John R. Stafford
Brandman University
Abstract
Treating clients with sexual issues poses considerable ethical problems, especially when the client wants to attempt to change their sexual attraction. For decades, society has placed a stigma on homosexuality, even going as far as crossing ethical boundaries by using techniques like conversion therapy, which forces the client to set aside their own sexual identity. Additionally, the involvement of family members and outside influences further complicate the matter.
Keywords: Ethics, Conversion Therapy, Therapeutic dilemmas
Same-Sex Attraction in a Traditional Family: An Ethical and Legal Perspective
Therapy is a positive process for a client to engage in when he or she is experiencing confusion or troubles with their sexual identity, or when learning to cope with societal pressures of what a proper sexual identity is. Unfortunately, there is a long history in modern society to denounce sexual identities that do not conform with the societal norm as viewed in the nuclear family model. For the therapist, there are multiple issues related to ethics and legal aspects of treating the client. These issues range from personal values, religious beliefs, and biases that the therapist may bring with them into the therapeutic relationship. Although there is no mention to informed consent or initial client paperwork being in place, this paper will make the assumption that the client has been advised of all aspects of the therapy process and has signed an informed consent form.
Assessment
The assessment process is required to determine the client’s overall need and goals for treatment. However, the therapist may also be in the position of deciding whether or not the client’s presenting problems could pose any ethical or legal conundrums that need addressing. Some client’s needs are straightforward, but others are more complex and require the therapist to evaluate the situation very carefully to ensure he or she is maintaining both client care and ethical and legal statutes. The first step in this process is the assessment of the presenting problem and the nuances involved. To accomplish this, the therapist should develop a thorough set of questions. In the case of Scott, the following questions would be appropriate.
Is Scott willing to sign a release of information [roi] for his pastor?
At the time of Scott’s referral, the pastor of his church requested an update after the third session. The request poses an ethical problem because therapy sessions are confidential. Even though clergy holds confidentiality with parishioners, the therapist should obtain written consent to share any details with the pastor. Asking Scott if he wants to share any information discussed in his therapy sessions is extremely important because the information Scott is discussing raises several concerns that he may not want to reveal to others.
How did Adam initially approach him to initiate sexual relations?
We want to know how long the sexual relationship has lasted, and possibly attempt to establish a pattern of predatory behavior of the MFT in question. If Adam is comfortable in his environment, he may also be coercing other members of the group into sexual relations as well. We already know the ethical standing of crossing the boundaries with Scott, but we need to be cognizant of legal aspects of his actions. It would be fair to consider that this is not the first case where Adam has pressured a client into sexual relations. The discussion may also lead to discovering if Scott has any feelings for Adam, and to discuss options for dealing with the situation.
Due to the issue with Adam’s sexual behavior and Scott coming in for individual therapy, it would be advisable for Scott to discontinue the group meetings. As a therapist, I would not be able to work conjointly with Adam because of his indiscretions, and I believe that continuing in the group would be detrimental to Scott’s overall well-being. I think that Adam’s influence over Scott would remain and Scott would not be able to take the appropriate steps to report the situation or that Adam could convince Scott to discontinue individual therapy. 1.5.2, 1.14
What does he do to control the urges with his students?
Scott’s attraction to his students is a serious concern. Scott’s behavior indicates there is something more to the issue. By asking how he controls his urges, we are approaching the topic in a non-threatening or judgemental manner in the hope of allowing Scott to open up more. If Scott has been able to control his urges, we have an opportunity to work with Scott to enhance his coping skills. However, if Scott discloses that he has acted on his calls, we need to determine our ethical and legal responsibilities. 1.5.5, terasoff?, mandated reporter, and civil code
Understanding Scott’s Moral Values and Beliefs?
I believe this question is crucial because it establishes a moral foundation of how Scott views himself as a person. Understanding how Scott feels about homosexuality helps the therapist understand any personal conflicts Scott may have regarding his sexuality and formulate a therapeutic process to help Scott discover himself in a safe environment. Additionally, it would allow Scott to consider what his life would be like if he just accepted his sexuality, and how he would continue a relationship with his wife and children.
