MFT and the Culture Wars

Over at his excellent blog MFT Progress Notes, my friend and colleague Dr. Ben Caldwell has been regularly blogging about the issue of therapists who have religious or moral objections to homosexuality.  There has been a flurry of legal cases against various schools and employers in the past couple of years, all of them due to students or therapists being told that refusing to see gay, lesbian, bisexual, or transgender clients was unacceptable.  In the student cases, trainees were told they needed to do some sort of diversity training or self-of-therapist work to help them explore the clinical and ethical implications of their biases.  In the workplace case, the employee was suspended and then fired.

These cases have made it clear that Marriage and Family Therapy (and the other mental health professions as well) can no longer keep playing both sides in the culture wars over sexual orientation and gender identity.

The mental health debate over sexual and gender minorities goes back to the very origins of the field.  Freud, although he believed that humans are inherently bisexual, often attributed homosexuality to traumatic experiences.  Although in some of his correspondence he advocated acceptance of homosexuality, and he rejected the idea of conversion therapy, this attitude did not become the norm for those who followed him.

For the next several decades (until at least 1973, when homosexuality was removed from the DSM, and arguably for a good while thereafter), the idea that homosexuality was a pathology was scarcely questioned.  Arguing that same-sex sexual orientation could be psychologically normal was so dangerous that professionals had to do so anonymously, or risk their careers.  At this point, negative beliefs about sexual minorities was taken as psychological fact; few reputable psychotherapists questioned this piece of received wisdom (with some notable exceptions, such as the redoubtable Dr. Evelyn Hooker.) Belief in the deviance of homosexuality was based on theory and research that was undoubtedly shaped by Judeo-Christian, European/American cultural norms and values masquerading as what’s “normal” and “natural” (see Hanne Blank’s new book “Straight” for a great discussion of this.)  But it was a belief that was shaped in large part by deference to the authority of the field of psychology and its “best practices.”

This distinction is important: Following the beliefs and “best practices” of a field doesn’t mean you’re acting without bias, not by a long shot.  But at least it represents an effort to take a position informed by research, professional consensus, and critical thinking.  As Alix Spegal says in the “81 Words” episode of This American Life:

[Until 1973], psychiatrists had always thought of homosexuality as a pathology, a problem so profound it affected, as one psychiatrist told me, the total personality. Now because psychiatrists believed that homosexuals were pathological, it gave scientific sanction for the rest of the country to see it the same way. Gays were routinely fired from teaching jobs, denied security clearances and US citizenship. For that matter, they were barred from practicing psychiatry, because you don’t let someone who’s pathological practice medicine on other people who are pathological.

Or anyway, that’s what the psychiatrists thought, had always thought. That’s what it said in the bible of their profession, what the psychiatrists called the DSM, or the Diagnostic and Statistics Manual. A book which listed in clear, clinical language every possible permutation of psychosis. Every variant of paranoia, every deviant mental tick that the children of Freud had ever encountered, all nicely bound together under an industrial yellow cover, with an authoritative OED style font.

There it was, diagnosis number 302.0. Three sentences, composed of 81 words, which certified homosexuality as sick.

But as the professional consensus that being a sexual minority is not inherently pathological has grown, it has become less and less defensible to be a clinician who views GLB people as sick or damaged. This has forced clinicians with homo-negative views to either rely on dubious research by discredited psychologists like Paul Cameron, or to openly affirm the religious and moral basis of their biases.

The January 2003 issue of Journal of Marital and Family Therapy hosted a now-infamous debate over attempts to change sexual orientation, an effort that has never proven to produce credible outcomes.  The author adopting a pro-conversion-therapy position, Christopher Rosik, straddled both justifications.  He relied heavily on Cameron’s writings as source material, and attempted to evoke clinical concern for clients whose desire to be straight was motivated by religious beliefs.  Ironically, he failed to acknowledge his own religious affiliations as a motivating factor in pursuing such research, while titling his rebuttal to Robert-Jay Green’s critique of his article “When therapists do not acknowledge their moral values.”

The result is a field in transition and flux, with a strong but shrinking cohort of members who cling to their own negative beliefs about same-sex sexual behavior and orientation, while the rest of the profession moves on.  Professional organizations have had trouble adopting a decisive approach to this field change.  While the APA has taken a leadership role in developing best-practice guidelines for serving sexual minority clients, other organizations, including AAMFT, have slowly evolved positions that are generally affirming but in many cases lag behind the real-life needs of clients and therapists, or whose conclusions are blunted in an effort to appease religious factions in their ranks.

And thus we come to the current dilemma for students, faculty, and those in practice.

I feel there should be responsibility on potential students to look seriously at any field they consider and ask themselves “am I willing to do the things needed in order to take on this career?” If you don’t want to go into burning buildings and risk life and limb, don’t become a firefighter. If you don’t want to carry a gun, don’t become a police officer or soldier. And as a member of the field for 15 years now, my strong feeling is:  if you don’t want to practice affirmatively with sexual and gender minority people (or any other kind of person for that matter – if you have strong prejudices about anyone!), don’t enter mental health. But the field, as a whole, has been very slow to take a clear stance and tell prejudiced members “follow the science or find another professional home.”

