Christian Counseling Ethics, 2nd Ed.

The book, Christian Counseling Ethics, has just been published in its second edition. This is a book edited by Randolph Sanders, former executive director of the Christian Association for Psychological Studies (CAPS). The opening chapters (by folks like Alan Tjeltveit, Richard Butman, and Horace Lukens) orient the reader to a Christian worldview and engagement with counseling and mental health. This is a greater challenge than it sounds like, as the book is for a broad audience and so takes up psychology, counseling, marriage and family therapy, pastoral care, and lay counseling.

The book then turns to specific populations and issues, such as couples therapy, children, those with chronic conditions, navigating multiple relationships, and working with sexual minorities. I worked with Stan Jones and Jill Kays on the chapter on sexual minorities. Other contributors here included Jennifer Ripley, Ev Worthington, Steve Sandage, Jeff Berryhill, Angela Sabates, James Jennison, and Randy Sanders.

Other chapters address some unique considerations for Christians, lay counselors, and ministry settings. These include chapters on the abuse of power (John Shackelford & Randy Sanders), business ethics (Randy Sanders), pastors and lay counseling (Bill Blackburn, Siang-Yang Tan), the military (Brad Johnson), and member care (Kelly O’Donnell).

Most of the chapters are revised, expanded versions from topics addressed in the first edition. Some are new chapters. However, given the changes in the field, even those chapters that are revised or expanded are often substantive updates. I know that material on working with sexual minorities has grown significantly since the first edition came out in 1997.

Sanders also did a nice job asking everyone to be practical. The most obvious signs of this are the appendices. Various ethical codes are reproduced in the appendix, as are sample forms for release of information, demographics, and so on. But even in the various chapters, authors made a concerted effort to make the resource more practical. In our chapter on working with sexual minorities, we added a lot of suggested language that could be used when obtaining informed consent, for instance.

This book is meaningful to me personally. The chapter I coauthored for the first edition was my first publication. When I contributed to that edition, I was a grad student working for Stan Jones at Wheaton College. It was nice to be able to return to that chapter and to update it for Christians in training today.

Having taught a course in Ethical, Legal and Professional Issues in Psychology for more than a decade, I can say that I have not found another comparable book that delves into the professional ethical issues that arise for Christians and that is written from a Christian worldview. Given that 16 years had passed since the publication of the first edition, it was definitely time for a second edition, and I think the reader will not be disappointed.

Training in Psychology and the Debates about Value-Based Referrals

The 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.

Also, 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.

The Julea Ward Case Settled Out of Court

Ward v. EMU has been settled out of court according to various new reports here and here. You will recall that this was a case in which 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 has EMU paying Julea Ward $75,000.

In my previous writing on the topic, I discussed my talk on value conflicts in counseling, so I will not reiterate all of what I wrote, but let me say this: I agree with Warren Throckmorton here that this case should not primarily be framed as a gay rights issue so much as a question about how value conflicts are handled in therapy. Value conflicts extend far beyond any one topic, as important as that topic may be. I believe the case is also an important lesson in professional mentoring of students who are training to function as licensed mental health professionals, who are essentially preparing to enter into fiduciary space, providing services to the public under a board of counseling.

There were many missed opportunities in this situation. Opportunities that have nothing to do with the culture wars but rather with how we identify superordinate goals and work together to provide the public broadly (and specific clients narrowly) with the best clinical services.

On the Prevention of Rape in Correctional Facilities

In the media and entertainment industries, the subject of prison rape has received a fair amount of attention. It stands as a real threat to many inmates and has been memorably portrayed in various movies, such as The Shawshank Redemption. For many people who have a stake in decisions made at corrections facilities, it is an important topic that deserves serious attention.

In 2003, Congress enacted The Prison Rape Elimination Act (PREA). PREA was enacted by Congress to address concerns about the sexual victimization and abuse of persons in U.S. correctional facilities. In 2004, the National Prison Rape Elimination Committee was formed to take the lead in this area. According to this report, this spring they published new provisions of PREA.

According to the National Institute of Corrections, PREA has many provisions, including the following:

• Adherence to a zero-tolerance standard for the incidence of inmate sexual assault and rape;
• Development of standards for detection, prevention, reduction, and punishment of prison rape;
• Collection and dissemination of information on the incidence of prison rape; and
• Award of grant funds to help state and local governments implement the purposes of the Act.

