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.

The Julea Ward Case Settled Out of Court

Julea_Ward-dismissed-from-East-Michigan-UniversityWard 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.

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.

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.

Value Conflicts in Counseling

A graduate student has reportedly been dismissed from a counseling program at Eastern Michigan University for not agreeing to go through a program to “remediate” her conventionally religious beliefs and values regarding same-sex behavior. Onenewsnow is reporting that Julea Ward had a value conflict with a client’s same-sex behavior, and that she did not believe she should affirm it. Her supervisor had her make a referral to another counselor who did not have the same value conflict, and Ward did so. Ward was then required to participate in a program that would address/remediate her Christian belief system. When she refused, she was dismissed from the counseling program. The Alliance Defense Fund (ADF) has filed suit.

Several questions arise from this case. One question is, When are referrals appropriate? One of the more common reasons for making a referral is when a counselor does not feel he or she is competent to provide services. Competence is determined by education, training, and supervised clinical experience, and mental health professionals are required to practice within the scope of their competence. So a referral is considered appropriate when a counselor who has no training in working with older adults, for example, refers an elderly client to someone who has that competence. But competence is not the only reason for referrals.

Are value conflicts a legitimate reason to consider a referral? Let’s back up a moment and ask this: How are value conflicts generally handled in counseling? Counseling ethics textbooks recognize that value conflicts are inevitable in mental health practice. 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.

Generally speaking, ethics textbooks tend to look at whether a value conflict between a counselor and a client is significant enough to have a negative impact on their work together. If so, a referral is thought to be appropriate. According to the complaint filed by the ADF, the professor who chaired the hearing on Ward actually taught a course in which a textbook was assigned that indicates the appropriateness of making a referral when value conflicts arise – specifically citing the instance of value conflicts regarding homosexual behavior.

It will be interesting to watch this case, as it has significant implications for how counselors and other mental health professionals are to work with clients when value conflicts arise. As it stands, it certainly runs contrary to how ethics has been discussed in textbooks and practiced in the field.

Note: I do not ususally post at this site material that is also posted at the Institute for the Study of Sexual Identity, but this story is one of those exceptions.