State licensing boards have been even more reluctant to step on the toes of powerful religious lobbies and declare religiously-motivated biases to be incompatible with professional mental health practice.  I’m glad to see the AAMFT-CA divison clearly coming out against conscience clause legislation, but notice a few things here:

1. AAMFT-CA is not the boss of anybody in California.  They’re a professional organization that MFTs voluntarily join.  And most California MFTs aren’t even members, because they belong to CAMFT (they of the notoriously-pathetic refusal to support gay marriage, even when AAMFT at the state and national level supported the fight against Proposition 8).  AAMFT-CA tries to advise legislation governing MFT practice, but they don’t run the BBS, who actually oversees ethical complaints against California practitioners and issues licenses.
2. AAMFT-CA’s statement manages to neatly side-step the whole “sexual orientation” issue.  The phrase doesn’t appear anywhere in their statement, nor does “homosexuality,” “gay,” “lesbian,” etc.  (Kind of like how the National Review managed to fire a columnist for writing unbelievably racist stuff in another publication, without ever using the word “race” or “racist” in their letter from the editor.)  One could argue, well, conscience clause legislation doesn’t specifically mention sexual orientation either; it covers any kind of “conflict… with a student’s religious belief or moral conviction.”  So why should their statement get specific if they’re reacting to a very general kind of law?
3. Except that this invoking of “conflict” is what as known as a “dog whistle“ – a coded phrase that allows plausible deniability for the speaker, because on the surface it looks innocuous or general, but to a specific group of people, it clearly references something in particular, in this case sexual and gender minorities.  No one is out there refusing to counsel old people or Latinos because old people or Latinos conflict with their religious beliefs, although Caldwell evoked these groups as co-equal targets in one of his blog posts, writing “students could refuse to treat homosexuals, Latinos, the elderly, or any other group they devalue.”  No one is refusing to treat people who eat pork or shellfish, or who wear clothing made of mixed threads, even though the Bible says those are unclean activities.  I haven’t seen anyone making a religious issue out of not wanting to counsel a child molester or someone who has committed intimate partner violence (it’s legitimate to say that you’re not ready to work alone with offenders if your own self-of-therapist issues would be too triggered to join effectively; the solution there is personal therapy, co-therapy, teaming behind a mirror, etc. – we have generally agreed on this as a profession for decades.) I have yet to hear about a case of someone saying their religious beliefs prevent them counseling woman pregnant out of wedlock, or a divorced person, maybe because both teen pregnancy and divorce rates are both higher in the infamously-religious “red states,” so maybe that moral tension is one that fundamentalist Christians are used to living with. No, when it comes to “conflict” with “religious values,” what we’re always referring to is GLBTQ people (this comes up in push-back against anti-bullying laws as well, which some Christian groups are saying infringes on their kids’ right to free speech, because I guess telling the gay kid in history class that you think he’s a dirty fag going to hell is an appropriate activity for school, or something). *

* Abortion is pretty much the only other item that ever takes this place on the firing range, and as a woman who both identifies as queer and who has had an abortion, I feel pretty comfortable saying that while it is pretty hurtful to have someone dismiss the idea that you deserve care because of a medical procedure you are considering or have undergone, it feels worse to know that your entire life is being used as the material for a turf war between religion and the state, that the fundamental value of your humanity is being pulled back and forth across the political field by a bunch of mostly straight people like the rope in a game of tug of war, because some people feel entitled to object to the fact that you exist.

So, I’m glad that AAMFT-CA and other groups are saying that this kind of legislation is a problem, because it is.  State legislatures dictating the actions of professional training programs, in ways that the training programs believe is actively harmful, violates the principles of good governance and professional practice simultaneously.  But it is pretty meaningless until and unless

1. State licensing boards make it clear that homonegativity, homophobia, transphobia, etc. is not compatible with contemporary understanding of ethical practice and may cause an intern or license holder to be subject to discipline upon receipt of a complaint.
2. Training programs in states which pass these laws (and mark my words, there will be many, thanks to ALEC and other such “model legislation” groups) refuse to abide by them and engage in civil disobedience, or close their doors because they cannot train students in a way that violates professional ethical codes.
3. Professional organizations, including AAMFT, ACA, and others, make it crystal clear that decades of research and best practices leave no room for ongoing negative stereotypes and prejudices against GLBTQ people by members of our professions, any more than they do for stereotypes against a racial or ethnic group, mentally ill people, disabled people, and so on, and show those who refuse to join the 21st century, the door.

I have my own issues with COAMFTE’s accreditation exemption for religious schools, quite frankly, because to re-work a quote from Caldwell’s recent post, I do not know how a program can engage in prejudice and discrimination and simultaneously train students to understand and counteract the mental health impacts of prejudice and discrimination, simply because the school holds a particular moral or religious belief. And in the case of programs located in schools with “conduct codes” that discriminate against or even preclude LGBT people as students and faculty, that’s exactly what’s going on.  This is just more evidence, in my opinion, that we are a field that can’t get it together to say “enough is enough; there is a difference between tolerance for diverse opinions, and refusal to follow the research. If you want to have a career based on your religious beliefs, get a divinity degree, and best of luck to you.”

What’s most frustrating to me as an educator is that I’ve been using these cases to try to raise awareness in my current program about our clear need for a programmatic policy and plan of action in this area, backed by the university, but these legislative efforts to hamstring our ability to set standards for our students means that nothing will get done any time soon.  Instead, I’m seeing evidence of policies trickling down from administrations insisting that faculty warn students against talking about religious topics, and in an effort to create some kind of pseudo-balance, also warn students that talking positively about liberation and civil rights for “various groups” (there’s that dog whistle again!) might be offensive to others.  Because nothing is more offensive to the privileged majority than the marginalized minority standing up for itself.