Warren Throckmorton has just published a preliminary document developed by himself and Mark Yarhouse. Titled Sexual identity therapy: Practice guidelines for managing sexual identity conflicts (100K pdf) Its intended audience is mental health professionals, and at this point the authors are going public with it in order to invite review from their peers.
Before going any further, let’s acknowledge the context in which this document is being presented. Much of the ex-gay movement has shied away from establishing standards of care, resisted external oversight, made vague and/or unverifiable claims, insisting that their role was limited to ministry or peer-to-peer support. Those that have made a case for ethical care have tended to be those who also cited Paul Cameron extensively. This document, at first glance, seems to move beyond those constraints.
And I need to make my personal limitations clear. I’m not a therapist of any flavor, and I won’t be trying to digest all of the references in the Guidelines and their historical and academic context. I’m going to post about my personal (very positive) experience with therapy and how it relates at A Tenable Belief, hopefully this weekend.
But, my initial impression is that the Guidelines offer some promise and some concerns.
The promise lies in Dr. Throckmorton’s and Dr. Yarhouse’s effort to get this far, first, and second, doing so with the intention of inviting input from their peers in order to work towards professional consensus.
Simply, it is essential that people — adolescents, young adults, all adults — working through issues related to sexuality, identity, culture, and religion should be able find professional care that neither demeans nor promotes the therapist’s or the individual’s religious perspectives. That’s a tricky thing to achieve. While many professional do, there are conservative Christians who discover disconnects with therapists’ perspectives about their faith, and clients who have found themselves at odds with their therapists’ faith-based practices.
So, what about the Throckmorton/Yarhouse Principles? What follows amounts to anecdotal observations by and questions from an amateur.
Under the heading, Working with Adolescents:
Adolescents should be dealt with conservatively because sexual identity confusion and change can be more prevalent during the teen years than during adulthood, when individuals begin to synthesize their identity (Savin-Williams, 2005). Adolescents should be followed, provided psychotherapeutic support, educated about identity options, and encouraged to attend to other aspects of their social, intellectual, vocational, and interpersonal development. Because an adolescent shift in self-reported sexual and religious identities can occur primarily to please family, peers, or other adult role models, changes may not persist or reflect a permanent in sexual identity. Clinical follow-up is encouraged.
Parents may bring in teens who are unable to provide legal consent. The role of the therapist here is to take a consultative role. Therapists can point parents and younger teens to research showing that confusion concerning sexual identity is common and that there should be no rush to declare a sexual identity at a young age (Remafedi, 1992; McConaghy, 1993; Savin-Williams, 2005). Clinicians should communicate that an appropriate parental stance is to provide consultation and support for their child and to refrain from shaming children for openly expressing their distress to parents and the therapist.
But, adolescence is also a period in which people wrestle with questions about “Who am I in relation to who my parents, family, and culture? In what ways do I find myself to be different, or do I want to assert myself as distinct?”
Key to that process is negotiating how one fits within, adapts to, accommodates, or rejects the faith and values of the parents, extended family, and/or culture. My experience in adolescence was that the orientation and the family/cultural issues could not be divorced from each other.
Under Phase one: Assessment, we read:
Sexual feelings that are in conflict with religious ideals can produce a sense of difference and distress. An assessment of the consequences of same-sex attractions and a potential gay identity to aspects of ethnic, cultural, and occupational identity as well as to familial attachments is vital. Therapists should be open to the possibility that embracing same-sex attractions may place other vital aspects of identity at risk. It is also important for therapists to take a neutral stance toward the client’s worldview.
A question: Therapists should attribute the distress of “sexual feelings that are in conflict with religious ideals” solely to the sexual feelings? Isn’t that at odds with taking a neutral stance towards the worldview?
Under Phase two: Advanced Informed Consent:
In all cases, therapists must provide clients with accurate information to support a client’s consent for further intervention.
[]Advanced informed consent is foundational to all subsequent interventions and should cover the following:
- Hypotheses as to what is causing their distress (including etiology of same-sex attraction, rationale for identity conflict and the subjective experience of distress);
- Professional interventions available, including success rates and definitions and methodologies used to report and define “success”;
- Alternatives to therapy, including reported success rates and the relative lack of empirical support for claims of success;
- Possible benefits and risks of pursuing treatment at this time;
- Possible outcomes with or without treatment (and alternative explanations for possible outcomes). (Yarhouse, 1998, p. 252).
