About CE
"CE Corner" is a continuing education article offered by the APA Office of CE in Psychology.
To earn CE credit, after you read this article, purchase the online exam at www.apa.org/ed/ce/resources/ce-corner.
Upon successful completion of the test — a score of 75 percent or higher — you can immediately print your CE certificate.
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Overview
CE credits: 1
Learning objectives: After reading this article, CE candidates will be able to:
- Identify the Ethical Principles and Ethics Code Standards involved in helping religious clients address sexual orientation concerns.
- Describe interventions that may help clients dealing with these issues.
- Discuss the importance of allowing for patient autonomy in therapy.
Several times a year, "CE Corner" will present a hypothetical ethical situation and ask psychologists who are ethics experts to offer insights on how to address it. Here is this month’s vignette:
Gabriel Muñoz is a 62-year-old Mexican-American, married, self-identified heterosexual male, who has had bariatric surgery within the last year. In a visit with his primary-care physician, he states that he has experienced sexual thoughts about men, some of which he has acted on, during his marriage. He reports that he gained weight prior to surgery in an attempt to be "less sexual." Now that he has begun to lose weight and feel better about himself physically, he is finding sexual thoughts of men returning. He clearly describes his thoughts as the "devil's work," indicating that his pastor has "worked me through this before, but now I feel the devil is getting the best of me." He requests therapy to learn how to cope with his sexual thinking about men, with the eventual goal of removing these thoughts. He feels strongly that he can either remove these thoughts, regain his weight as self-protection or endure spiritual consequences and lose his marital relationship.
While this patient, Mr. Muñoz, is a fictional example, the ethical and psychological issues surrounding his case are concerns most clinicians will be faced with at some point in their careers, says W. Brad Johnson, PhD, a psychology professor in the department of leadership, ethics and law at the U.S. Naval Academy. "Practitioners need to anticipate clinically relevant religious conflicts and be ready to help clients work them through," he says.
For this case, the most obvious guidance for psychologists comes from the APA's Ethics Code Principle A: Beneficence and Nonmaleficence, which instructs psychologists to only do things that are of benefit to their patients, and have little or no risk of harm, a concept also addressed in Standard 3.04: Avoiding Harm.
However, says APA Ethics Committee member Nicole Najar, PsyD, in Mr. Muñoz's case, there is no simple answer to the "do-no-harm" guidance. "This is a tricky one because avoiding harm can come from two directions—the patient himself, who is saying it is too harmful for him to have these thoughts, and from any sort of treatment that focuses on changing one's sexual orientation, which is neither scientific nor appropriate," says Najar, who is a clinical health psychologist at the Battle Creek VA Medical Center in Battle Creek, Michigan.
Judith Glassgold, PsyD, chair of APA's 2009 Task Force on Appropriate Therapeutic Responses to Sexual Orientation, agrees, noting that the task force report found insufficient evidence to support the use of psychological interventions to change sexual orientation—and even found in some circumstances that these practices harmed the client. "Instead, practitioners should focus on things that the patient can change—prioritizing his physical health, reducing stress, identifying conflicts, and getting rid of irrational thoughts," she says.
Practitioners also need to be competent, both in understanding the science and approaches to helping someone address his or her sexual orientation, as well as in the psychology of religion and faith, says Glassgold, who is a visiting research scholar at the Center for Health and Wellbeing at the Woodrow Wilson School of Public and International Affairs at Princeton University.
Prioritizing physical health
Given this patient's very recent bariatric surgery, from a clinical health perspective, Najar says she would first work with Mr. Muñoz to address the connection he's made between his weight loss/gain and sexuality. "I'd want to unmarry these two because we need to focus on making sure that this client is successful in maintaining his weight loss," she says. She suggests using Acceptance and Commitment Therapy (ACT) to work with him on identifying how his thoughts about his weight and his sexual attraction are intertwined, and then help him figure out which are thoughts and which are behaviors, and focus their discussions on his control over behavior, independent of his thoughts.
"Empowerment comes in identifying a behavior as controllable and removing the power from the thoughts or attempts to control the thinking," Najar says. "The purpose of unpairing [his sexual thoughts and weight thoughts is to help him] maintain a healthy weight regardless of his process with his sexuality."
Jennifer Kelly, PhD, a clinical health psychologist at the Atlanta Center for Behavioral Medicine, agrees, noting that she would also recommend that Mr. Muñoz enroll in an aftercare program designed to help him obtain and maintain weight loss after surgery, as well as deal with any weight-loss challenges postsurgery.
