Dear Young Therapist: Sometimes Race and Sex Matter

In a recent post on Psychology Today, psychologist/blogger Todd Kashdan wrote a post entitled "Sometimes Race and Sex Don't Matter: An Attempt to Stop the Madness with Political Correctness Run Amok." He starts with a story about his six year old twin girls:

Its beautiful to observe how at 6-years of age, my twin girls do not describe friends, teachers, neighbors, or strangers by race. This is rather typical: 

"Dad, you know who I'm talking about, the guy with the nose that kind of bends around, with the puffy cheeks. Why are you looking at me like that, you know him, I've seen you talk to him." 

"Why does that guy with the round head and bunched up legs walk his dog in the rain?" 

"My best friend at school right now is Tamina. She wears glasses, her hair is long and crunchy, and she talks really fast." 

These interactions require my full mental capacity because unfortunately, I have no idea who the hell they are talking about. In my career as a psychologist, race becomes a paramount descriptor. And while there are many reasons to do this, I want to suggest that this has gotten out of control, causing more harm than good

The blogger appears to be promulgating a color-blind perspective that involves seeing a person as a whole rather than a person with a complexion of a particular skin tone. In the above quote, the blogger/psychologist  describes his children as not seeing people by their race because they make observations about stereotypical phenotype differences in people they encounter (texture of hair, shape of nose, etc.) rather than making a specific mention of their complexion.

Hidden within his proud fatherly talk about his children, Kashdan obscures a significant body of literature within the field of psychology about the color-blind approach to race and human differences. Here are a few highlights of the thousands of peer reviewed articles written about problems of being color-blind:

Never do this young therapist. Never.

Yesterday I wrote about an adoption agency that posted photos and protected health information about children who were in a disrupted adoption (their adoptive parents were going to sign them away to another parent because things didn't work out). Through the efforts of many individuals, Wasatch International Adoptions was pressured to take the information down.

I found the blog of the Wasatch International Adoptions.

We use the internet to post a story about the child, using a false name, but using real photos. Our Second Chance Facebook site has over 10,000 members, and when we post a child, there are 10’s of 1000’s of cross posts. Our administrative page shows that we often have 100,000 or more people view the post! It has been as high as 300,000 views of a child.

I'm just floored that a licensed social worker would appear to have such little understanding and knowledge of the ethical codes and laws which govern their practice. Maybe I'm being generous in my assessment. Perhaps these licensed social workers are wantonly ignoring the expectations of privacy that the ethical codes of Social Workers demand.

Licensed therapists don't show real photos and real stories about their clients. There is no excuse for this. There is no reason for this to happen. Ever. There is absolutely no reason to display a client's picture and personal story to 10,000 facebook members, who cross post that information 10s of 1000s of times, making a child and their personal experiences displayed to 300,000 strangers.

How would you feel if your therapist told everyone in the city of Anchorage Alaska (population 298,610) or Pittsburgh Pennsylvania (population 305,704) about what you talked about in therapy last week? What would it feel like if the population of Valladolid Spain (312,434) knew that your mother sexually abused you? Would you be comfortable if I told the everyone in Suncheon South Korea (population 304,528) that you had problems with inappropriate masturbation?

This is just the kind of information that this adoption agency displayed on the internet--intentionally displayed on the internet--and acted as if it was ethical, legal, and the right thing. The agency felt that because they had a release of information from the parents of the children (parents who want to abandon their adoptive children), they had discharged their ethical duty to protect their patients privacy, dignity, and confidentiality.

Never do this young therapist. Never. 

Children For Sale: Get 'Em While They're Hot

Through Yahoo and Facebook groups, parents and others advertise their unwanted children and then pass them to strangers with little or no government scrutiny, sometimes illegally, a Reuters investigation has found. It is a largely lawless marketplace. Often, the children are treated as chattel, and the needs of parents are put ahead of the welfare of the orphans they brought to America. The practice is called "private re-homing," a term typically used by owners seeking new homes for their pets. [read more here]

Imagine that. Adopting a child and for whatever reason--lack of skill, planning, or resources--choosing to give that child up. What a horrible decision to have to make. I'd like to think parents agonize, soul search, and try their hardest to make it work. I'd like to think that parents marshall their resources, get help, and keep to their commitment to raise, love, and nurture their adopted child.

Based on the Reuters article, it appears this is not always what happens.

