American Counseling Association members have consulted ACA staff and leaders regarding the practice of conversion therapy and the 2005 Code of Ethics. For this reason, the ACA Ethics Committee is sharing its formal interpretation of specific sections of the ACA Code of Ethics concerning the practice of conversion therapy and the ethics of referring clients for this practice.
Committee members individually considered a hypothetical scenario that was based on actual questions posed to the members and staff. The Ethics Committee then met to reach a consensus opinion. Space limitations preclude us from presenting a complete review of the consensus opinion reached by the Ethics Committee. We encourage readers to review a more in-depth article posted in the Ethics section of the ACA website (www.counseling.org/ethics).
During the third session of counseling, a client reports that he is gay and states, “I want to change my way of life and not be gay anymore. It’s not just that I don’t want to act on my sexual attraction to men. I don’t want to be attracted to them at all except for as friends. I want to change my life so I can get married to a woman and have children with her.” At the suggestion of a friend, the client has read about reparative/conversion therapy and has researched this approach on the Internet. He is convinced this is the route he wants to take.
The counselor listens carefully to what the client has to say, asks appropriate questions and engages in a clinically appropriate discussion. The counselor informs the client that although she is happy to continue working with him, she does not believe reparative/conversion therapy is effective and no empirical support exists for the approach. She further states that this form of therapy can actually be harmful to clients, so she will not offer this as a treatment.
The client says he is disappointed that the counselor will not honor his wishes. He then asks for a referral to another counselor or therapist who will work with him to “change his sexual orientation.”
The ACA Ethics Committee considered many factors and derived a consensus opinion that addresses several sections of the ACA Code of Ethics and moral principles of practice present in such a scenario. We started with the basic goal of reparative/conversion therapy, which is to change an individual’s sexual orientation from homosexual to heterosexual. Counselors who conduct this therapy view same-sex attractions and behaviors as abnormal and unnatural and, therefore, in need of “curing.” The belief that same-sex attraction and behavior is abnormal and in need of treatment is in opposition to the position taken by national mental health organizations, including ACA.
The ACA Governing Council passed a resolution in 1998 with respect to sexual orientation and mental health. This resolution specifically notes that ACA opposes portrayals of lesbian, gay and bisexual individuals as mentally ill due to their sexual orientation. In addition, the resolution supports dissemination of accurate information about sexual orientation, mental health and appropriate interventions and instructs counselors to “report research accurately and in a manner that minimizes the possibility that results will be misleading” (Standard G.3.b., 1995 ACA Code of Ethics and Standards of Practice). In 1999, the Governing Council adopted a statement “opposing the promotion of reparative therapy as a cure for individuals who are homosexual.” In fact, according to the DSM-IV-TR, homosexuality is not a mental disorder in need of being changed. With this in mind, we have a difficult time discussing the appropriateness of conversion therapy as a treatment plan. Regardless, there are clients who seek out counselors in hopes of changing their sexual behaviors, orientation or identity, so the ACA Ethics Committee conducted a review of the literature on reparative therapy.
We found that the majority of studies on this topic have been expository in nature. We found no scientific evidence published in psychological peer-reviewed journals that conversion therapy is effective in changing an individual’s sexual orientation from same-sex attractions to opposite-sex attractions. Further, we did not find any longitudinal studies conducted to follow the outcomes for those individuals who have engaged in this type of treatment. We did conclude that research published in peer-reviewed counseling journals indicates that conversion therapies may harm clients (refer to the full article posted on the ACA website for references).
These findings bring several questions to the forefront:
- Is a counseling professional who offers conversion therapy practicing ethically?
- Since ACA has taken the position that it does not endorse reparative therapy as a viable treatment option, is it ethical to refer a client to someone who does engage in conversion therapy?
- If a client insists on obtaining a referral, what guidelines can a counselor follow?
- If professional counselors do engage in conversion therapy, what must they include in their disclosure statements and informed consent documents?
Ethics Committee members agreed that it is of primary importance to respect a client’s autonomy to request a referral for a service not offered by a counselor. In the 2005 ACA Code of Ethics, Standard A.11.b. (“Inability to Assist Clients”) states, “If counselors determine an inability to be of professional assistance to clients, they avoid entering or continuing counseling relationships. Counselors are knowledgeable about culturally and clinically appropriate referral resources and suggest these alternatives.” Additionally, Standard D.1.a. (“Different Approaches”) reminds us that “counselors are respectful of approaches to counseling services that differ from their own.”
