Friday, June 10, 2011

It's About Risks and Reasons, NOT Possibilities

The debate over whether "reparative/change therapy" is valid or harmful usually focuses on whether it's POSSIBLE to change. That's the wrong focus. For it is also possible that there is a teapot orbiting the sun somewhere between Mars and Jupiter.

Whether some aspect of "reparative therapy" effectively treats depression or other issues is a sideshow. The core part of this therapy model is about repairing an aspect of a person's psyche seen as broken and changing something about a person seen as abhorrent, not the treatment of depression or any other issue. Assurances from a therapist that change is possible leads a person engaging in such therapy to expect that change will occur with enough effort. That sets a person on a path with an endpoint that more often than not looks like the edge of a sheer cliff.

For me, the focus in this discussion should be two-fold.

First, the RISK of harm. That some people have found temporary "success" or that many have survived run-ins with agenda-laden therapists who skirt the edges of professional ethics does not negate the long-term harm large numbers of people have experienced. To the extent that legitimate therapists seek to use this model, a meaningful conversation among their peers and especially with their patients about the risks involved, is required.

Second, and just as vital to the discussion, is WHY advocates for "reparative therapy" begin with the assumption that change of one's sexual orientation is superior to acceptance of one's sexual orientation. When push comes to shove, "change" advocates point to their interpretation of the Bible (or other religious text) and historical norms that are no longer widely accepted (and some that have been discredited) to justify their position. That's not science.

Call me jaded, but I suspect that a factor in the thinking of those in the APA task force allowing for this therapy model was fear of "reparative therapists" creating their own echo chamber institution that the APA would then have to spend time and effort countering.

To paraphrase Lyndon Johnson, it's probably better to have the "reparative therapy" charlatans inside the tent pissing out, than outside the tent pissing in. Of course, I'd prefer they deposit their excrement in the toilet where it belongs.


  1. This is a very helpful perspective. Thanks!

  2. You have some good points, Paul.

    I do have to err on the side of the therapists on this one, however. My intuition says that whether or not we agree with why society pushes people into situations where they seek reparative therapy, society does push. These individuals are seeking some form of help. They're desperate for something, anything to help them with their struggles.

    Are they ready to come to accept themselves? Probably not, seeing as they're seeking help to change. Is it time for them to accept that they probably won't ever change? Maybe.

    But we don't know that. We can't assume that our opinions or views that such things shouldn't be allowed to thrive should take precedence over an individual's right to seek out the form of help they want and need.

    The APA task force document states: "Psychologists respect the rights of individuals, including lesbian, gay and bisexual clients to privacy, confidentiality, self-determination and autonomy;"

    If someone wants, with their self-determination, to seek reparative therapy, I'd rather have something for them, rather than nothing. Should claims be adjusted? Maybe. But would that make these treatments less appealing to those needing help? Definitely. The point is that the population seeking reparative therapy most certainly has a high co-morbidity of other disorders that reparative therapy can easily treat (such as depression, anxiety, low self-esteem, etc.) and I'm not sure where else they'd get such help.

    As for an echo chamber...I think you'd have more to worry about a teapot orbiting your mom than that.

  3. Regarding the first focus:

    "Risk" is inherent in many things for which people feel compelled to seek help. There is risk when people bring their kids with behavior problems to me: Will they learn the skills I intend them to learn? Will the parents follow through with the regimen? If not, they run the risk of teaching the wrong things or actually strengthening the behavior we intended to get rid of. There is risk when seeking treatment for cancer. There is risk in almost everything we do. What makes this risk unique? The way change advocates view it, the risk is worth it. All the emotional risks could be worth the change in orientation that may or may not happen. And maybe all they need is to perceive that there has been a change. That's what drives them to seek change. Perhaps efforts should be placed on guiding this moment to something worthwhile? Moreover, there hasn't been any reliable global evidence (i.e., research) that harm is done in the process. All we have at this point is anecdotal evidence, and that evidence is not one-sided:

    "Among those studies reporting on the perceptions of harm, the reported negative social and emotional consequences include self-reports of anger, anxiety, confusion, depression, grief, guilt, hopelessness, deteriorated relationships with family, loss of social support, loss of faith, poor self-image, social isolation, intimacy, self-hatred, and sexual dysfunction. These reports of perceptions of harm are countered by accounts of perceptions of relief, happiness, improved relationships with God, and perceived improvement in mental health status, among other reported benefits. Many participants in studies by Beckstead and Morrow (2004) and Shidlo and Schroeder (2002) described experiencing first the positive effects and then experiencing or acknowledging the negative effects later. Overall, the recent studies do not give an indication of the client characteristics that would lead to perceptions of harm or benefit… We conclude that there is a dearth of scientifically sound research on the safety of SOCE" (APA Appropriate Therapeutic Responses, p. 42).

    And perhaps we just don't have the needed technology to change orientation in a non-aversive manner. In sum, the research conducted in this area is weak, not much can be concluded, and we need more research before we make sweeping, global pronouncements one way or the other.

  4. Thanks for the comments.

    MoHoHawaii: Thank you as well. I loved your post on Wednesday on the "LDS Message for Pride."

    Dan: I agree there is much desperation among people struggling to understand their sexuality. What bothers me is that there are many therapists who subscribe to this unproven model while at the same time assuring a likelihood of change. There are many other models available that don't rely on th kinds of assumptions made about the reasons for change. A therapist who makes those kinds of assumptions and gives those kinds of assurances undermines a client's self-determination. Deeply religious people in particular are very susceptible to appeals to authority. And in a therapeutic setting, the therapist will be seen as the one in power.

    Ryan: Even if there is no evidence of harm, if there is no credible, quantifiable, peer-reviewed evidence of efficacy, why pursue it when so many other sound models exist?

    Unless a process using the scientific method determines that reparative/change therapy actually works, it shouldn't be used by practitioners on a global level.

  5. This is an interesting post... Ironically enough I was just doing some studying about the 1973 removal of homosexuality from the DSM

    When the definition of homosexuality was first changed, it wasn't just simply deleted from the professional bible of mental health, rather, it was removed and replaced then with a section on ego-dystonic homosexuality, which was basically if you were gay and it bothered you, then you were sick. Curiously enough though, it was the being bothered by being gay that defined this "disorder". Later on, in 89, ego-dystonic homosexuality was then removed also from the DSM and the APA counseled all member professionals that "treating" a patient for sexual reorientation was unethical and dangerous. More information can be found at

    Speaking as one who subjected himself to reparative therapy, the only thing I got out of it was frustration and more self-hatred...

  6. I'm sorry, James, but can you provide a link to an official statement by the APA saying that sexual reorientation is unethical and dangerous?

    While I love This American Life, and especially "81 Words," I am unaware of the APA saying the reorientation therapy is "unethical."

  7. Paul,

    As far as "unproven models", the scientific method works with unproven models all across the board. Rarely, if ever, is something "unproven." Science doesn't work that way--rather, models fail to be disproven, the null hypothesis is rejected. This doesn't mean that results for sure are 100% lawful in every circumstance. In the case of reparative therapy, the results are all inconclusive because the studies have all be seriously flawed. Not making it true, not making it false.

    I think you are grouping all reparative therapies into one bundle, and analyzing motivations that you assume to be there. I don't know that the people who design these approaches disagree with homosexuality. Neither do you.

    But that's not the point--it doesn't matter whether they agree with us or not, the point is that there are people who are going to these places seeking help. Maybe it's not the help you want them to have, but it's their choice.

    A therapist who administers reparative therapy to a client is in no way taking away a client's self-determination. The client used that determination to come to the therapist in the first place. If society coerced the client there, it is not the fault of the therapist.

    "Unless a process using the scientific method determines that reparative/change therapy actually works, it shouldn't be used by practitioners on a global level. "
    --If we followed that method you would be hard-pressed to find a therapeutic technique for anything.

    "why pursue it when so many other sound models exist?"
    Because there's a demand for it. As long as people out there want to change their orientation, there will be techniques that attempt to do so and one day they will succeed. Which is why it's important that the LGTBQ community has some other moral reasoning for their way of life aside from the "born this way" argument. It's as asinine as "God told me so."