It is beyond the scope of this article to fully delineate all information that might be needed during this phase.
Providing informed consent seems to be a major challenge of ex-gay groups, ministries, and therapists. Call me an amateur, but I don’t understand why it might be unreasonable to expect this document to develop these points in greater detail. What are the hypotheses? What general classes of hypotheses, given that this field of study is rife with misrepresentation, exaggeration, and hyperbole, might safely be labeled untenable?
And, what about success rates? Or, perhaps more importantly, what about the dearth of credible results garnered from peer-reviewed studies?
From the same section:
What is most important during informed consent is to help each client make a truly informed decision about the kinds of goals they might have for treatment and the kinds of services that are available. This can be an involved process when clients frequently ask about change of same-sex attraction and behavior. Clinicians may find that this takes more than one or even two sessions to process with some clients. Informed consent is also an ongoing process depending on how a person is progressing in treatment. If in therapy a client is not making much headway, it is important (just as in any other treatment program) to revisit treatment goals as to whether they are the best fit for their present needs.
Truly. Informed. Consent. Absolutely! Maybe it’s just that I’m an ordinary gay guy, and the authors are as invested in their psycho-babble as I am in techno-babble with my colleagues, so the language keeps me from getting my arms around this paragraph.
It just makes sense that more than one or two 45-minute sessions are necessary to come to terms with the coming-out process. Full disclosure at this point, in my mind, would include that very few folks experience black-to-white shifts in their baseline attractions to men or women.
Advertising by Jenny Craig and Weight Watchers includes disclaimers specifying that long-term, stable, 80+ pound weight loss happens but is outside the norm. Full disclosure by Throckmorton and Yarhouse, it seems to me, should include that the experiences of Stephen Bennett and D.L. Foster (going from 100% gay to 100% straight) represent a tiny minority; the experience of Randy Thomas (going from actively gay to finding purpose, value, and spiritual fulfillment in being single and celibate) is another option, and it is possible that being married in sync with life-long struggling/questioning is another common outcome.
There is much more to explore in the Principles document. So, let’s explore. Thoughtfully. Openly. Appreciatively toward professionals opening up their work to review by their peers.
Glad to see it finally published! We will have a good read through, as it deserves.But in a nutshell — the paper appears to offer no support for the positions and practices of a great slab of exgay groups. (I’d go so far as suggesting no exgay groups, given that individuals attending even a respectful group will rapidly encounter the attitudes etc of Exodus etc as a whole).And at the outset we’d like to see the section on adolescent “clients” given a bit more of a bite; particularly talk about young people who are — albeit often unsaid — developing in an anti-gay (and not just “conservative religious”)social environment. This is, of course, nearly eveyone; even if they personally have little apparent self-conflict.But, happy to see it published as we said.Now all we need is for the author/s to stop being official spokespeople for Exodus and the atitudes and practices linked to Exodus… and begin supporting social initiatives/organisations that aim for full and complete legal equality of gay individuals and gay couples.Not holding my breath on that one 🙂
I am somewhat bothered by the term “etiology”. I’m not a doctor or therapist, but I thought this word implied disease or disorder.
Can anyone clarify that for me please.
Yeah, Timothy, it just means “what makes it happen”.It is normally used only by medicos, but a rather disturbing turn of events are the number of “organisation consultants” (read: “complete tossers”) who use the term. Typically with regard to HR issues.Mike, I am permitted to use “tosser”? I hope.
grantdale said:
Mike, I am permitted to use “tosser”? I hope.
Well if he is like me, he has no idea what it means 🙂 I do wish you would learn to speak American!
Perhaps you could post a cheat sheet 😉
David
Timothy,You may also be muchly pleasured by reading the side conversation in this… :)WT!Hmmmm? The World still turns, we are pleased to report.
