Training in Psychology and the Debates about Value-Based Referrals

imagesThe Board of Educational Affairs of the American Psychological Association (APA) has just put forth a new statement that is the result of a several month process by which a working group has been meeting to discuss the complexities associated with value-based referrals in the context of professional training.

This has been a topic that has received a great deal of attention with the Ward v. Eastern Michigan University (EMU) case that was recently settled out of court. You may recall that Julea Ward was dismissed from her counseling program for not participating in a remediation program after making a referral of a gay client who requested counseling for relationship issues. That referral was made in consultation with her supervisor, but her program had insisted she go through remediation. The settlement to Ward was for $75,0000.

Unfortunately, I see a lot of polarization occurring in response to value based referrals. Now we are seeing attempts to address these complex issues through legislation, which I see as the wrong venue for this topic. Just as I am concerned with attempts to ban reorientation therapy for minors in California (see here), I am concerned about attempts to legislate conscience clauses for students in training to become psychologists.

The APA appears to want to get ahead of the curve on this one, which I think is a good idea. The pedagogical statement is reproduced here in its entirety:

Preparing Professional Psychologists to Serve a Diverse Public: A Core Requirement in Doctoral Education and Training

Statement of Purpose

For psychologists to competently serve all members of the public now and in the future, professional psychology training programs strive to ensure that psychology trainees demonstrate acceptable levels of knowledge, skills, and awareness to work effectively with diverse individuals. Clients/patients are complex individuals who belong to diverse cultures and groups. Trainees also bring a complex set of personal characteristics and diverse cultural or group memberships to the education and training process. An important component of psychology training to explore is when and how trainees’ world views, beliefs, or religious values interact with and even impede the provision of competent professional services to members of the public. It is essential that potential conflicts be acknowledged and addressed during training so that psychologists are prepared to beneficially and non-injuriously interact with all clients/patients. This statement is intended to help training programs address conflicts between trainees’ worldviews, beliefs, or religious values and professional psychology’s commitment to offering culturally responsive psychological services to all members of the public, especially to those from traditionally marginalized groups.

Commitment to a Supportive Training Environment

Training environments foster the ability of trainees to provide competent care to the general public, and trainees’ competencies in professional practice are evaluated regularly. Some trainees possess worldviews, values, or religious beliefs that conflict with serving specific subgroups within the public.   For example, they may experience strong negative reactions toward clients/patients who are of a particular sexual orientation, religious tradition, age, or disability status. Trainers take a developmental approach to trainee skill and competency acquisition, and support individual trainees in the process of developing competencies to work with diverse populations. Trainers respect the right of trainees to maintain their personal belief systems while acquiring such professional competencies. Trainers also model the process of personal introspection; the exploration of personal beliefs, attitudes, and values; and the development of cognitive flexibility required to serve a wide diversity of clients/patients. Training to work with diverse clients/patients is integral to the curriculum, and consists of both didactic coursework and practical training.

Training programs, trainers, and trainees cannot be selective about the core competencies needed for the practice of psychology because these competencies are determined by the profession for the benefit of the public. Further, training programs are accountable for ensuring that trainees exhibit the ability to work effectively with clients/patients whose group membership, demographic characteristics, or worldviews create conflict with their own. Trainers respectfully work with trainees to beneficially navigate value- or belief- related tensions.  At times, training programs may wish to consider client/patient re-assignment so trainees have time to work to develop their competence to work with client/patients who challenge trainees’ sincerely held beliefs. Trainers utilize professional judgment in determining when client/patient re-assignment may be indicated in this situation as in all other possible situations in which client/patient re-assignment may be considered. The overriding consideration in such cases must always be the welfare of the client/patient. In such cases, trainers focus on the trainees’ development, recognizing that tensions arising from sincerely held beliefs or values require pedagogical support and time to understand and integrate with standards for professional conduct. Thus trainees entering professional psychology training programs should have no reasonable expectation of being exempted from having any particular category of potential clients/patients assigned to them for the duration of training.

Commitment to Transparency in Educational Expectations, Policies and Procedures

Psychology training programs inform prospective trainees and the public of expected competencies to be attained during training. Publicly available program descriptions and admission materials should include the program’s goals and objectives, content about training standards, and the commitment to serving a diverse public.  These expectations are reiterated throughout the course of training and in documents such as practicum contracts. Training programs are responsible for notifying prospective trainees, current students and the public that the failure to demonstrate appropriate levels of competence as set forth and assessed by the program could lead to dismissal from the doctoral training program.