Yesterday I was made aware of one particular organization that helps "rehome" adopted children. This organization, Wasatch International Adoptions, has a program called Second Chance Adoptions. They have a Facebook page where they have pictures and information about children who are being shopped for new parents.

I was aghast at their Facebook page. The descriptions of the children, attached to their pictures, includes what appears to be protected health information about psychiatric treatment, developmental disabilities, experiences of sexual and physical abuse, and physical conditions. (n.b. since the time this blog post was initially posted, the adoption agency removed their Facebook page and later put it back up with edited information that disclosed significantly less personal information).

In exchange for $950 a year the organization offers, among other things, to "post a picture and a profile of your child on Rainbow Kids, other disruption blogs and websites, and also on our own website."

"In order for WIA to post your child’s picture you must provide a detailed profile with information about your child and also sign a release of confidentiality allowing WIA to share this information with any family who contacts us about your child." 

I understand that a prospective adoptive family would need to have access to all of a child's protected health information. I don't dispute that. I do dispute whether information like this should be made available to anyone who looks at a Facebook page.

What right do I have to know that there is a seven year old girl who has experienced sexual trauma and beats up her baby dolls? Should I know about the six year old boy who sometimes acts out in sexualized ways? How about a 15 year old girl? Should I be reading about her residential treatment, developmental disabilities, and her diagnosis of reactive attachment disorder?

Is this disclosure of information ethical? I thought it might be helpful to sort through this ethical dilemma in a public forum. 

I'm not a social worker. I'm a licensed psychologist and health service provider in the Commonwealth of Massachusetts. I'm obligated to think this through by the ethical codes, guidelines, and laws that I am responsible for following. Laws and ethics for social workers in general, and social workers in Utah specifically, might be different.

Dear Young Therapist: Allow for the Unexpected

Dear Young Therapist:

No graduate program can prepare you for everything that is going to happen in your career. As you embark on your journey as a therapist you'll want to be sure you make allowances for the unexpected to happen. It will--in ways that you'll never expect. 

My training did not prepare me for what happened on April 15, 2013. Bombs went off just two and a half miles away from my office in Cambridge. While I could not hear the explosions, I could hear sirens and helicopters as the day progressed. My heart sank hearing the news between my appointments: my city--my home--was under some sort of assault. 

I reached out to friends and family. I was safe. They were safe. 

My mind quickly turned to my patients--some forty people scattered across the Boston region who call me their psychologist.

Were they safe? 

Some volunteer every year at the finish line of the Boston Marathon. Others live or work within the area of the blasts. Some, experienced survivors of all sorts of trauma, were likely to be stimulated and flooded with fear. I worried about them reliving their own personal hell from the past.

I wasn't trained to reach out to patients when I think they might be in distress. I wasn't trained to know what to do when bombs exploded just a couple of miles away from my office. What teacher could anticipate such a thing?

You'll learn in your practice that sometimes the right answer to the situation isn't the thing that your supervisors taught you. Ethics are important. It's important that you spend years studying your ethical code so you can develop a deep understanding of the complexities of being ethical in your practice. You'll need lots of colleagues to talk things over with. You also need to learn how to be responsive in ways that codes and protocols cannot teach you.

You've got to make allowances for the unexpected and know how to make decisions when the world around you has fallen apart. Days will come when you'll have no supervision, guideline, or protocol to follow. You'll be on your own. You'll know you've finally earned your license when you know how to make a path of your own that's strong, clear, ethical, and wise. 

Confidentiality and the Unthinkable: Murder

Perhaps you've been in therapy at some point in your life. Your therapist--whether they be a psychologist, social worker, psychiatrist, mental health counselor, or marriage and family counselor--should have notified you about the nature and limits of your confidentiality.

I've been thinking about this a lot recently. The news report instantly got my attention. Anderson Cooper reported that a notebook that was mailed to a psychiatrist at the University of Colorado was handed over to the police. That notebook, made by the alleged killer James Holmes, detailed his plans for the murders in Aurora Colorado. More news has since come forward. The psychiatrist, Dr. Lynne Fenton, treated James Holmes for schizophrenia. He was at one point, her patient.

We don't know the nature of that treatment. We don't know how the journal was released to the authorities. Unnamed sources. That's what the news reports say. Unnamed sources leaked information that James Holmes was treated for schizophrenia and sent his psychiatrist a notebook that contained stick figure drawings of his plans for the massacre that left twelve dead and 58 wounded.