Scott referenced helping “cure” his sexual desires and “make him straight again.” The issue of sexuality needs to be discussed more to help Scott understand that a therapist cannot cure people, they can only help people discover their path and assist the client in finding his or her way through issues. He also needs to understand the limitations of changing certain aspects of self. Scott has several presenting problems that need attention. It is also the time to discuss the ethical and legal concerns about conversion therapy, and the reasons why a therapist would be unable to participate in such practice.
Has he considered or made attempts to commit suicide in the past?
The suicidal thought is probably the most critical issue to address in the very first session. Discussion on this issue must be direct and to the point. We need to determine if Scott is ready to carry out such a threat or not. Is Scott prepared to work through his issues and possibly sign a no-suicide contract or admit himself on a 72-hour hold for evaluation? It is also the opportunity to reiterate the therapist’s responsibilities. 1.15,
Evaluation
The evaluation process starts with assessing the ethical and legal aspects of Scott’s situation. The above questions should aid the therapist in determining the proper course of action with the client and with outside sources that may need be involved. Additionally, it will help the therapist advise the client as to what aspects of the issue cannot be performed or accomplished in a therapeutic setting. In Scott’s case, there may be areas where ethical standards may appear to conflict; these areas need particular attention from the therapist.
Confidentiality
The first issue is confidentiality. Scott’s pastor requested a status update after the third session. However, even though clergy does share confidentiality parishioners, The California Marriage and Family Therapists [CAMFT] ethics code 2.1 clearly outlines the responsibility of maintaining client confidentiality. To discuss any details with Scott’s pastor, he would need to sign a release of information [ROI] form as indicated in CAMFT ethics code 2.2 that allows the therapist to disclose client information. Additionally, California Business and Professions Code §41982(m) defines failure to maintain confidentiality, except when required or permitted by law, to be unprofessional conduct (Benitez, 2004).
Issues surrounding Adam
The problems Scott is having with Adam raise multiple ethics violations on behalf of the other MFT. First, Adam has initiated a dual relationship with Scott as defined in CAMFT ethics code 1.2, then extends to an unethical dual relationship as outlined in CAMFT ethics code1.2.1. Because the unethical dual relationship is one of a sexual nature, CAMFT ethics code 1.2.2 will also apply to this part of the situation. Arguably, Scott’s behaviors and sexual advances revolve around his own interests, which applies CAMFT ethics code 1.6. Additionally, one could suggest that Scott’s actions are exploitive, for this we would assert CAMFT ethics code 3.8, and because of the seriousness of the issues, we would also look at CAMFT ethics code 7.1 which holds therapists accountable to the standards of the profession (CAMFT, n.d.). From a legal standpoint, Adam’s actions violate California Business and Professional Code and Civil Code section §43.93, which discusses the sexual exploitation of clients by therapists (Zur, 2017).
It is not uncommon for therapists to perform conjoint therapy, however, in this particular case, it would be inadvisable for Scott to continue meeting with his support group. Although CAMFT ethics codes 1.4 and 1.41 discuss patient autonomy and patient choices, it would be wise to consider the risk and benefits of remaining in the group sessions as outlined in CAMFT ethics code 1.5.2. Additionally, there would be apparent conflicts as discussed in CAMFT ethics code 1.14 because of the issues addressed about the MFT managing the group (CAMFT, n.d.).
Sexual Urges
Scott’s sexual urges are concerning. California Penal Code, Sections §11164-§11166 requires mandated reporters to make a report whenever reasonable suspicion of abuse exists (Zur, 2017). The responsibilities of the therapist and the legal code associated with mandated reporting directly correlate with CAMFT ethics code 1.5.5, which addresses the limits of confidentiality (CAMFT, n.d.). Although the information Scott has relayed appears to apply reasonable suspicion, there is also the fact that he is conflicted and in great distress with his personal life and sexual identity. During the initial conversation, Scott did not indicate that he actually acted on his urges and his crying and withdrawal from the topic could readily associate with extreme levels of shame and conflict. Because of these concerns, I would first consult with a colleague as indicated in CAMFT ethics code 1.11 to discuss Scott’s situation. It is important to mention that this particular case has several aspects of concern that would require thorough documentation per CAMFT ethics code 1.15 (CAMFT, n.d.).