In my area of research, which is primarily sexual and gender identity concerns, I am particularly interested in how this affects sexual minorities. This refers (in PREA) specifically to lesbian, gay, bisexual, transgender, and intersexed persons, as well as gender nonconforming persons. Here is what is written in PREA:

The standards account in various ways for the particular vulnerabilities of inmates who are LGBTI or whose appearance or manner does not conform to traditional gender expectations. The standards require training in effective and professional communication with LGBTI and gender nonconforming inmates and require the screening process to consider whether the inmate is, or is perceived to be, LGBTI or gender nonconforming. The standards also require that post-incident reviews consider whether the incident was motivated by LGBTI identification, status, or perceived status.

In addition, in a change from the proposed rule, the final standards do not allow placement of LGBTI inmates in dedicated facilities, units, or wings in adult prisons, jails, or community confinement facilities solely on the basis of such identification or status, unless such placement is in a dedicated facility, unit, or wing established in connection with a consent decree, legal settlement, or legal judgment for the purpose of protecting such inmates. As in the proposed standards, such placement is not allowed at all in juvenile facilities.

The standards impose a complete ban on searching or physically examining a transgender or intersex inmate for the sole purpose of determining the inmate’s genital status. Agencies must train security staff in conducting professional and respectful cross-gender pat-down searches and searches of transgender and intersex inmates.

In deciding whether to assign a transgender or intersex inmate to a facility for male or female inmates, and in making other housing and programming assignments, an agency may not simply assign the inmate to a facility based on genital status. Rather, the agency must consider on a case-by-case basis whether a placement would ensure the inmate’s health and safety, and whether the placement would present management or security problems, giving serious consideration to the inmate’s own views regarding his or her own safety. In addition, transgender and intersex inmates must be given the opportunity to shower separately from other inmates.

As I have reviewed a number of articles related to PREA and blogs dedicated to discussions and comments on it, opposition seems to be framed around the following concerns: (1) it reflects political correctness to attend to the concerns of sexual minorities; (2) actions have consequences, so any inmate who is concerned about safety should have thought about before offending; and (3) there are limited resources for attending to the inmates who have special needs or considerations.

I am particularly concerned that Christians not stand behind the first two objections. Let’s look at the fist one. Although I suppose PREA could be implemented in a spirit of PC culture, it most certainly could be implemented simply out of regard for emerging sexual minority visibility. In this context, read “sexual minority” to mean individuals who experience sexual or gender identity in ways that do not reflect the experience of the majority (most individuals). How a person responds to those differences around sexual and gender identity may be up for grabs, and the prevailing script is clearly supporting an LGBTI identity, as I have discussed elsewhere. In certain settings and contexts, these experiences of sexual and gender identity appear to put some people at greater risk than others. While large segments of the population in different regions of the country (and globally) may disagree with the morality of same-sex behavior, that does not mean that safeguarding sexual minority persons should not be a concern shared by all.

As for the second objection, let me say first off that not all those who are in prison deserve to be in prison, and some groups are overrepresented in the prison population and that can reflect other injustices beyond the scope of this reflection. However, even in cases in which the person ought to be in prison, no one in prison deserves to be sexually assaulted. Being in prison was their sentence–not being raped.

The third concern is an issue of funding and resourcing, and that is always a concern. So implementing relevant regulations will be important in light of funding challenges, issues with space and other resources, as well as the safety and regard for all other inmates and the corrections staff as well. So this issue ought to be given careful consideration.

Why should Christians care about what happens to sexual minorities in prison? It concerns me that I even have to ask this question, but I know there are Christians who would be thinking this, even if they do not admit it. There are many reasons, but issues of justice are one–what was the sentence and how was it carried out (as contrasted with victimizing people in a corrections facility).

Also important, I think, is the commitment to honor the image of God in all persons, including those who are in prison. So much of our legal system is based on broad Judeo-Christian considerations that safeguard the process, and we ought not to lose site of both the foundations of the legal system and the implementation in these instances.

Third, we do well to recognize that it is not helpful to think “us” versus “them” with either the prison population or the LGBTI population. Christians are imprisoned. NonChristian people in prison become Christians. Christians experience same-sex sexuality and may or may not identify was LGBTI. There is no “us” and “them” in discussions of rape prevention in correctional settings, although there may be groups that are at greater risk than others, and how policies are written and enforced to respond to those needs is an important next step for everyone who has a stake in these discussions.

I will be involved in some consultations in this area over the next several months. These consultations will consider how religion may be explicitly or implicitly cited to justify turning a blind eye toward behaviors that place some people at risk in correctional facilities. Let’s hope for consensus as multiple stakeholders work to move forward with recommendations that serve the needs of everyone involved.