What is the nature and limits of confidentiality in psychotherapy? Here is what I tell each and every patient that walks into my office. I'm not a lawyer. Keep that in mind. This is my best understanding of the laws that govern my practice as a licensed psychologist in the Commonwealth of Massachusetts. The laws don't differ much from state to state.

What you say here, stays here. It is important to me that you know that this. As a licensed psychologist the things we talk about remain confidential except under very specific circumstances. I want to spend some time talking about this and I'd like you to spend some time asking me questions. Confidentiality means that I cannot and will not talk to other people about you and our work except under very specific circumstances that I will explain. This means your husband, wife, partner, friend, parents, or police can't call me up and ask about you. If they do, I say I cannot confirm or deny knowing you. As soon as I get a call like this, I will contact you and tell you. If you are under 18, your parents can ask about you, and have a right to know what we are talking about. If you are over 16 and under 18, you can tell me not to talk to your parents and I would have to respect your wishes. However, your parents still have the right to inspect your medical records.

That is the basics of confidentiality. I don't ever reveal information, except in certain special circumstances, about my patients. It is the beginning of a special relationship where a patient can talk about whatever they wish. Their fantasies, their fears, their hopes, their traumas, their crimes, and their crimes against others. I listen. I don't talk to other people about it. Without this basic trust no patient would ever feel safe exposing the contents of their minds, hearts, and souls.

Psychologists have a duty to protect people from abuse. This is what I say:

Here are the limits of confidentiality. It's important that you know them. I do not want you to find yourself in a situation where you talk about something and then have unexpected consequences because I have to take action. We can talk about this as much and as often as you'd like. You can ask me hypothetical questions should you want to know what I'd do in particular kinds of circumstances. If you talk about and identify a child under the age of 18 that is being abused, anyone over the age of 60 that is being abused, and anyone, of any age, that has a disability that  is being abused, I will have to break your confidentiality. It is important that you understand that if you identify the person being abused, or I can reasonably ascertain their identify from what I know about you, I will have to break your confidentiality and protect that person.

Psychologists have a duty to protect patients from committing suicide. This is part of what I say:

The second circumstance when I would have to break your confidentiality is if I have reason to believe you will kill yourself. This doesn't mean that I will immediately hospitalize you if you talk about having a dark night of the soul, or wonder what it would be like to not be alive. Many people talk about suicide and contemplate their own deaths. Many people are also chronically suicidal and do not require hospitalization. We can talk a lot about this, what this means and what it doesn't, and we'll work together to make sure you can talk openly about any feelings you have about suicide while also making sure you are safe.

Psychologists have a duty to warn and protect intended victims of homicide. This is what I say:

The last circumstance when I would have to break your confidentiality is if you are planning to kill someone. Often times people say "Oh my boss, I could just kill him." I understand that is a figure of speech. You wouldn't be hospitalized for that. However, should you have planned and and have intention to commit murder and you tell me about it, and you identify your intended victim or victims, I will have to take every action at my disposal to protect you from committing this crime and protect your intended victim. This likely means I will attempt to have you secured in a psychiatric hospital. If I cannot do this, I am required to warn your intended victims and am required to warn the police.

Think of what would have happened should that journal Holmes made was been found before the crime was committed. Lives could be saved. Traumas could be prevented. Dark Night Rising would be about Batman, not about murder. Our  movie theaters could feel safe.

None of this, of course, will ever happen. Nothing will undo the murder of twelve people and injuries of 58 others. Nothing can undo what has already happened.

Had Dr. Fenton had knowledge of the intended crime before it happened, she would have had an affirmative duty to protect and warn. We do not know what Dr. Fenton knew, and when she knew it. We only know that Holmes was in treatment at some point in time, and that a journal detailed the crimes arrived at the University of Colorado at some point in time.

What does a psychologist do when a patient has already murdered someone? What if the unthinkable happens and a patient of mine walks into my office, sits down on the couch, and confesses to a murder?

I cover this in my first session with patients.

If you murder someone, and then tell me about it, I believe that I cannot break your confidentiality. You need to understand that. I would have a lot of questions for you. We would talk about what you did, and how you want to move forward in making the right choices. This would be very difficult for me, however, your confidentiality would remain and it is my understanding that I would not be able to turn you in to the authorities. Any other crime you might be involved in, as long as it doesn't involve planning murder or the abuse of a child, person over 60, or a person with a disability, is not something that I can tell other people about. 

How could someone get my records? That's covered in the first appointment, too.