Moral Beliefs and Values
It is imperative to correct the assertion that Scott has that a therapist can “cure him” and to discuss Scott’s moral values and beliefs to determine how to work with Scott on his presenting issues. The first thing we need to relay to the client is that he is in control of his treatment as discussed in CAMFT ethics code1.4 and that our role is to work with him to make choices that will help him achieve realistic treatment goals as outlined in CAMFT ethics code 1.4.1. Scott referenced conversion therapy as a method of treatment for becoming normal. As a therapist, CAMFT ethics code 1.13 requires us to discuss various treatment alternatives with the client and CAMFT ethics code 1.5.2 requires that we examine the risks and benefits associated with therapeutic methods (CAMFT, n.d.).
Additionally, the therapist needs to be aware of how his or her values are affecting the discussion as outlined in CAMFT ethics code 3.7. Conversion therapy is a heated topic because it has received numerous rebuffs on efficacy and negligent process (Human Rights Campaign, n.d). Additionally, California and several other states have outlawed conversion therapy for minors, and there is current legislation AB 2943 that seeks to prohibit conversion therapy for adults in California based on the fraudulent nature of the process (Riley, 2018).
Suicidal Ideation, Depression, and Anxiety
Suicidal Ideation is a serious concern, as is depression and anxiety. When a client mentions red flags like “people would be better off without me” or “I have a gun.” The therapist must act in the best interests of the client and thoroughly document any treatment options as outlined in CAMFT ethics code 1.15. The therapist should immediately discuss treatment alternatives under CAMFT ethics code 1.13, which could include a non-suicide agreement with the therapist, self-admitting into a hospital, or other options available to the client. It may also be a good reason to consult with colleagues about Scott under CAMFT ethics code 1.1 (CAMFT, n.d.).
The above references ethics codes also apply excellently to working with clients experiencing depression and/or anxiety. The therapist should quickly recognize the correlation between the client’s depressive state, anxiety, and other presenting problems when assessing the client’s suicidal probability. Direct questioning about the client’s previous suicidal tendencies will help determine if there is a pattern.
Management
After the initial assessment and evaluation of the client’s situation, the therapist needs to formulate a proposed treatment roadmap to discuss with the client. The roadmap should start with the most critical presenting issue[s] with the goal of addressing secondary matters along the treatment path. In some cases, secondary problems are relieved by treating the primary concerns, but these may need the resolution to aid the central issues.
Confidentiality
When Scott’s pastor requests a status update after the third session, it would be appropriate to recognize privacy afforded to clergy, but also remind him that therapist confidentiality prohibits any discussion of Scott’s therapy sessions unless he completes a release of information form. In the first meeting with Scott, privacy is essential to discuss during the informed consent process. After the informed consent process, the therapist would ask Scott if he wanted to complete a release of information form for his pastor. The informed consent discussion also includes the limits of confidentiality, which needs occasional reiteration.
Issues surrounding Adam
The situation with the MFT, Adam requires multiple approaches. Working with Scott on this issue is best suited for a psychoeducational process that includes immediate disbursement of the Professional Therapy Never Includes Sex pamphlet produced by the California Board of Behavioral Sciences. I believe that going over this pamphlet with Scott during the session is a positive step in helping Scott determine what to do next. It also opens up a dialog that allows the therapist to describe his or her professional and legal responsibilities, and the risks and benefits of remaining in the group therapy meetings while the problem[s] still exist. A crucial concern is that Scott will not successfully work on his presenting issues if he is experiencing trauma related to the sexual advances of Adam. Encouraging Scott to discuss his feelings and emotions about the situation will begin a healing process.
Outside of the therapeutic relationship, there is more work to do. This situation involves a colleague’s behaviors and failures to comply with ethical and legal responsibilities. The therapist should first consult with CAMFT legal advisors, and possibly other colleagues to determine what steps to take. Discussing with the offending therapist is usually a good first step for most issues, including personal relationships. However, there is concern that Scott is not the first client to be approached by Adam. I believe this issue is so heinous that formal complaints are required.
Sexual Urges
Scott has a tremendous amount of confusion and shame because of his sexual tendencies resulting in extreme anxiety and depression. However, there are severe considerations for this issue that require a proper diagnosis. I believe the best course of action to take with Scott directly is a Cognitive Behavioral Therapy process and Socratic questioning to both diagnose and help treat Scott’s maladaptive thoughts.