AACC Statement on Michigan HB 5040

The American Association of Christian Counselors (AACC) issued a statement today on Michigan legislation HB 5040, also referred to by some as the “freedom of conscience” legislation. Here is the statement in its entirety:

“Freedom of Conscience Act” Protects Christian Counselors through Values-based Referrals

Last week, the Michigan House of Representatives passed HB 5040, named the “Julea Ward Freedom of Conscience Act.” This legislation affirms a counseling student’s “freedom of conscience” from providing mental health services that contradict and/or conflict with personal religious beliefs, including affirmative gay therapy. The law, in part, reads as follows:

A public degree or certificate granting college, university, junior college, or community college of this state shall not discipline or discriminate against a student in a counseling, social work, or psychology program because the student refuses to counsel or serve a client as to goals, outcomes, or behaviors that conflict with a sincerely held religious belief of the student, if the student refers the client to a counselor who will provide the counseling or services.

Instead of requiring counselors-in-training to continue providing therapy to a client whose value system is in direct conflict with their own, the bill offers another option called values-based referrals. This approach presents a refreshingly balanced, but also professionally consistent, ethical response to complex value conflicts within the therapeutic relationship.

In situations where a client’s presenting problem and requested treatment focus lies outside of a counselor’s deeply held personal beliefs, values, and convictions, counselors-in-training would be instructed to skillfully refer the client to another clinician who can offer the treatment and assistance the client desires. While many law proposals have focused primarily on the client’s right to treatment, the “Freedom of Conscience Act” considers both the client’s right to self-determination, as well as the counselor’s right to freedom of conscience.

Speaking to this important issue, AACC President, Dr. Tim Clinton, said, “Every responsible academic and clinician knows that there will always be the potential for value conflicts in counseling, and they are not all related to spirituality. Ethical counselors operate under informed consent, respect for client self-determination, and refer clients in a professional manner when a values conflict takes place in professional counseling and psychotherapy. This approach also makes sense, both professionally and ethically, because research shows that therapeutic alignment in counseling is significant to positive outcomes.”

The value-based referral approach supported by HB 5040 does just that—assuring that all clients can get the help they need from a therapist who offers treatment within the same worldview, while at the same time preserving each counselor’s freedom of personal and religious values.

The bill was introduced in response to Julea Ward’s religious discrimination case that led to her expulsion from the Eastern Michigan University counseling program. During her practicum, Ms. Ward faced this challenge while working with a client who asked her to affirm his gay lifestyle. As a committed Christian, Ms. Ward’s personal religious beliefs were in direct conflict with the client’s desired treatment goal, but she was told that a values-based referral was not an option.

Contrary to the views of some who criticize the bill, the “Freedom of Conscience Act” represents significant progress in responsibly addressing the ethical challenges that often arise in the counseling profession. It has always been the ethical duty of mental health providers to connect clients with another professional who can render quality care when the presenting issue lies outside of their area of expertise or core value system. The Michigan House of Representatives is to be applauded for taking on this ethical challenge, rather than avoiding it.

The bill passed the House 59-50 and will now go before the Senate for review.

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)

EMU Lawsuit Dismissed

The Detroit News is reporting that the lawsuit brought against Eastern Michigan University by Julea Ward has been dismissed by District Judge George Caram Steeh. You’ll recall that Ward reportedly had a value conflict with a client’s same-sex behavior in that she did not believe she should affirm it. Apparently her supervisor asked her to make a referral to another counselor who did not experience that value conflict. She was then required to participate in a program that would remediate her Christian value system. When Ward refused, she was dismissed from the counseling program.

The news story on the opinion suggests that the judge cited the program’s commitment to the ACA Code of Ethics for accreditation purposes as significant. Also important was the requirement that students provide counseling services to clients “without imposing their personal values.” More from the opinion as reported by the Detroit News:

“In the case of Ms. Ward, the university determined that she would never change her behavior and would consistently refuse to counsel clients on matters with which she was personally opposed due to her religious beliefs — including homosexual relationships.”

One other line from the opinion was that Ward’s “refusal to attempt learning to counsel all clients within their own value systems is a failure to complete an academic requirement of the program.”

