Conflicts between trainees' beliefs and clients' needs may arise in psychology education and training. For example, students with conservative religious identities may not want to counsel clients who are lesbian, gay, bisexual or transgender (LGBT) on treatment goals that are counter to the students' sincerely held beliefs. LGBT students may object to serving clients with outspoken conservative views. Other students may strongly disapprove of abortion and may refuse to counsel clients considering that option.
Yet psychology's education and training community isn't always well-equipped to help students navigate the need to achieve competency while negotiating their own identities and beliefs, says Linda Forrest, PhD, a professor emerita at the University of Oregon. In fact, she says, 86 percent of participants informally surveyed at APA's 2014 Educational Leadership Conference said they felt faculty were unprepared to effectively manage training situations when students' beliefs conflict with their ability to provide competent patient care.
An APA working group that Forrest chairs is trying to change that. With the emergence of "conscience clause" court cases and state legislation that would allow trainees to opt out of training they say conflicts with their values, the working group has developed a pedagogical statement and educational materials to help the training and education community respect students' rights while ensuring they're prepared to serve a diverse client population. "We need to be pro-competence, not anti-religion or anti-conscience," says Forrest.
And as legislators have started proposing bills that would allow practicing psychologists and other licensed service providers to assert freedom of religion and conscience to determine their treatment and referral practices, the working group has expanded its mission to include both training and practice settings.
Training for diversity
Laws that allow people to opt out of activities that conflict with their religious beliefs date to the Civil War era, when conscientious objector status allowed men to refuse to participate in military service. But conscience clauses have only moved into the mental health arena in recent years (see "Further reading" below).
In 2011, for example, the U.S. Court of Appeals for the 11th Circuit upheld a university's decision to expel a counseling student for failing to adhere to the profession's ethics code, rejecting the student's claim that counseling LGBT patients violated her rights to religious freedom and free speech. In 2012, on the other hand, the U.S. Court of Appeals for the 6th Circuit remanded to the district court a case involving another student expelled from a counseling program for refusing to serve a gay client, asking that court to determine if religious discrimination had occurred and prompting the program to settle with the student.
In 2011, Arizona enacted a law preventing psychology, counseling and social work programs from taking action against students whose religious beliefs run counter to serving certain clients, as long as they consult with supervisors about how to avoid harming those clients. Legislators in two other states — Michigan and Tennessee — have proposed similar legislation.
APA opposes such laws, says Forrest.
"Our position is that the training of psychologists requires that students become competent to deal with a wide cross section of future client populations and that trainees are not in the position of dictating which populations they will or will not see," she says. "Those responsibilities rest with the faculty and supervisors of professional psychology training programs."
To help programs balance the need to produce competent professionals while respecting students' beliefs, the APA working group has developed a pedagogical statement, sample program policies, a flow chart that gives training programs step-by-step guidance on preventing and responding to conflicts, and other materials. The working group is also creating resources for state psychological associations lobbying against conscience clause-related legal cases or legislation.
The main idea undergirding the group's materials and workshops is psychology's responsibility to prepare a workforce trained to meet the needs of a diverse client population. Attaining competence to work with a diverse public isn't optional, says Forrest, explaining that students can't simply opt out of training they don't agree with. While there may be times when reassigning a client to a different trainee would be best for the client, that's a decision for the trainer — not the trainee — to make. Students who can't or won't attain competence in serving all clients will be placed on remediation. If that fails, the student may be dismissed.
Trainers have responsibilities, too. They need to respect the fact that it can take a while for students to figure out how to maintain their personal beliefs while still providing competent care, for example. And they need to avoid acting in a way that's hostile to trainees' religious beliefs, practices or values.
The working group's stance doesn't just apply to religious students, Forrest emphasizes. It applies to any students with beliefs that might conflict with providing competent care. "We can't allow a student committed to antiracist work to refuse to provide services to clients with racist beliefs, for example," says Forrest.
Transparency is key, she says. Education and training programs should promote these ideas in their admissions materials, orientations and curricula so students with strong beliefs fully understand training expectations.
Proposed revisions to APA's Standards of Accreditation in Health Service Psychology make these ideas much more explicit, says Kathleen J. Bieschke, PhD, who heads Penn State's department of education psychology, counseling and special education and serves on both the working group and APA's Commission on Accreditation. The proposed revisions are expected to be approved this year.