Your records are confidential, as is the contents of anything we talk about inside this room. If you give me permission to release information about you to someone, and we agree it is in your best interest, I will do that. I will release information without your permission if you are a risk to self, risk to others, disclose abuse that I am mandated to report, or if your decision making is impaired based on the symptoms of a mental illness. Short of that, I would need a court order from a judge to release information. Am not required to hand over medical records based on a warrant or a subpoena. 

I also share with patients how I break confidentiality in these circumstances. There is a specific and progressive order of steps that I take that escalate until I either am assured the individual is safe or I have progressively exhausted all means I have available to protect an individual.

So why am I writing about this? I believe I have no business, as a  member of the public, knowing that James Holmes was in treatment for schizophrenia. I believe I have no business knowing that he wrote a journal in which he detailed his plans for the murders.

As difficult and as unpopular as this might be, if I was his psychologist, I believe I would have the responsibility to hold onto this confidentiality and not release the journal or any information about his treatment until such time as I was served with a court order. 

Somewhere, somehow, Holmes lost his confidentiality. I think it was wrong that this happened. He had already committed the alleged crimes. There was no duty to warn or protect, therefore no ethical or legal reason to disclose the journal or information about his treatment.

There was every reason to protect his confidentiality. Not because of Holmes, mind you. We needed to do a better job of protecting Holmes' confidentiality because of everyone else that ever enters into a therapeutic relationship.

My work starts with a promise. I promise to keep your confidentiality and hold your secrets. I promise to do my best to keep you safe. I promise to keep those around you safe. This breach of confidentiality (whether a failure of the doctor, the university, a mail clerk, a student assistant at the health center...) makes every patient, everywhere, a little more afraid to reveal the contents of their minds, hearts, and souls to the professionals they entrust with their secrets. 

That promise, the most important promise of the therapeutic enterprise, was broken.

____
Updates

As I find specific information for licensed individuals in various jurisdictions I'll add them here.

Ohio 

(G) Divisions (A) and (D) of this section do not require disclosure of information, when any of the following applies:

(1) The information is privileged by reason of the relationship between attorney and client; doctor and patient; licensed psychologist or licensed school psychologist and client; member of the clergy, rabbi, minister, or priest and any person communicating information confidentially to the member of the clergy, rabbi, minister, or priest for a religious counseling purpose of a professional character; husband and wife; or a communications assistant and those who are a party to a telecommunications relay service call.

(5) Disclosure would amount to revealing information acquired by the actor in the course of the actor's duties in connection with a bona fide program of treatment or services for drug dependent persons or persons in danger of drug dependence, which program is maintained or conducted by a hospital, clinic, person, agency, or organization certified pursuant to section 3793.06 of the Revised Code.

(6) Disclosure would amount to revealing information acquired by the actor in the course of the actor's duties in connection with a bona fide program for providing counseling services to victims of crimes that are violations of section 2907.02 or 2907.05 of the Revised Code or to victims of felonious sexual penetration in violation of former section 2907.12 of the Revised Code. As used in this division, "counseling services" include services provided in an informal setting by a person who, by education or experience, is competent to provide those services.

An Open Letter

I recently sent this letter to all of my collegues in Massachusetts who are licensed psychologists. For those of you whom I've missed, consider this my invitation for you to consider these important ethical concerns.

Dear Friends:

As some of you know, I recently became outraged when I saw a YouTube clip of a licensed marriage and family therapist advocating the discredited notion that therapy can be used to help gay and lesbian individuals remove "unwanted same sex attractions." Every credible professional organization has repudiated these attempts to repair or remove same sex attractions. Yet organizations, such as the National Association for Research and Therapy about Homosexuality, continue to peddle a pseudo-scientific agenda that preys on vulnerable people across the United States and the world.

Over the past 15+ years I've met the occasional patient who has been victimized by ex-gay therapies. Since speaking up about these issues many more have crawled out of the woodwork and shared their stories with me. I think this is important--and I think it's an opportunity for psychologists to stand up for what is right.

I've recently wrote both the licensing board and the Mass Psych Association asking them to carefully consider the ethical issues involved in so-called reparative therapy. I've encouraged them to make a public statement about this issue.

I hope each of you also take the time to consider these ethical issues. Perhaps some of you might be moved to contact our licensing board and professional association. Perhaps you might even be moved to speak with your colleagues about this--and share my letter with them.