In a previous post I covered the lawsuit and discussed the issue of making appropriate referrals in counseling. In some ways the opinion raises more questions than answers. For instance,  When are referrals appropriate?  What I shared at that time was that counselors make referrals when they are asked to work outside of their competence as determined by education, training, and supervised clinical experience. I also noted that value conflicts are generally understood as inevitable in mental health service delivery. Most of these conflicts are worked through, and services are provided uninterrupted. However, from time to time value conflicts may be so great that a referral is worth considering:

A politically liberal counselor will meet with a client with strong conservative views; a gay counselor will meet with an Evangelical Christian client; a Catholic counselor will meet with a woman deciding on abortion; an atheist will meet with a devout Muslim. The question is, At what point does a counselor make a referral when a value conflict arises? The major mental health organization’s ethics codes each tend to stress respect for differences – these are often identified as differences due to age, gender, sexual orientation, religion, socioeconomic status, and so on. Showing respect for these differences can mean different things in counseling, but it at least means being aware of how these factors impact the client and their presenting concern. It often also mean taking these factors into consideration in assessment, case conceptualization, and treatment planning.

So the question that remains and that does not appear to be answered in this ruling is:  At what point does a counselor make a referral when a value conflict arises? Or perhaps some people will believe that the answer can be found in this ruling. Perhaps some will hold that value conflicts are not a sufficient reason to make a referral. If so, that would have ramifications that extend far beyond this discussion of same-sex behavior. Value conflicts can cut across the board.

An important question that was apparently being raised by Michican lawmakers has to do with protecting conventionally religious students in such programs. It will be interesting to see where the ruling yesterday takes that discussion.

Remediating Christian Beliefs?

The Alliance Defense Fund (ADF) is bringing a lawsuit against representatives of Augusta State University on behalf of Jennifer Keeton, a student in the Counselor Education program. The complaint alleges that Keeton, who intends to become a school counselor, is being asked to go through a remediation plan to “alter her central religious beliefs on human nature and conduct.” What are some of these beliefs?

From page 6 of the complaint:

…sexual behavior is the result of accountable personal choice rather than an inevitability deriving from deterministic forces.  She also has affirmed binary male-female gender, with one or the other being fixed in each person at their creation, and not a social construct or individual choice subject to alteration by the person so created.  Further, she has expressed her view that homosexuality is a “lifestyle,” not a “state of being.”

I am sure that this part of one paragraph does not capture all of Keeton’s beliefs or the layers of complexity reflected in a Christian worldview, but it will be interesting to watch where this goes. This is a different complaint than that by Julea Ward against Eastern Michigan University, in which Ward says she would not want to counsel a homosexual client about that person’s same-sex relationship in a way that affirmed same-sex behavior as morally good. It didn’t get to that point with Keeton, apparently. The alleged remediation here comes from class papers, discussions, and conversations outside of class.

I have been in academics long enough to know that there are always two sides to a story, so it will be important to see how the university officials respond and what their perspective is on the complaint. But it would be concerning if a program was unwilling to respect the conventional religious beliefs and values of students.

There is a unique opportunity here to help all students expand their multicultural competence by identifying differences and finding ways to engage one another and provide appropriate services (or make appropriate referrals) in a way that demonstrates respect for multiple expressions of diversity, including sexual orientation and religion. Faculty and supervisors, too, have an opportunity to model this respect for multiple expressions of diversity to their students and supervisees, and they have an opportunity and an obligation to train their students in ways that recognize and respect our diverse society and the real value differences that exist within the broader culture.

CAPS Panel on Ethical Conflicts in Marital Therapy

Yesterday at the CAPS national conference I participated in a panel chaired by my colleague at Regent, Dr. Jennifer Ripley, on Ethics in Couples Interventions. The other panelists were Ev Worthington (Virginia Commonwealth University), Toddy Holeman (Asbury Seminary), and Bill Berman (Christian Family Institute). We had several interesting discussions on a range of topics in marriage therapy. The topics included use of forgiveness protocols, dealing with violence in relationships, confidentiality when working with couples, managed care and billing, and working with same-sex couples.

Ev Worthington discussed his work on forgiveness, and all of the panelists shared how they might introduce the concept of forgiveness, challenges when people come at forgiveness with different assumptions, distinguishing forgiveness from other concepts, such as reconciliation or exoneration, and so on. We also discussed a number of clinical issues, such as timing, the misuse of Scripture, etc.

On dealing with violence in relationships, we discussed again the potential misuse of Scripture to rationalize violence (as justified by some abusers to establish authority or maintain order), issues with the use of separation, what it means for the offender to repent, and so on.

The discussion about confidentiality recognized different models for handling it with couples: (1) not keeping secrets, (2) keeping secrets said in an individual session/phone, and (3) using clinical judgment about whether specific information is kept secret (but not promising to hold secrets). Emphasis was placed on working with the disclosing spouse to share information that the other spouse should know (that they themselves would want to know if their roles were reversed), as well as discerning when disclosing a secret is for the good of the marriage or to get a weight off of the disclosing spouse’s shoulders.