Commitment to Establishing and Maintaining Standards for Professional Competence to Protect the Public

As the largest professional and scientific organization of psychologists in the United States, the American Psychological Association (APA) has sought to create, communicate, and apply psychological knowledge for the public’s benefit for more than a century. It does this, in part, by establishing a professional code of ethics and standards for professional education and training for practice.  These APA documents mandate that education and training programs take reasonable steps to ensure that doctoral-level graduates are prepared to serve a diverse public.

Those who want students to retain the right to make a referral due to their “sincerely held beliefs” may not be pleased with this document. However, it goes a long way in the right direction. Let me elaborate.

There is a shift away from the language of “referral” to “re-assignment” which I like. The language of “referral” tends to place the emphasis on the student in training, as though that student were to make these decisions. I understand that this gets complicated, but I struggle with the idea of having the student be the final arbitrator of the kinds of clients he or she is going to see. They are in training to become a psychologist. There is an important training context that is often under-appreciated in these discussions (and rarely appreciated once it moves to legislation). The language of “re-assignment” keeps the focus on the training aspect of these issues.

values_22315404_std.255115903_stdAlso, I appreciate that the focus is on those who are providing the training to use their professional judgment: “Trainers utilize professional judgment in determining when client/patient re-assignment may be indicated in this situation as in all other possible situations in which client/patient re-assignment may be considered.”

I understand that those who want a certain “conscience clause” emphasis may not care for the language of having “time to work to develop their competence” in an area in which there is a value conflict, but it does reiterate the importance of the training aspect of their professional identity, which is discussed in the context of providing students with time and support, which is significantly different than what is being discussed elsewhere. In other words, programs that adhere to this statement would be expected to show how they work with students who hold “sincerely held beliefs” — in a case like that of Ward v. EMU, it would seem to heighten expectations for how training programs would show respect to a wider range of diversity considerations, such as sexual orientation and religion. It suggests programs will be expected to create the kind of climate that is supportive of students as they embark on a developmental process that takes them to a place of professional responsibility to serve the public — that both the outcome and the process will demonstrate regard for diversity in its various expressions.

I also like that what is of utmost importance is the welfare of the client. Back to the document: “The overriding consideration in such cases must always be the welfare of the client/patient.”

The closing line in this particular paragraph has some important language:

Thus trainees entering professional psychology training programs should have no reasonable expectation of being exempted from having any particular category of potential clients/patients assigned to them for the duration of training.

Having trained students in psychology for the past 14 years, I would be concerned about having a student who went into training with a list of people they would not see professionally. I do think there is a process here that we would do well to appreciate. It is a professional training and identity process that takes time to instill. It is not fostered by simply telling students to meet specific expectations; in fact, I suspect such an approach would lead a student to only be further entrenched in his or her own position.

You might be asking, “What about the conscience clause? Can a student make a value-based referral or not? Yes or No?” I don’t think this document is intended to provide a simple answer to those kinds of questions, in part because this is a professional development topic, and it is a complicated one. It does not lend itself to black and white answers, but to nuance, which is why it should not be adjudicated through the courts.

One thought on “Training in Psychology and the Debates about Value-Based Referrals

  1. I feel like in the real world clients self select therapists that will support their worldview or direction of change so I wonder how often this kind of scenario comes up. I guess in a training scenario it is different though. Still, I do think that a conservative Christian mental health professional should be able to treat GLBT clients. As a trainee they shouldn’t be able to say “I won’t see this kind of client”. They may not be able to affirm some specific behaviors of GLBT clients but as long as that is clear from the beginning then the fact that a client is GLBT shouldn’t make a difference. In a training situation I have had clients ask to be referred because they wanted a gay affirmative therapist. I was disappointed but it seemed like the appropriate thing for them to do as I think they simply recognized that I couldn’t give them what they wanted. I hope a training program, even if it doesn’t have tremendous respect for the worldview of the trainee, would at least listen to the client. Perhaps a perceptive trainer would hear the GLBT client before the words were even spoken. In that light the fact that this statement says that the overcoming consideration should be the welfare of the client seems positive to me.

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