Think about this for a moment--in the Commonwealth we are the first-in-the nation to recognize same-sex marriages. We also are in a peculiar situation where licensed therapists can go about trying to remove unwanted same sex attractions from vulnerable youth. Which is it going to be--full recognition of gay and lesbian people as human beings--or continued shaming and sham attempts at 'repairing' something that is not broken? I think it's time to push back and make it clear that it's not okay to victimize our patients with discredited and damaging therapies.

Thanks for listening--and a quote that my doctoral program gave me on bookmark during my interview day is worth remembering here: 

“Be ashamed to die until you have won some victory for humanity.” Founding President of Antioch College, Horace Mann, 1859

For more information see:

A Call for Ethics

Confessions from a Reparative Therapist

Homosexuality 101: A video Response

Exploring Practices and Harm in Reparative Therapy

Homosexuality 101 -- A Video Response

I remember a conversation I once had with a clinical mentor. She told me that once I put it out into the universe that I had concerns about the safety of a patient, I needed to diligently, vigorously, and continuously pursue all of my options to make sure that patient is safe. I could not rest until I did everything that I could do to protect my client.

I've taken Debora's words seriously. I've thought of them a lot these past couple of weeks since first encountering a video clip from the Family Research Council. I took what some have told me is an extraordinary act: I wrote a letter to a therapist from Florida who is engaging in so-called reparative therapy. I questioned her about her ethics. I don't find this act extraordinary. I find it a duty that is incumbent upon me to perform as a licensed psychologist. 

I take my ethical code seriously. When I watched the initial video and saw a licensed therapist using her position of authority and trust to spread pseudo-scientific propaganda. I saw a licensed therapist that furthers a damaging agenda that has caused untold pain on a vulnerable population. I felt violated as a person and as a psychologist. I  felt called to stand up for my profession--and most importantly--I felt called to stand up for vulnerable people who are damaged by this propaganda that Dr. Hamilton spews through her platform with NARTH.

For the record:

• Psychologists strive to benefit those with whom they work and take care to do no harm.
• Psychologists establish relationships of trust with those with whom they work.
• Psychologists seek to promote accuracy, honesty and truthfulness in the science, teaching and practice of psychology.
• Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures and services being conducted by psychologists... [and do not] condone unjust practices.
• Psychologists respect the dignity and worth of all people... and they do not knowingly participate in or condone activities of others based upon such prejudices.

For more information on what I'm doing to stand up for what I think is ethical, right, and just, please see my new blog The Truth About Homosexuality. For a discussion about what an ethical and competent psychologist might do, see my post Confessions from a Reparative Therapist.

Confessions from a Reparative Therapist

I admit it. I am a reparative therapist (also called conversation therapy)--just not the kind you think. As a psychologist I have worked with people who have sought to be relieved of unwanted same sex attractions since the dawn of my practice in 1997. Shocked? Expecting some sort of twist here? Of course there is a twist. Before we get to the twist, let's take a look at what the pseudo-scientific organisation called the National Association for Research and Therapy on Homosexuality, commonly called NARTH, has to say. This organization, by the way, has been called a hate group by the Southern Poverty Law Center.

NARTH writes:

Reorientation therapy is simply psychological care aimed at helping clients achieve their goals regarding their sexual attractions, sexual orientations and/or sexual identities. Reorientation is not decidedly different from other therapies. There are many psychological approaches to helping clients with unwanted homosexual attractions. All approaches supported by NARTH are mainstream approaches to psychotherapy. The term "Reparative Therapy" refers to one specific approach which is psychodynamic in nature, but not all who offer therapy aimed at orientation change practice Reparative Therapy.  

The Irreverent Psychologist (that's me!) wonders just what mainstream approaches to psychotherapy NARTH is speaking about. As you may have noted in another blog post of mine, not a single mainstream professional association endorses "reorientation" therapy.

Let's look at one more bit of what NARTH says before I get to my practice of reorientation therapy:

We respect the right of all individuals to choose their own destiny. NARTH is a professional, scientific organization that offers hope to those who struggle with unwanted homosexuality. As an organization, we disseminate educational information, conduct and collect scientific research, promote effective therapeutic treatment, and provide referrals to those who seek our assistance. NARTH upholds the rights of individuals with unwanted homosexual attraction to receive effective psychological care and the right of professionals to offer that care. We welcome the participation of all individuals who will join us in the pursuit of these goals.

It all sounds good, doesn't it? This business about achieving one's goals pertaining to their sexual orientation makes for a lovely thought, right? Remember the part about choosing their own destiny. This will be important.