The managed care discussion centered on how to treat individual psychopathology in a marital context. One panelist discussed providing services individually with the other spouse present, while others discussed treating individual psychopathology systemically by improving the marital relationship. Still others discussed having couples pay out of pocket if there is no identifiable disorder that can be diagnosed.

In the discussion about Christian mental health professionals working with same-sex couples, the panelists reflected on the challenges some Christians have faced in whether or not to provide services, issues related to professional competence, and value conflicts. A few current cases were mentioned, including the Ward case at Eastern Michigan University. There was some disagreement among panelists on how Christians can (or should) respond to these issues, with one voice emphasizing more of the issue of religious rights and competence, while another voice emphasized value conflicts being normal and occasionally rising to the level of a referral. The panelists discussed different options for Christians in practice, as well as relevant training concerns and what is in the best interest of the client seeking services.

On the Battle for Freedom

I was reminded today of the opening to Christian hip-hop artist Tedashii’s song, Make War. In the opening to this song you hear John Piper say: “I hear so many Christians murmuring about their imperfections, and their failures, and their addictions, and their shortcomings. And I see so little war! Murmur, murmur, murmur. Why am I this way? Make war!”

The student chapter of the American Association of Christian Counselors hosted a talk today an explicit integration protocol. The title of the presentation was “Faith-Based Interventions in Psychotherapy.” The first half of the presentation was by Dr. George Hurst, lead author of a peer-reviewed journal article which was an empirical study of the use of Steps to Freedom model prayers as a protocol for people suffering from depression, anxiety, and other mental health concerns. (The study was published in 2008 in Southern Medical Journal, vol. 101, no 4.) He walked through the details of the study itself in which his team used a 12-item questionnaire to measure outcomes from the use of Steps to Freedom by Neil Anderson. They reported on data pre- and post- intervention (6-7 hours of ministry) and 3-4 months later. He shared that some of the items on the quessionnaire had been correlated with some items from the SCL-90, a reputable and reliable measure of symptom distress. They reported significant changes over that time for the group (N = 33) receiving Steps to Freedom (and no significant changes in the control group).

The second speaker, Judith King, is a licensed mental health professional and she discussed the Steps to Freedom. According to Knig, the Steps to Freedom are seven lies that need to be renouced. They are counterfeit (replaced by what is real); deception (versus the truth); bitterness (versus forgiveness); rebellion (versus submission); pride (versus humility); bondage (versus freedom); and curses (versus blessings). So you see that all of what is a lie has to be renounced and replaced by what is true. Although she was unable to unpack the specifics in each of these areas, she was suggesting that these essentially make up one’s primary identity in Christ.

I sat in on the presentation because I teach a course on applied/clinical integration, and this kind of approach would be classified as an explicitly integrative model. I don’t know that I’ve thought about it this way because Steps to Freedom has to my understanding been a ministry model provided by lay persons in the church (rather than mental health professionals). King is a licensed mental health professional, however, and she spoke about its adaptation for licensed professionals.

The questions that came up for had to do with informed consent, which King says she provides, as well as how billing is handled, as some (many?) third party payors might not reimburse for an explicit protocol like this. It seems to me that having lay people provide Steps to Freedom in ministry keeps the roles clearer – that ministry is being provided rather than mental health services. So I think that is an area worth exploring further.

I think the other questions I had have to do with how a person distinguishes depression as “lie-based” from depression that is due to levels of neurotransmitters (e.g., dopamine, serotonin) or some other factor(s). Same thing with anxiety disorders and the other examples she provided, such as sexual addiction, characterological concerns, etc. In fact, she was sharing that one of the common myths about Steps to Freedom is that everything is demon-based. The other common myths were that meds are never needed and psychotherapy is never needed. She was saying that meds are beneficial, as is psychotherapy. But, again, this raises the question of how is that assessed? How does one make the distinction?

I also wondered if it lends itself to people who are open to the language used here. Words like “bondage” and “curse” and “lie” were not part of my Christian vocabulary growing up, so to hear about a model that regularly uses such language sounds quite foreign. I wonder if people who are drawn to it comes out of traditions that use similar vocabulary or ways of conceptualizing difficulties.

There was definitely an emphasis on spiritual battle and on identity in Christ. I think those in attendance have been given a lot to think about. For me, there was something about it that I couldn’t quite put my finger on. It raised more questions than answers, but perhaps that is because of my own background and approach to conceptualizing concerns. I genuinely appreciated that they studied the approach empirically and took the time to get it published in a peer-reviewed journal. It sounded to me like they intend to do more of that, and that’s an important step for Christians interested in using explicit protocols in clinical practice.