  8. Yes, the scientific method works with unproven models all the time. They are subjected to the proving process, meaning that they are subject to rigorous testing according to accepted practices in the relevant field(s) of science, followed by critical peer review. Nothing is ever 100% definitive; nor are theories 100% disproven. But we should at least have clear and convincing evidence of the efficacy of a treatment or therapeutic model before applying it beyond a scientific control group in which the proving/testing process takes place. I say this as a layperson. I will defer to the community of psychiatrists and psychologists with years of sound experience to work through these issues, applying their generally-accepted practices.

    I would welcome an explanation “unbundling” reparative therapies. My experience is that there is only one general model. But that is only my personal experience. As for “knowing” the motivations of those advocating reparative therapy, yes, I don’t know for certain. But there is a rebuttable presumption that these advocates have an agenda that opposes acceptance of homosexuality in society. I haven’t seen that presumption rebutted.

    So far, I’ve seen statements like those from Dean Byrd who complain that certain “ideologies” weren’t represented in the review process undertaken by the APA task force addressing reparative therapy. Nicolosi has made countless interesting assertions. Statements tend to illuminate motivations. If a therapist is actively applying their bias against acceptance of homosexuality in society in providing treatment to a client, rather than working to lay that bias aside for the benefit of the specific goals of a specific client, there’s a problem.

    Dan, you’re my friend. And that transcends any disagreement here. But the way I read your comment, you seem to assume that my pointing out problems with the reparative therapy approach means that I want to take away therapeutic choices or that I don’t want people to have certain types of help. I never said that. I am calling for a clear, open and honest discussion about the risks and motivations when it comes to reparative therapy. I don’t need to be right. I want solid information from credible sources subject to a sound process of critical inquiry. And when there is broad acceptance regarding which therapies are effective and which therapies are not supported by credible evidence of effectiveness, that holds weight. If new evidence is presented, then it’s time to reassess the prior conclusions.

  9. part 2:

    I never claimed that a therapist offering reparative therapy is “taking away” a client’s self-determination. I asserted that doing so undermines a client’s self-determination, as in causing it damage or limiting it in significant ways, or rendering that self-determination functionally meaningless in some cases. The issue isn’t the “fault” of the therapist. It’s the ethical considerations the therapist must recognize and address regarding how the client arrived at treatment and what that client’s goals are. This doesn’t take place in a vacuum.

    “One day they will succeed” is a bit presumptuous as a statement. I’m a reasonable guy, so I’ll freely admit that one day someone MAY succeed in their quest for reorientation. However, what is the psychological cost overall? And is it worth it? Maybe for some people it is. Of course, that is their choice. That doesn’t absolve therapists of responsibility to use reasonable professional judgment.

    As for moral reasoning, that’s certainly worth discussing, but it’s outside of the scope of this particular topic. Besides, this comment is already too long.

    This book seems to address some of the ethical issues presented in the debate over reparative/reorientation therapy:

    In addition, this article (again, written for the layperson, it seems) is enlightening regarding the APA’s institutional approach to efforts geared toward changing a person’s sexual orientation:

  10. To your question "why pursue [rep. therapy] when so many other sound models exist?" I understand that the APA is pushing people to use other therapies that have been found to be more helpful than reparative therapy. I also understand that people seem to hear the APA saying that reparative therapy is harmful and unethical. That interpretation seems to be more about dogma that critical evaluation of what has actually been stated. I don't know where you sit as far as that goes, but it seems a great many have interpreted statements by the APA wrongly.

    For the record, I am not for reparative therapy as it has been practiced up to this point. I am open to the possibility that future research may develop an approach to reparative therapy that is not harmful, does work, and will help those who don't want homosexual attractions. That would require tightening down the methods that have been used in the past and taking ethical considerations into account (e.g., clients' rights to self-determination, etc). I can agree that much of what has been done in this area has been less about client and more about preserving the ideologies, biases, and business of Rekers, Byrd, Nicolosi, (i.e., NARTH), etc. That's another thing I have a problem with. Not to mention much of their output is slightly… bitchy? Can I say that?