"Our job is to hold students to developing the competence to maintain who they are while providing high-quality services to their clients," says Bieschke. "The proposed standards make it clearer that we expect programs to train students to navigate these kinds of values differences."
In the practice arena
In response to state legislation that would affect psychologists in practice, the APA working group has expanded both its membership and its focus.
Nebraska legislators have repeatedly introduced the Health Care Freedom of Conscience Act, which would allow psychologists and other clinicians to refuse to provide services or make appropriate referrals because of religious or moral objections. Thanks in part to the Nebraska Psychological Association's advocacy, the bill was indefinitely postponed last year.
Also in 2014, Arizona's governor vetoed a bill that would have allowed businesses, including psychologists' practices, to use religion as an excuse for denying service to gay and lesbian customers.
Earlier this year, legislation was introduced in Virginia's General Assembly that would have exempted psychologists and anyone else with a government-issued license, certificate or registration from any disciplinary action arising out of a refusal to provide services that licensees said would violate their religious or moral convictions surrounding homosexual behavior or same-sex marriage.
"We don't use the term ‘conscience clause,'" says Claire Guthrie Gastañaga, JD, executive director of the American Civil Liberties Union of Virginia and the public member of APA's Board for the Advancement of Psychology in the Public Interest. "We call these bills ‘licenses to discriminate.'"
Of course, practicing psychologists — especially those in independent practice settings — can make decisions about which patients they will or will not serve, says Antonette Zeiss, PhD, who represents APA's Board of Professional Affairs (BPA) on what is now the joint Board of Educational Affairs/BPA working group. In some cases, psychologists may opt out of treating people because they lack the competence needed; in other cases, they may have personal beliefs that keep them from being the most appropriate choice.
But, the working group emphasizes, practicing psychologists should engage in personal introspection, training, supervision and consultation to help them integrate their personal beliefs with their ability to provide competent care. The goal should be developing competence rather than "escaping from uncomfortable situations," says Forrest.
Refusing to treat or refer patients because of certain aspects of their identity falls short of psychology's commitment to compassionate public service, says Forrest. Practitioners should also be aware that they could face claims of discrimination if they're always referring a certain group of would-be patients based on some aspect of their identity that makes them uncomfortable or challenges their personal beliefs, she says, pointing out that APA's Ethics Code forbids unfair discrimination based on race, ethnicity, gender identity, sexual orientation and other factors. In a 2001 case, she adds, a federal appeals court upheld the firing of a counselor who cited religious beliefs as a reason for asking to be excused from counseling a lesbian client with relationship problems.
If psychologists do decide they cannot treat a would-be client, they can't just turn that person away: They have a responsibility to ensure that all patients receive the care they need, even if they can't or are unwilling to provide that care themselves.
The kinds of situations that might trigger a therapist's desire to use a conscience clause usually involve people who are at a really vulnerable time in their lives, says Zeiss. "It's crucial that they be handled with sensitivity and respect and that if you're not going to see that patient for some reason, you at least make a very thoughtful referral to someone who could provide the services requested," she says.
To guide practitioners through that process, the working group is developing a statement similar to its pedagogical statement. In addition to addressing private practice, the statement will cover the responsibilities of psychologists working in Department of Veterans Affairs facilities, university counseling centers and other institutional settings where they are hired to serve a diverse population. "Institutions can't afford to let their psychologists pick and choose which clients they will see or not see based on their personal beliefs," says Forrest. "It could create organizational nightmares and would be counter to a mission to provide compassionate care to all."
Accompanying the statement will be informational materials designed to assist state psychological associations, licensing boards and others advocating against conscience clauses. The materials will include strategies for how to analyze legislation, collaborate with other professional groups and contact legislators, for example. The working group plans to work with the Association of State and Provincial Psychology Boards (ASPPB) to disseminate the resources.
"It's important for clinicians to understand how their own values and personal standards influence the work they do," says Zeiss. "But what we hope is that clinicians will understand that nonetheless they have a responsibility to vulnerable populations and have to treat all potential clients with full respect and dignity and do whatever is necessary to get that person to the right care."
Rebecca A. Clay is a journalist in Washington, D.C.