Addressing issues regarding protection versus risk in this client's sexual behavior is also important, says Clinton Anderson, PhD, acting executive director of APA's Public Interest Directorate and Lesbian, Gay, Bisexual and Transgender Concerns Office.
Exploring religious beliefs
After some short-term work with this patient to ensure his physical health is stabilized, Najar and Kelly say they would then refer this patient for additional consultation with a psychologist who not only specializes in people questioning their sexuality, but also has training and experience in working with religious clients in order to be in line with Standards 2.01: Boundaries of Competence and 2.04: Bases for Scientific and Professional Judgments.
It's clear in this case that there are some religious beliefs surrounding sexual attraction that are working at cross purposes with this client's mental and physical health, says Johnson, and his beliefs need to be addressed sensitively. This work should be guided by the APA Ethics Code's Principle E: Respect for People's Rights and Dignity, which promotes practitioners' awareness of and respect for cultural, individual and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language and socioeconomic status and consideration of these factors when working with members of such groups.
Unfortunately, says Johnson, some practitioners interpret "respect" to require hands-off avoidance. "Religion and other cultural variables can make otherwise effective practitioners timid, even immobilized," he says, adding that it is important to balance the principles of respect and beneficence. "Remember that culturally competent confrontation can be executed quite respectfully. In this client's case, we have to honestly address the fact that his cultural/religious beliefs are linked to anxiety and depression."
It may make sense to first develop a greater understanding of this client's religion, in partnership with him, Anderson says. "Latinos are predominantly Roman Catholic, but the use of the concept of the devil suggests perhaps he is evangelical or Pentecostal," he says. "I also think his guilt and shame about breaching his marriage and the possibility that he may feel he has betrayed his wife or even duped her if those feelings go back before his marriage are important elements of the situation."
While some psychologists may feel more comfortable referring Mr. Muñoz's case to a member of the clergy or mental health professional with expertise in integrating a client's religious worldview into psychotherapy, Johnson says that psychologists have some ethical obligation to be thoughtful about such referrals. A poorly considered referral might perpetuate or even exacerbate the client's distress. Instead, he advocates for competent clinicians to consider conducting—with informed consent—a respectful exploration of beliefs and behavior with this client, including a supportive discussion of the ways his interpretation of scripture or beliefs about God are entwined with his current psychological distress.
Johnson also says that if the client is reluctant to speak with a local clergy member (for fear of people in his community finding out about his feelings), a psychologist might recommend a pastor that the client could email or telephone to clarify some of his concerns, or provide him with some recommended reading.
"There are a lot of different ways I'd try and open the door for this client to explore his own cultural beliefs about sexual attraction; I am concerned there might be some selective interpretation of religious scripture going on for this man," Johnson says. "If a referral appears appropriate, I'd like to be able to recommend some clergy or pastoral practitioners who are likely to be as concerned as I about ameliorating the client's emotional pain."
Identity exploration
No matter what evidence-based treatment is pursued in this case, what's most important is for clinicians to allow for patient autonomy, says Fred Millán, PhD, vice-chair of the APA Ethics Committee and a psychology professor at SUNY Old Westbury, who specializes in cross-cultural and diversity issues.
Millán says he'd work with Mr. Muñoz to explore what may be behind these thoughts and what they mean for him. He'd also play out some of the worst-case scenarios that might be running through the patient's mind if he ever acted on such thoughts—such as that he'd lose his family or be excommunicated from the church. Such a discussion could help the client figure out how reasonable they may or may not be and begin a process of sorting out his options.
"The fantasy of many patients is that we're going to give them a pill or other type of treatment to make it all go away, when obviously that's not the way this works," Millán says. "The work here isn't to remove those thoughts from his mind. It's really to help him come to terms with them—that is, to understand how they came to be, what they mean for him and work them through enough to integrate them into an identity that makes sense for him."
Glassgold notes that in these types of cases it can also be helpful to share information with the patient on the scientific basis of homosexuality and sexual attraction, pointing to research showing that it is thought to be primarily biological.
"Identity exploration is a key element in treatment, and Mr. Muñoz may benefit from exploring his sexual orientation and faith in an environment of affirmation and acceptance, being able to talk about it and accept all of himself can be a crucial part of his treatment," she says. Then a clinician can move on to helping the client discover what feels the most authentic to him. He may decide that his faith and his marriage are most important and provide him with the most fulfillment, or he may decide that he wants to explore an alternative Christian faith, one that is more accepting of same-sex attractions and same-sex relationships.
"These are all decisions Mr. Muñoz has to face, and it's good for him to go through that in an environment where he does not feel pressured to any particular outcome, consistent with the ethical principle of autonomy and self-determination," she says.