Let's talk about the work I do, shall we?

I'd like to introduce you to four patients. They are all representative of real people. I've changed biographical details to protect their identities and privacy. I've asked for their permission to include them in this way: they have all agreed. I am thankful for the people who are behind these stories for allowing me to share a small portion of their experience. 

• A sixteen year old male teenager coming to therapy because he's worried he might be gay.
• A Mexican-American woman with elderly parents, struggling between staying with her same-sex partner or caring for her aging parents who believe homosexuality is a sin.
• A businessman in his 50s who stayed closeted out of fear of his business would suffer. Facing the second half of his life, he struggles between satisfying his desire for companionship with men and maintaining strong business relationships in his conservative line of business.
• A hipster 20 something woman, raised by a father who was a Baptist minister who sexually abused her. "I'm not even sure I'm gay, I think it might just be something that happened because of my father."

In each of these clinical situations, a person grapples with important concerns. A teen grapples with schoolyard bullies, his Catholic upbringing, parental expectations, and the confusing desires of an adolescent.  A Mexican American woman struggles with a conflict between her heart and a cultural expectation to, as the youngest daughter, stay close to home and care for her parents. A businessman struggles with strong feelings that same-sex attraction is negative, a strong attraction to men, and making a choice to risk loosing life-long friends who might reject him for his sexual orientation. A hipster struggles with separating out desire, love, and attraction from trauma and abuse.

Four very different people, with very different life situations, clinical presentations, and developmental issues. Each of them, however, questioned their same-sex attraction at one point or another in their treatment with me. Among the things they wanted to explore and work on was furthering their understanding of their same-sex attraction.

Each of these four patients, at one point or another, had the goal to remove unwanted same sex attraction. Here's where it gets complicated. Who gets too decide what the goal is? Who is deciding whom's destiny?

I have a quiz for you. Don't worry, it's painless and will be over before you know it. Who decides whom's destiny in a psychotherapist-patient relationship? Circle one: (and grammar people, is it who, whom, whose, or whom's -- I'm sure someone will tell me.)

1. The patient
2. The psychologist
3. The intersubjective self

Many of you might circle number one. I like that choice. Almost without exception, I accept my patients exactly where they are at. It is not for me to decide what makes for a life worth living. Rather, it is for me to ask really good questions that help open and explore new ways of looking at their life and provide tools for my patients to be more effective agents in their life (thus making for a life that they make happen, rather than a life that happens to them). 

Choice number one, however, doesn't always make sense. Sometimes it is choice number two. For a large portion of my career, I've worked with patients who self-injure and are highly suicidal. Patients have starved themselves to near death, injected themselves with poisons, broken their own bones, and have tried to (or actually did) kill themselves. It would be disingenuous of me to say that I don't have a say in what the goals of therapy are.

There are, based on laws, ethics, and my own sense of decency, places where I need to exert power over a patient's decision making. I must intercede and protect children, senior citizens, and disabled people from abuse. I must intercede and protect my patients from killing themselves or killing another person (though from what I have gathered, if a patient kills someone and then tells me I cannot violate their confidentiality). Lastly, if I believe someone's decision making is impaired because of a mental illness I can have them involuntarily hospitalized. Those are the four ways in which the law and my ethical code dictate me to intercede and take over the life of my patient. I loathe to do this, and try to take every step I can so that my patients remain active agents in their life--not me.  

Members of SPLC Hate Groups Need Party Hats

Beyond ethics, there are myriad ways my personal beliefs directly and indirectly exert power over the the decisions I make in my consultation room. My job, as a seasoned and reflective psychologist, is to constantly work to become more and more aware of the ways in which I am using power to influence patients--and to use that power wisely, thoughtfully and transparently as possible.

Now what about therapy to rid oneself of unwanted same sex attraction? That's when we get to circle number three, the intersubjective self. What's that? That's where psychologist and patient get to have fun exploring an idea together. The patient and psychologist join together and explore many different ways of thinking. Our selves merge in a way, become one for a moment, and can see much further and deeper into any given issue. 

Choice number three isn't for the novice therapist or the weak at heart. It's painful, difficult, and challenging to be open enough to connect with another in this way. It's also dangerous if a psychologist isn't self aware enough to recognize their power and all the different ways they can use it to demand rather than guide.

What issues might one contemplate in regards to sexual orientation? Religion, morals, culture, spirituality, oppression desire, wishes, family, needs, homonegativity, heteronormativity, relevant scientific literature, scripture, and, well, it's endless really.