Standard A.1.a. (“Primary Responsibility”), however, states that “the primary responsibility of counselors is to respect the dignity and to promote the welfare of clients.” Referring a client to a counselor who engages in a treatment modality not endorsed by the profession and that may, in fact, cause harm does not promote the welfare of clients and is a dubious position ethically. This position is supported by Standard A.4.a. (“Avoiding Harm”), which says, “Counselors act to avoid harming their clients, trainees and research participants and to minimize or to remedy unavoidable or unanticipated harm.”
Professionals also engage in treatment only after appropriate educational and clinical training and do not practice outside of their areas of competence (Standard C.2.a., “Boundaries of Competence”). This standard clearly states that “counselors practice only within the boundaries of their competence, based on their education, training, supervised experience, state and national professional credentials, and appropriate professional experience.” In addition, per Standard C.2.b. (“New Specialty Areas of Practice”), “Counselors practice in specialty areas new to them only after appropriate education, training and supervised experience. While developing skills in new specialty areas, counselors take steps to ensure the competence of their work and to protect others from possible harm.” Therefore, any professional engaging in conversion therapy must have received appropriate training in such a treatment modality with the requisite supervision. There is, however, no professional training condoned by ACA or other prominent mental health associations that would prepare counselors to provide conversion therapy.
In addition, requests by clients seeking to change their sexual orientation should be understood within a cultural context. Standard E.5.c. (“Historical and Social Prejudices in the Diagnosis of Pathology”) requires that “counselors recognize historical and social prejudices in the misdiagnosis and pathologizing of certain individuals and groups and the role of mental health professionals in perpetuating these prejudices through diagnosis and treatment.” Historically, the mental health professions viewed homosexuality as a mental disorder. But in 1973, homosexuality was removed as a mental disorder from the Diagnostic and Statistical Manual of Mental Disorders. Within various religious and cultural communities, however, same-sex attractions and behaviors are still viewed as pathological. Yet the professional communities of counseling and psychology no longer diagnose a client who has attractions to people of the same sex as mentally disordered. To refer a client to someone who engages in conversion therapy communicates to the client that his/her same-sex attractions and behaviors are disordered and, therefore, need to be changed. This contradicts the dictates of the 2005 ACA Code of Ethics.
Clients may ask for a specific treatment from a counseling professional because they have heard about it from either their religious community or from popular culture. A counselor, however, only provides treatment that is scientifically indicated to be effective or has a theoretical framework supported by the profession. Otherwise, counselors inform clients that the treatment is “unproven” or “developing” and provide an explanation of the “potential risks and ethical considerations of using such techniques/procedures and take steps to protect clients from possible harm” (Standard C.6.e., “Scientific Bases for Treatment Modalities”).
Considering all the above deliberation, the ACA Ethics Committee strongly suggests that ethical professional counselors do not refer clients to someone who engages in conversion therapy or, if they do, to proceed cautiously only when they are certain that the referral counselor fully informs clients of the unproven nature of the treatment and the potential risks and takes steps to minimize harm to clients (also see Standard A.2.b., “Types of Information Needed”). This information also must be included in written informed consent material by those counselors who offer conversion therapy despite ACA’s position and the Ethics Committee’s statement in opposition to the treatment. To do otherwise violates the spirit and specifics of the ACA Code of Ethics.
Informing clients about conversion therapy
So what do ethical counselors do if clients state they are still interested in pursuing a referral for a counselor who offers conversion therapy? We advise professional counselors to discuss the potential harm of this therapy noted in evidence-based literature from scholarly publications in a manner that respects the client’s decision to seek it. This again relates to Standard A.1.a. (“Primary Responsibility”) and Standard A.4.b. (“Personal Values”), which requires counselors to be “aware of their own values, attitudes, beliefs and behaviors and avoid imposing values that are inconsistent with counseling goals.” The responsibility of counseling professionals at this juncture is to help clients make the most appropriate choices for themselves without the counselor imposing her/his values. To do so respects a client’s request and leaves open the possibility that the client can return to the professional counselor if the conversion therapy is ineffective or harms the client.
Again, Ethics Committee members agree that ethical practitioners refer clients seeking conversion therapy only under the conditions previously discussed. Further, it is imperative that counselors provide clients seeking conversion therapy with information about this form of treatment, including what types of information clients should expect from referral counselors. This information as well as implications for counselor educators can be obtained on the ACA website at www.counseling.org/ethics.
Joy S. Whitman, Harriet L. Glosoff, Michael M. Kocet and Vilia Tarvydas are members of the ACA Ethics Committee. Letters to the editor: firstname.lastname@example.org