Oh, David, how may I do this without being, well, crude?Tosser = Wanker = (in American) Person who self abuses (and that, LORDY, is a SIN!!!). One with Onan tendancies. One who should not keep his hands to himself. From: masturbation as a self-centered activity.It basically means someone who farts on with their (uneducated) opinion, and is paid to do so. Also used of foorball players etc who have an (unwarranted) high opinion of themself as a social critic etc. Or the office fathead.Despite the blunt origin, it is a permitted adjective/noun in Australia, UK, NZ in normal conversation. Not used in formal correspondnce — although, well, maybe it could be. 90 year old grandmothers have been known to use the expression at times. Not about their grandsons, of course :)Yes… a people separated by a common language…
Oh, I give up. I also just used “fart” in our meant-to-be-non-offensive sense.
David: also to amuse you…”Someone” has just reminded me that a neice used the word “crapper” in a Catholic girls school a few days ago, during a class presentation. And, as it was in context, no black-clad nun swooped down from her perch amoung the gargoyles and et her.(Neice was presenting a cardboard and glue-gun extravaganza as part of mediaeval history class — including a very complex castle that her and an austistic uncle assembled one evening. The “toilet” hanging off the side of the castle, as they did, was of course actually called The Crapper in those times. She let her class know this important fact.)
I’m puzzled about the etiology and expected outcome of these practice guidelines. Clearly, they fly in the face of the usual justifications for reparative therapy, i.e., that homosexuality is either sinful/immoral (the religious right belief) or psychiatrically pathological (the NARTH position). Would reparative therapy proponents be able to assume a nonjudgmental attitude in providing “education” for informed consent? And what research evidence would they provide when discussing expected outcomes of treatment since, if one is being honest, the quality of research on reparative therapy is dismal?
I’m also puzzled about what these guidelines add to those that currently exist. The American Psychological Association’s Ethical Principles Of Psychologists And Code Of Conduct provides general, comprehensive guidelines. It’s Guidelines for Psychotherapy with Lesbian, Gay, and Bisexual Clients provide much more explicit guidelines and place significant responsibility on the therapist to be informed about context: the wide range of social, cultural, religious, and other factors that impact the lives and mental health of LGBT people and the resources available to them. In advancing new guidelines, Throckmorton needs to be explicit about how his guidelines differ from those of APA and should address training issues for those who would do this kind of counseling. Otherwise, I’m afraid this just puts lipstick on the pig.
One of the most disturbing things in Throckmorton’s guidelines is his conflation of sexual “identity” (i.e., male/female) with sexual ‘orientation’ (i.e., gay/straight). This is a Psychology 101 distinction and such an error shouldn’t be made by an “expert” in the field.
grantdale said:
The “toilet” hanging off the side of the castle, as they did, was of course actually called The Crapper in those times.
I can’t imagine how we go here but I may as well ask, wasn’t “crapper” a term coined in the late 19th Century?
David Roberts
Ahhh, you mean Thomas Crapper — the well known perveyor of cast iron sanitary ware?Yes, you are utterly correct. His name, cast onto the cistern, reinvigorated the use of he word around 1900 etc. But… where do you imagine his family name originally came from?Rather ironic, isn’t it :)(And no, neither of us have ANY idea where conversation goes from here. Your call.)
I took a brief look at the document, and was struck by how dissimilar it looks to what I have normally seen in Clinical Practice Guidelines (CPGs). The organization I work for requires health plans to have their own CPGs and to use outside ones, where applicable, in Disease Management programs (which focus on chronic diseases). Typically, these CPGs have direct, clear steps for one to take in the course of a disease, from appropriate diagnosis to treatment.
For comparison purposes, see the GOLD guidelines on Chronic Obstructive Pulmonary Disease – emphysema to most people – at this link: https://goldcopd.com/Guidelineitem.asp?l1=2&l2=1&intId=1116. Go to the bottom of the page to see the link to the PDF pocket guide. Also see the World Federation of the Societies of Biological Psychiatry for Depression Guidelines: https://www.wfsbp.org/pdf/guides/827MDDTreatmentBauer.pdf.
The differences may be because there is too little consensus literature around the concept of “changing” sexual orientation to devise a true stepped approach. But that also implies guidelines are premature, if not useless, in this area. Without a consensus on how to identify patients, assess the problem and its severity, and recommend treatments, which would typically change as condition severity changes, there is no way to truly create guidelines. Granted, this is a first step, but I don’t see these as much as Clinical Practice Guidelines for a condition as they are ethical guidelines for appropriate psychological practice. As someone else notes, the major specialty societies already have general ethical guidelines.