Do I have an opinion about people who are gay, lesbian, bisexual, queer, transgender, or questioning? Yes. I think they are people to be loved and people who are to be cared very deeply about. It's not really for me to decide whether people should or should not be LGBTQ--it is for them to decide. It's for me to help them explore, to separate fact from fiction, and to hold a picture bigger than they can hold on their own.

Some of the patients I've worked with over the years have decided (a) they are indeed an LGBTQ person. Other's have decided that (b) while they are likely an LGBTQ person, they would prefer to contain that part of their self because of a variety of reasons (family, culture, religion, etc.). Others have decided that (c) they aren't actually and LGBTQ person at all.

Options (a) and (c) are easy. I've yet to have a patient select option (b) as a way to lead their life. They have explored the notion for a long time, and in the end, opted for for either being LGBTQ and having loving fulfilling relationships with same sex partners, or choosing to LBGTQ and be celibate for religious reasons, family reasons, etc. A small handful have selected option (c)--they aren't gay, or not yet ready to decide if they are gay.

This is how therapy is done. Thoughtful. Reflective. Taking into account multiple perspectives, multiple ideas, and multiple positions. Let's return again to the so-called reorientation therapists. 

Julie Hamilton at NARTH--she had a lot to say in response to my questioning of her ethics. In reviewing her official statement on the NARTH website (this link will actually get you there, have fun with the others)

• Dr. Hamilton demonstrates both an unsophisticated understanding of ethics in her reliance of choosing option one (remember my little quiz!) 
• Dr. Hamilton appears to be falsely pretending that she isn't exerting any influence on her patients (a likely failure of even knowing there is a choice 3, and it's unclear if she is is able to admit to choice number two). 
• Dr. Hamilton demonstrates an egregious misuse of science and a total failure of scientific thought. Some day I'll have to review her failings--which in her capacity of president of NARTH become NARTH's failings--in a later blog post.

NARTH states on their website they believe in open scientific dialogue. Strangely they don't invite this dialogue. Note the comments on their blog are closed. Let's be serious here: they aren't interested in dialogue. NARTH is interested in foisting their agenda of propaganda and pseudo-science on a vulnerable population.

It seems likely that Julie really isn't in the market of helping patients. It seems that she is in the market of peddling her agenda of propaganda and personal beliefs under a thinly veiled guise of pseudo-science.

Julie writes:

Ethical therapists do not solicit clients or coerce clients into seeking change. The clients served by NARTH therapists are clients requesting change.  

Ultimately it is the client who must choose with proper informed consent and without therapist-coercion, the most satisfactory life for himself or herself.

Sounds good on paper, doesn't it? It's not good. It's dangerous. Julie's unsophisticated understanding of ethics and clinical practice is dangerous. What her words reveal is a situation in which a therapist, unaware of her own agenda, dangerously foists her world view on another. Therapists who do this are, in my opinion, are engaging in the worst kind of malpractice.

So I say this: I know you are out there--survivors of damaging reparative therapy--lost, forgotten, hurting, and silenced by alienation. Come find me and let's use this place to tell your stories, to find connection, and come back into community. Come take a critical look at ex-gay propaganda with me. Come tell your story (anonymously if you're scared).

I am standing up for you. Come find me.

The Human Costs of Reparative Therapy

Have you hear about the so-called reparative therapy, in which unethical therapists attempt to change the sexual orientation of a person? Check out here and here if you are outraged and want to stand up for love, compassion, and what is right.

A Call for Ethics

This morning I came across a  YouTube clip that I live tweeted and also made available on my blog.  It's a sad clip, filled with an enormous amount of misinformation. I was aghast to discover a credentialed mental health professional spewing some of the misinformation. Her actions, to me, violate the ethics and responsibilities of someone in our field. In that it is incumbent upon me as a licensed psychologist to seek a resolution of ethical dilemmas directly with the offending individual, when possible, I have sent out this letter today:

May 11, 2012

Julie Harren Hamilton, Ph.D., LMFT

P.O. Box 1382

West Palm Beach, FL 33402

Dear Dr. Hamilton:

It is my obligation as an ethical psychologist to directly address other psychotherapists who are engaged in behaviors that I believe are unethical. In watching the video published on YouTube by the Family Research Council, I became concerned about your work as a representative of NARTH as well as within your private counseling practice.

Specifically, you state:

“While the general public seems to believe that people are born gay and can’t change, that has not been the conclusion of researchers.”

