approved Bill 1172. (5.30.12)

6 Comments

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s