Outside of therapy, I would consult with colleagues and possibly CAMFT legal to determine if my assessment is correct or not. Because the issue is severe enough to find reasonable suspicion to report I feel it imperative to get second and third opinions. Because reporting regulations are time restrictive, consultation must take place immediately following the therapy session with Scott. Should discussion reveal that reporting is the appropriate action, the therapist must file a report with Child Protective Services immediately.
Moral Beliefs and Values
It is crucial to understand Scott’s moral beliefs and values related to same-sex attraction before moving forward with therapeutic action. The first step is to educate Scott using psychoeducational tools designed to enlighten people on the medical and psychological aspects of same-sex attraction. Part of this education is learning that same-sex attraction is not a curable illness, and one has to find peace with his or her sexuality. Because Scott has shown interest in conversion therapy, additional psychoeducation is needed to educate Scott on the dangers, failures, and fraudulent claims of conversion therapy. Additionally, it may help if Scott and his wife engaged in couples therapy to address his sexual attractions, and how to move forward. I would also advise Scott that I would not conduct conversion therapy, nor would I have any credible referrals for the process.
Outside of working with Scott and potentially his wife and family, I would consult with colleagues to ensure I was on track for the treatments I would be capable of recommending and to gain additional confidence on the ethical boundaries of conversion therapy. I may consider working with another therapist who would be able to work with Scott on a family therapy level so Scott would have a degree of confidentiality with me that would allow him to open up and disclose more information in other areas.
Suicidal Ideation, Depression, and Anxiety
The first step in working with Scott is to determine if he is a risk to himself. Applying the standard process of assessment is the proper course of action. Because Scott raised some red flags, it does not mean he is actually at risk. However, preventative measures like a no-suicide contract, providing additional education and resources to the client and discussing both his and the therapist’s responsibilities are vital components of the process.
Although I am not a proponent of anti-depressants and anti-anxiety medications for all situations, I believe that working with Scott’s medical doctor or a psychiatrist is warranted. Because Scott presents with significant issues, a co-treatment using therapy and pharmacology may provide some relief for Scott’s symptoms of depression and anxiety.
References
Benitez, Bonnie R. “Confidentiality and Its Exceptions (Including the US Patriot Act) .” The Therapist, 2004, www.camft.org/images/PDFs/AttorneyArticles/Bonnie/Confidentiality_and_its_Exceptions.pdf.
California Association of Marriage and Family Therapists. “Code of Ethics.” CAMFT, California Association of Marriage and Family Therapists, www.camft.org/images/PDFs/CodeOfEthics.pdf.
Human Rights Campaign. Policy and Position Statements on Conversion Therapy. www.hrc.org/resources/policy-and-position-statements-on-conversion-therapy.
Riley, John. “California Considering Bill to Declare Conversion Therapy a ‘Fraudulent Practice.’” Metro Weekly, 6 Apr. 2018, www.metroweekly.com/2018/04/california-considering-bill-to-declare-conversion-therapy-a-fraudulent-practice/.
Zur, Ofer. “On Law-Imposed Dual Relationships With Emphasis on California Laws and Regulations Relating to the Practice of Psychology.” Some of the Most Controversial Issues in Psychology, 2017, www.zurinstitute.com/duallaw.html.
Benitez, Bonnie R. “Confidentiality and Its Exceptions (Including the US Patriot Act) .” The Therapist, 2004, www.camft.org/images/PDFs/AttorneyArticles/Bonnie/Confidentiality_and_its_Exceptions.pdf.
California Association of Marriage and Family Therapists. “Code of Ethics.” CAMFT, California Association of Marriage and Family Therapists, www.camft.org/images/PDFs/CodeOfEthics.pdf.
Human Rights Campaign. Policy and Position Statements on Conversion Therapy. www.hrc.org/resources/policy-and-position-statements-on-conversion-therapy.
Riley, John. “California Considering Bill to Declare Conversion Therapy a ‘Fraudulent Practice.’” Metro Weekly, 6 Apr. 2018, www.metroweekly.com/2018/04/california-considering-bill-to-declare-conversion-therapy-a-fraudulent-practice/.
Zur, Ofer. “On Law-Imposed Dual Relationships With Emphasis on California Laws and Regulations Relating to the Practice of Psychology.” Some of the Most Controversial Issues in Psychology, 2017, www.zurinstitute.com/duallaw.html.