Let me not mince words here Julie, you are simply wrong. There is no credible evidence in any peer reviewed journal that provides substantive empirical evidence to suggest that so-called reparative therapy is effective or ethical. Further, the American Academy of Pediatrics, American Association of School Administrators, American Counseling Association, American Federation of Teachers, American School Counselor Association, American School Health Association, Interfaith Alliance Foundation, National Association of School Psychologists, National Association of Secondary School principals, National Association of Social Workers, National Educational Association, and School Social Work Association of America have all taken  the position that “homosexuality is not a mental disorder and thus is not something that needs to or can be cured” (APA, Sexual Orientation and Youth, 2008, pg. 6). Your own professional association, the American Association of Marriage and Family Therapists, also states that “same sex orientation is not a mental disorder. Therefore, we do not believe that sexual orientation in and of itself requires treatment or intervention.” (AAMFT Board of Directors, July 31, 2005)

In the YouTube clip, you continue:

“There are many people who claim that it’s harmful for a therapist to try to help someone change in their sexual orientation and so when clients come in saying I have these attractions—these homosexual attractions and I don’t want to be gay there are many people who say that therapists should not assist those clients in achieving the goals for their lives because it is harmful yet the research reveals it is not harmful. There have never been research studies that have concluded that therapeutic attempts to change sexual orientation are harmful. In fact, it’s unethical not to assist a client in seeking to accomplish their goals for their lives, including their goals of living a life beyond their homosexual attraction.”

Again Julie, the evidence here is that reparative therapist is harmful, doesn’t work, and shouldn’t be done. Your public statements are not consistent with the professional literature. You are misrepresenting science and your field. Your apparent failure to understand the literature is putting those you serve at great potential risk for harm.

I’m deeply concerned that the patients you see become trapped in therapy and are not given ample opportunity to both consider the effects of discrimination, oppression, and misinformation about sexual orientation as well as what their faith teaches about sexual orientation. Further, I am concerned that you misrepresent the professional knowledge about sexual orientation to your patients causing them additional potential harm.

I am writing to ask that you practice within the established professional guidelines and that you meet your ethical responsibilities. Be truthful about the data, do not misrepresent the science, and assure that each of your patients are afforded the opportunity to explore their experience both within the context of their own faith as well as within the context of an understanding of oppression.

I further ask that you respond to these ethical concerns, in writing, so I can be assured your patients are receiving the best possible treatment and care. If I do not hear from you in a timely manner I will assume you are not interested in clearing up these ethical concerns and I will issue a complaint with your professional association and/or licensing body to seek assurances that you are practicing in an ethical manner.

                                                                                                                                   

                                                                                                                         

Sincerely,

Jason Evan Mihalko, Psy.D.,

Massachusetts Licensed Psychologist

and Health Service Provider

Why Weep?

Online discussion forms can be an interesting place. Take for example a thread of discussion about an older gentleman who was weeping in therapy. The psychotherapist posted the question "what do you make of weeping in a case of an [older] gentleman with major depression who has been seen in therapy [a handful of times]?

The range of responses are interesting. The original poster commented that in many years of clinical experience, they have never seen a person with major depression weep. Others have pondered if there is some sort of unexpressed grief, while many others talked about us living in a culture where men don't cry. Others have questioned if there is some sort of underlying medical disorder that is causing the weeping. The most useful comment is the most recent: "Have you thought about asking the patient why they are crying?"

My first thought is that I think every psychotherapist needs to think twice about having discussion about current patients anywhere on the internet. The second thought of the psychotherapist should always be "no, I'm not going to discuss this online." Supervision is great, peer supervision is great. Internet discussions with strangers about patients is nothing more than gossip. We owe our patients more than that. In fact, our ethics require us to offer our clients more than that.

My second thought is that if you are a patient, ask you psychotherapist about their privacy policy. Ask them directly if they discuss their work with anyone else. Most skilled and competent psychotherapists seek out some sort of supervision (with a peer, with a more experienced mentor) at various points in their career. This is perfectly acceptable. In asking how they talk about you with other's, ask if they have a policy about discussion on the internet. If you aren't comfortable with their policy, discuss it with your therapist until you are either comfortable or decide that you want a different therapist.

My third thought is about weeping. What a ridiculous question. Did you know one of the first things that comes up on a search of 'weeping' is a site that lists 52 medical causes for weeping. Have we really turned a normal human emotion and behavior into a disorder? Really?